IntroductionThe risk management project of The University Hospital "A. Gemelli" aims to define the necessary procedures to manage clinical risk, by identifying the structures involved within this process, so that all of the personnel can contribute to a measurable improvement in the safety of both patients and staff.MethodsThe Risk Management Program is comprised of 5 long-term phases:Phase 1 - Strategy Definition and Communication: a clear and shared Risk Management Strategy is indispensable to guarantee a coordinated action plan, in order to focus all of the interventions towards the achievement of common and measurable results.Phase 2 - Risk Management System Governance: all of the organisational structures have been activated in order to effectively manage the Risk Management System. The system has been introduced to interact within all areas of the hospital and to transfer information.Phase 3 - Promotion within the Organisation: this phase fosters the aims of the project within the whole organisation, by stressing the concept of "learning from errors". This is crucial if organisational and healthcare workers are to understand the true aims of risk prevention and protection and offer to contribute to the process.Phase 4 - Risk Assessment: a data survey system was created and institutionalized. This phase begins with an analysis of the information flow, in order to estimate the probabilities that certain risks occur, and ends with defining the interventions to undertake. Risk assessment makes it possible to forecast the consequences of certain risks and thus prioritise those for prevention.Phase 5 - Risk Management: this consists of planning and implementing all of the actions necessary to prevent risks, protect and finance ( in terms of prevention) A. Gemelli University Hospital.ResultsThe results achieved are remarkable especially when one considers the organisation of a complex clinical risk management system within a large university hospital. An information flow that examines and identifies risks from surveying the data has been created. Preventative activities have been planned in the laboratories, transfusion and pharmacotherapy sectors as outlined in the risk map, together with clinical audit activities. Furthermore, all of these issues have been highlighted across all sectors with the creation of an accredited ECM training program as well as the implementation of an anonymous survey. These initiatives have not only increased the interest in Risk Management issues, but have also fostered the integration of different groups and their working methods.ConclusionsIntroducing risk management processes to A. Gemelli University Hospital represents a step from the promotion and dissemination phase to that of a formal organic risk management system in medicine. This initiative, involving the participation of all personnel, has produced a measurable improvement in safety of both patients and staff.
Background: Waist circumference (WC) is a useful surrogate marker of abdominal adiposity and a risk factor of cardiovascular disease and hypertension. Asians have higher abdominal fat at a lower level of body mass index (BMI). Previous studies showed that WC was the best measure and correlate of abdominal fat and general adiposity, respectively, among the Bengalee people of Eastern India including the present sample.This study aimed to evaluate the clinical usefulness of waist circumference and its appropriate cut-off in identifying obesity and hypertension.Methods: Adult male slum dwellers aged between 18 and 60 years were included in the study. Height, weight, skinfolds, waist circumference, systolic- (SBP) and diastolic blood pressures (DBP) were measured.Body mass index (BMI) and percent body fat (PBF) were also calculated. Obesity was defined as >25% of body fat. Mean (+ SD) and range statistics were used to describe the variables. WC values were divided into four categories, viz. <72cm, 72-79.9cm, 80-84.9cm and ≥ 85.0cm. ANCOVA was performed to observe the differences in mean SBP and, DBP between the WC categories, with age, smoking and alcohol consumption status as covariates. Pearson correlation and multiple linear regressions were employed to examine the relationship of WC with SBP and DBP. Adjusted odds ratios for hypertension by WC categories were obtained through logistic regression analysis. Receiver operating characteristic (ROC) curve analysis revealed the optimal value of WC to identify obesity. Results and conclusions: PBF increased significantly (F = 208.74, p<0.001) from the lowest WC category (10.6%) to the highest one (26.9%). Mean SBP and DBP also increased significantly from the lowest to the highest WC categories. Waist circumference had significant positive effect on both SBP (T=2.559, p<0.01) and DBP (T=3.256, p<0.05) irrespective of age and PBF. WC value >80.9cm could be accepted as the best cut-off point for WC to identify obesity. Participants with a WC of 80-84.9 cm were around three times more likely to have HT(p<0.005), however the likelihood increased to over 5 for those with a WC of > 85.0 cm when compared to lower WC categories. The odds ratio significantly increased for WCs at or above 80cm.Therefore the measurement of WC could be used to identify general obesity and be used as a screening toolfor HT risk factors in Bengalee urban slum dwelling men. The WC cut off to define obesity and identifyinghypertension was around 81cm
Background: Population based screening for cardiovascular disease risk factors can potentially reduce coronary heart disease mortality and morbidity. There is little contemporary evidence that has examined the actual impact of such a programme on population health and on reducing inequality in health between affluent and deprived areas. Methods: 82,015 residents of Stockport Health Authority, UK age 35-60 took up an invitation to be screened for cardiovascular disease risk factors from 1989 -1999. We compared uptake of screening and coronary heart disease (CHD) mortality and hospital admissions (1997 – 2003) between screened and unscreened male and female populations from affluent and deprived areas. Results: Males and females in the unscreened population were more likely to die from CHD (IRR=3.60; p<0.001, IRR=4.64, p<0.001) and to have a hospital episode (IRR=1.75, p<0.001, IRR=1.94, p<0.001) than those in the screened population. This was independent of age and deprivation. The highest rates of CHD mortality and hospital admissions were found for unscreened deprived populations, the lowest for screened affluent populations. For both males and females mean rates of CHD mortality and hospital admissions were significantly lower for those who were screened and living in deprived areas compared to those who were unscreened and living in affluent areas. Conclusions: Screening for cardiovascular disease risk factors improved the cardiovascular health of the population by targeting and treating ‘high risk’ groups, including those living in deprived areas. The potential of screening to reduce health inequality by promoting faster and more substantial health improvement in deprived areas was not observed in this study.
Background: The burden of injuries and disabilities in Pakistan is significant. Our study attempted to describe the circumstances, risk groups, types and severity of injuries experienced by patients attending a tertiary care hospital in Karachi, Pakistan. Methods: A retrospective study was conducted in the department of Emergency Medicine (ED) at Aga Khan University Hospital of Karachi, Pakistan. Past medical records from June 2006 till May 2007 of injured patients presented to ED were reviewed. Data were recorded regarding the basic epidemiological features, hospital stay, body parts injured and severity of injuries. Results: A total of 631 patients with injuries were identified. The majority of them were males (80%; n=502), aged 21-40 years (63%). Road traffic injuries (RTIs) 65% (n=411) followed by gunshots (14%, n=85) were the most common types of injuries. Upon arrival to hospital 82% (491/598) of patients had a Glasgow Coma Scale (GCS) ≥13. The mean hospital stay and Injury Severity Score (ISS) of patients were 3.5 days (SD ±6.4) and 4 (SD ±5.2) respectively. The head, neck and face were the most affected body parts (50%; n=276). Three percent (n=17) were pronounced dead on arrival to the ED. Among RTIs, multivariable logistic regression identified sex (aOR: 3.797; 95% CI: 1.066–13.528), and mode of travel (aOR: 2.883; 95%CI: 1.330–6.250) as independent predictors for severe GCS (GCS<8). Conclusions: RTIs were the most common type of injuries, common among young males. In RTIs, children were mostly pedestrians, and females and motor vehicle occupants were more likely to have severe GCS. This study may assist local authorities in Karachi to prioritize interventions to address common injuries in those who are high at risk.
This article is intended to be an initial report on the experiences gained while using HIA. Although it is provisional and pragmatic, it ought to provide useful elements for comparison with other territorial situations, both Swiss and foreign. The large differences between the three cantonal political-institutional contexts probably explain the profound differences in the way that HIA processes were introduced in each canton. Nevertheless, the article - through the concept of institutionalization - seeks to identify supracantonal elements. Finally, by presenting HIA implementation methods in different Cantons, it endeavours to demonstrate the existence of a common matrix in the Swiss context beyond the differences arising from the actual political-institutional situations linked to them.
According to the WHO-European region Tallin-Charter, Stewardship (S) is on the health agenda of many European countries and in particular of those involved in the devolution of powers, as is the case of Italy. Many observers agree that, in such cases, both the configuration and the application of state authority in the health sector should be realigned so as to achieve desired policy objectives.We present an experience of what could be meant by S in practice, applied to the field of planning preventive interventions.The Italian National Preventive Plan 2010-2012 is a comprehensive Plan dealing with many areas of prevention. For all these areas, the main health objectives, the specific regional goals and the intervention - called "central" actions-that the Ministry of Health (MoH) is in charge of carrying out in order to support regional preventive programs, are stated in this Plan. In order to carry out its task, the MoH has referred to the model of stewardship and has reconsidered its role. Therefore, the MoH has matched the sub-functions of S according to the model outlined by Travis et al, and the prior actions that have been proposed by local and national governments, as the main aspects of how to deal with the governance of prevention. Overall, we experienced that the S framework is a suitable and helpful tool to tackle what the challenge of national planning, in the scenario of devolution, is. In doing so, we have learnt some practical lessons about the running of the system and about how to plan according to stewardship, in particular.Among these, given that the steward's most specific responsibility in planning is to assure stewardship, a sound capacity building is needed as a cornerstone in evolving the culture of the NHS. Furthermore, in order to put this effectively into practice, the Steward must be able to measure S functions, and putting in practice a S model needs international comparison and cultural growth.
Background: parameter uncertainty in the Markov model's description of a disease course was addressed. Probabilistic sensitivity analysis (PSA) is now considered the only tool that properly permits parameter uncertainty's examination. This consists in sampling values from the parameter's probability distributions.Methods: Markov models fitted with microsimulation were considered and methods for carrying out a PSA on transition probabilities were studied. Two Bayesian solutions were developed: for each row of the modeled transition matrix the prior distribution was assumed as a product of Beta or a Dirichlet. The two solutions differ in the source of information: several different sources for each transition in the Beta approach and a single source for each transition from a given health state in the Dirichlet. The two methods were applied to a simple cervical cancer's model.Results : differences between posterior estimates from the two methods were negligible. Results showed that the prior variability highly influence the posterior distribution.Conclusions: the novelty of this work is the Bayesian approach that integrates the two distributions with a product of Binomial distributions likelihood. Such methods could be also applied to cohort data and their application to more complex models could be useful and unique in the cervical cancer context, as well as in other disease modeling.
Background: acne vulgaris, is one of the most common skin disorder. Previous studies about the role of smoke in the pathogenesis of acne reported contradictory results. The aim of this study was to conduct a case-control study investigating the relationship between tobacco smoking and acne. Methods: a case-control study was performed during the period September 2009 - February 2010. A questionnaire was administrated to each participant, to assess the association acne - smoke. Cases were outpatients of the Dermatologic Ambulatory of the “Fiorini” Hospital, Sapienza University of Rome (Italy). Controls were age and gender-matched to the cases. The ratio cases-controls was 1:2. A univariate and a multiple logistic regression analysis were conducted; Odds Ratio (OR ) and the relative 95% confidence interval (95%CI) were assessed. The statistical significance was set at p < 0.05. Results: crude OR for the association acne - smoke was 7.26 (IC=2.27-23.18); adjusted OR for sex and age was 5.47 (IC=1.67-17.97). Of 93 cases, 6 had a severe grade of acne (6.5%), 19 had an intermediate grade of acne (20.4%), and 68 had a mild grade of acne (73.1%). No one of the smokers had a severe grade of acne, one had an intermediate grade of acne and 11 had mild acne; these differences are not statistically significant. Conclusions: the association between acne and smoke shows an increased risk (OR=7.26) with a statistically significant CI. Moreover, people ≥ 18 years of age have twice the risk compared to persons < 18 years of age (OR=2.31).
Objectives: Previous work reports mixed results on the roles of intelligence and academic achievement on child injury risk. Some early research offered evidence of links between lower levels of intelligence and higher rates of pediatric injury, but other work has suggested there is no relation between the variables. This study investigated the matter further, in the context of a large sample and with strong statistical power. Methods: Data from a national sample of 8002 kindergartners in the United States, all from low-income families, were analyzed. Intelligence was estimated using the Peabody Picture Vocabulary Test-Revised and academic achievement with the Reading and Mathematics scales of the Woodcock Johnson Psycho- Educational Battery-Revised. Mothers reported whether children had experienced an injury in the previous year that required professional medical attention. Results: Results of both bivariate and multivariate ordinal logistic regression models suggest higher levels of reading achievement and of mathematics achievement were associated with slightly reduced risk of pediatric injury. Intelligence was not related to injury history. Conclusions: Academic achievement, but not intelligence, appears to relate in a small but statistically significant inverse manner with risk for pediatric injury among kindergartners from a low-income background. Possible mediators include children’s ability to learn and remember safety-related rules or the fact that parents who encourage learning in the household might also safeguard children more effectively.
Objective: The aim of the present study is to evaluate the presence of Salmonella spp. and Listeria monocytogenes in ready-to-eat foods by comparing the performance and sensitivity of BIO-RAD commercial Kits based on real-time PCR detection with traditional culture (ISO) procedures. Materials and methods: Sixty-five samples of ready-to-eat foods were analysed as described above. In order to verify the validity of both culture and biomolecolar methods and to compare the sensitivity of real-time PCR versus conventional culture (ISO) procedures, five food samples were artificially contaminated with the Salmonella enteritidis ATCC strain by using scalar concentration from 103 to 10-1 cfu/g while one food sample was artificially contaminated with the Listeria monocytogenes ATCC strain. Finally, statistical analyses of the results were performed using the statistics “K” to confirm the agreement between the compared methods. Results: Both procedures showed the absence of Salmonella spp. and Listeria monocytogenes in the processed samples; results in agreement appeared both for the five food samples artificially contaminated with Salmonella enteritidis ATCC strain and for the food sample artificially contaminated with Listeria monocytogenes ATCC strain. The sensitivity of the biomolecolar test was 1 cfu/g. Therefore full agreement between the two methods was detected, with a K value of 1. Conclusions: The real-time PCR system appears to be extremely useful in the rapid screening of food samples, allowing for the rapid identification of Salmonella spp. and L. monocytogenes.
This paper describes the process that lead to the passing of the Act for Patient Safety in the Danish health care system, the contents of the act and how the act is used in the Danish health care system.The act obligates frontline health care personnel to report adverse events, hospital owners to act on the reports and the National Board of Health to communicate the learning nationally. The act protects health care providers from sanctions as a result of reporting. In January 2004, the Act on Patient Safety in the Danish health care system was put into force. In the first twelve months 5740 adverse events were reported. The reports were analyzed locally (hospital and region), anonymized and then sent to the National Board of Health.The Act on Patient Safety has driven the work with patient safety forward but there is room for improvement. Continuous and improved feedback from all parts of the system is essential to maintain the level of reporting.
Background: Immigration towards Ferrara is a recent occurrence. We evaluated the immigrants’ health requests. Methods: This report is based on data collected by Local Health Authority. Results: The analysis of ambulatory cares and hospitalizations are comparable. It emerges the age class 31- 65 is the most represented. Females’ requests are more than males’ one, due to pregnancy and gynaecological health requests. The capital hospital sustained the heaviest workload. We found differences respect European Union population regarding length of stay. The predominant kind of access are through emergency room and self-access. Conclusions: This complex pattern of health care requests requires dedicated approaches.
Objective: Investigations of injecting drug users (IDUs) have suggested that the social context may influence high-risk behaviours in this population. The aim of this study was to describe knowledge, attitudes and behaviours of IDUs attending public drug-treatment centres in our area.Study design and methods: A cross-sectional survey was conducted between July 2002 and February 2004, enrolling 607 drug users attending four public drug-treatment centres in the Palermo area. Two of them were located inside the urban area, whereas the other two were in rural districts near the city. All participants answered an anonymous questionnaire concerning social and demographic characteristic and potential high-risk behaviours.Results: IDUs living in urban context have a higher educational level, higher number of sexual partners, as well as a lower prevalence of exchanging sex for drugs. Conversely, IDUs living in suburban/rural context are less likely to share syringes and more likely to have used light drugs in the past. Suburban/rural IDUs drink more alcohol but smoke less cigarettes/day, although both groups are strong smokers.Conclusions: The results suggest that public drug-treatment centres should take in consideration the adoption of specific programs targeting specific groups, in line with the profile and needs of the subjects in each context in order to promote approaches leading to risk reduction.
Services provided for European citizens' healthcare are not services like standard commercial services. Healthcare services need to be accessible, independent of the citizen's economic or social background and should at the same time be available to all at the best possible quality level. The Luxembourg Declaration on Patient Safety recognizes these challenging fundamental principles. Patient safety is a key aspect for all European policy makers, as it is a vital question of equitable access to health care. Nevertheless we know that unfortunately a considerable amount of avoidable safety events still occur all across Europe!However differently organized our national health systems may be, it is vital to share experience and knowledge at a European level in order to be able to learn from the experiences of the different member-states. No uniform solution can be found and decreed from the bottom down, nevertheless Europe can contribute and help to raise standards by a common effort. The Luxembourg Declaration is a launching pad for European progress in this field as it sets important goals and demonstrates the steps to be undertaken. It is a calling and gives us hope for measurable progress in the future.
Background: In colon cancer, the effectiveness of the cure is largely dependent on the early detection of the pathology. It is therefore useful to investigate the quality prevention programs. As a result, the Italian Healthcare System is increasingly adopting Quality Assurance by implementing diagnostic and therapeutic guidelines.In this study, a comparison was made between the current pathways undertaken by patients with colon cancer and the prescribed guidelines. The analysis investigates the diagnostic pathways that lead to the discovery of colon cancer, the service center where the pathway started and the therapy regimen administered to treat the cancer. Methods: The analysis covers all 205,000 patients who accessed one Italian Local Health Agency during the year 2007. In order to fund the costs of the services, the local regional council requested the collection of data from the Agency itself. Starting from this raw data, a data warehouse was built, the required data extracted and, eventually, the actual pathways were created. Results and conclusions: Only 11.2% of colon cancer patients underwent the sequence of exams recommended by the official guidelines. 54.4% of them only partly followed the sequence of recommended exams. The remaining patients underwent exams that did not comply at all with the guidelines. Furthermore, there is evidence of a lack of prevention for some patients, particularly for those that only discovered the pathology when they arrived at the Emergency Department.
Background: infectious low pathogenic avian influenza viruses (LPaIVs) have been recently detected on feathers of wild ducks. Laboratory trial results suggested that the preen oil gland secretion, covering waterbirds’ feathers, may attract and concentrate virus particles from aIV-contaminated waters to birds’ bodies. We evaluated whether ducks can become infected by the ingestion of preen oil-associated viral particles, experimentally smeared on their plumage. In addition, we compared virologic and serologic results obtained from mallards whose feathers were experimentally infected, with those from wild mallards naturally carrying aIVs on feathers. Methods: we experimentally coated 7 mallards (anas plathyrynchos) using preen oil mixed with a LPaIV (h10n7 subtype), and housed them for 45 days with a control, uncoated duck. cloacal, oropharyngeal and feather swabs were collected from all birds and examined for aIV molecular detection and isolation. Blood samples were also taken to detect influenza specific antibodies. In addition, sera from 10 wild mallards, carrying on feathers infectious LPaIV h10n7, were examined. Results: virologic and serologic results indicated that through self- and allopreening all the birds experimentally coated with the preen oil/aIV mix and the control duck ingested viruses covering feathers and became infected. Virus isolation from feathers was up to 32 days post-coating treatment. one out of 8 wild mallards showing antibodies against type a influenza virus was seropositive for h10 subtype too. Conclusions: our experimental and field results show evidences suggesting that uninfected birds carrying viruses on their feathers, including immune ones, might play an active role in spreading aIV infection in nature. For this reason, routine aIV surveillance programs, aimed at detecting intestinal and/or respiratory viruses, should include the collection of samples, such as feather swabs, enabling the detection of viruses sticky to preened birds’ bodies....
Background: Because of the increasing availability of clinical information on the basis of electronically processed data obtained through the hospital discharge records in the HIS, large databases are being set up to develop risk-adjustment models for outcome assessment. This study is aimed at assessing the validity of hospital discharge data from the Hospital Information System (HIS) of patients with hip arthroplasty.Methods: 677 records were extracted from the database of the pilot project "Lazio Region Hip Arthroplasty Register (Ripa-L)" and were compared to the corresponding HIS discharge records. The Ripa-L dataset was used as a reference to evaluate the completeness and accuracy of the socio-demographic and clinical HIS data.Results: Data such as the patients' age and sex, principal diagnosis, and surgical procedures, showed a very high level of agreement. By contrast, clinical information about comorbidities on admission and in-hospital complications mostly showed unacceptable variances in the datasets. The sensitivity of hospital data reporting was generally very low for almost all conditions, with the highest value being observed for diabetes (58%) and the lowest for endocrine and peripheral venous diseases (4%).Conclusions: Gaps in clinical information may compromise the ability to carry out high quality appraisals. In particular, the underreporting of comorbidities in hospital administrative data may lead to misestimation of the providers' skill and quality of care, as a consequence of imperfect risk-adjustment. Stakeholders should highlight the potentialities related to the use of high quality administrative datasets also in clinical evaluations by stimulating health professionals to further improve the quality of the collected data.
In a recent survey among more than 6 000 nephrology professionals, almost half were in favour of the use of high-flux HD and HDF as their best option for extracorporeal dialysis therapy. An analysis of clinical literature suggests that on-line HDF provides an increase in years of life gained, a reduction of adverse events, reduced hospitalizations, a reduced use of drugs and improved organizational efficiency. All the following elements have...
Background: Cities are engines of health development and not merely settings for health promotion. However, political scientists contest the extent of their powers and the scope of their influence. Methodology: Assuming local governance is a locus of decision-making about intermediate determinants of health, then there are three methodological challenges to evaluating its impact: first, accounting for context; second, addressing multiple, interactive interventions; and third identifying mechanisms for change. ‘Realist’ evaluation is more appropriate for this task than traditional paradigms of public health research. Review: Commissioned evaluations of the first three phases (1987-2002) of the WHO European Healthy Cities Network are reviewed against the three methodological challenges. Conclusions: These evaluations are stronger in identifying necessary city structures and processes but weaker, as are the Network cities themselves, in identifying change mechanisms which convert sector interventions into health gains. This lacuna is addressed in Phase IV (2003-2008) of the Network by the themes of healthy urban planning and health impact assessment.
The effectiveness of legislation and regulation as tools for injury prevention is well recognized in Europe. There is another tool that has been used effectively in the United States, but which is not substantially discussed in the European injury prevention literature. Litigation against the makers of unsafe products has been used in the US to create an incentive for manufacturers to invest in safer product design rather than risk a lawsuit and pay a penalty for neglect. This commentary discusses the use of litigation in the US as a tool for preventing injuries, and speculates on whether such an intervention might be feasible and desirable in Europe.
