AIDS: medicolegal considerations for Canadian hospitals.

Given the increasing endemicity of human immunodeficiency virus (HIV), the agent implicated in the causation of acquired immune deficiency syndrome (AIDS), in numerous sizeable subgroups of society, hospitals can expect increasing exposure to the legal implications presented by patients with AIDS. This paper reviews the duty of care owed by hospitals, both directly, through contractual obligations, and indirectly, through the acts of their employees and private contractors, to patients with AIDS, other patients and the public. Owing to the absence of case law directly related to AIDS or to HIV antibody reactivity, inferences were drawn from precedents set with other infectious diseases. Recommendations are made in the areas of confidentiality, informed consent, standards of care and vicarious liability.     

Neonatal resuscitation in Canadian hospitals.

A survey of Canadian hospitals providing obstetric care was undertaken to assess preparation, protocols, training and staff availability for neonatal resuscitation. Of the 721 hospitals contacted 577 (80%) responded. The reported availability of written guidelines for resuscitation varied greatly, depending on hospital size and proximity to a tertiary care centre. Many hospitals, especially those with 300 births or fewer annually, reported that they depend on family physicians or nurses to start and to continue neonatal resuscitation. Approximately one third of the hospitals had written guidelines for summoning personnel for additional help, and one third used a list of maternal or fetal indications for the presence of a physician specifically for the care of the infant at birth. Of 200 hospitals 138 (69%) had to summon additional medical help from outside the institution, 60% at all times. A neonatal resuscitation team in which members'' roles were defined was established in 22% of the hospitals. Few hospitals held rehearsals for resuscitation. Nurses were permitted to perform intubation in 21 hospitals (4%), 7 of them in Alberta. National professional bodies should develop guidelines for training and skill maintenance, and hospitals should develop protocols for maintaining equipment and for neonatal resuscitation team activities, including regular practice. Training should be improved in family practice and obstetrics programs, and consideration should be given to training senior obstetric nurses and respiratory therapists in intubation of neonates.     

Indirect costs of teaching in Canadian hospitals.

We sought to determine whether there are indirect costs of teaching in Canadian hospitals. To examine cost differences between teaching and nonteaching hospitals we estimated two cost functions: cost per case and cost per patient-day (dependent variables). The independent variables were number of beds, occupancy rate, teaching ratio (number of residents and interns per 100 beds), province, urbanicity (the population density of the county in which the hospital was situated) and wage index. Within each hospital we categorized a random sample of patient discharges according to case mix and severity of illness using age and standard diagnosis and procedure codes. Teaching ratio and case severity were each highly correlated positively with the dependent variables. The other variables that led to higher costs in teaching hospitals were wage rates and number of beds. Our regression model could serve as the basis of a reimbursement system, adjusted for severity and teaching status, particularly in provinces moving toward introducing case-weighting mechanisms into their payment model. Even if teaching hospitals were paid more than nonteaching hospitals because of the difference in the severity of illness there should be an additional allowance to cover the indirect costs of teaching.     

Antimicrobial drug use in three Canadian general hospitals.

Total amounts of antimicrobial drugs used to treat inpatients during 1975 were calculated for three Canadian general hospitals, one of them the principal teaching hospital of a medical school. Use of drugs was compared with that reported for Boston City Hospital during periods when antimicrobial therapy was and was not supervised by infectious disease consultants. Ampicillin, tetracyclines, cephalosporins, erythromycin and aminoglycosides for prophylactic oral administration were used excessively in the three hospitals. The degree of overuse was comparable to that at Boston City Hospital during years when drug use was uncontrolled. Overuse or improper choice of antimicrobial drug decreases the quality of patient care and increases its cost. More rigorous education is needed for both medical students and practising physicians in the rational use of antimicrobial drugs. Informal consultation with an infectious disease unit should be required before certain overly popular or toxic antibiotics are administered to hospitalized patients.     

Profile of Canadian physicians: results of the 1990 Physician Resource Questionnaire.

OBJECTIVE: To determine the supply, mix and distribution of physicians in Canada and to compare data with those of the 1982 and 1986 physician surveys. DESIGN: National census mail survey. SETTING: Canada. PARTICIPANTS: All physicians licensed to practise medicine in Canada, excluding interns and residents. A total of 52,422 questionnaires were mailed, of which 771 were ineligible. There were 38,313 valid responses (response rate 74.2%). MAIN OUTCOME MEASURES: Activity status, workload, specialty certification, practice setting and demographic profiles. MAIN RESULTS: A total of 88.7% of the respondents were active physicians; 19.4% were women, compared with 16.8% in 1986. Physicians reported working on average 4.1 fewer hours per week in total activities than in 1986 and 5.7 fewer hours per week than in 1982. As was found in 1982, about 50% of active physicians were certified specialists; 30% of specialists and 21% of general/family practitioners were 55 years of age or more. Approximately 11% of active physicians were in rural practice, as was reported in 1986. Similar proportions of foreign graduates and Canadian graduates were located in rural areas (10.9% and 11.4% respectively). CONCLUSIONS: Factors such as aging and retirement will affect specific specialty groups (e.g., general surgery and obstetrics/gynecology) in the near future. Specialty groups must address the issue of the future supply of physicians and the demand for their services when developing targeted needs within their specialties. The increasing proportion of women in medicine is changing the specialty mix and practice profiles of physicians as a whole. The issues associated with the recruitment and retention of physicians in rural areas remain complex.     

Acne in schoolchildren: no longer a concern for dermatologists.

OBJECTIVE--To determine the prevalence and severity of acne among schoolchildren in Glasgow. DESIGN--Secondary schools in Glasgow were divided by postcode into five socioeconomic cluster groups. Different numbers of schools were selected at random from the five groups to ensure proportional representation. One class from each registration year of the chosen schools was selected at random and the whole class recruited into the study. SETTING--15 Secondary schools in Glasgow. SUBJECTS--2014 Randomly selected schoolchildren aged 12-17 (5% of total secondary school roll). INTERVENTIONS--None. END POINT--Assessment of facial acne by two independent examiners by a recognised acne scoring system. MEASUREMENTS AND MAIN RESULTS--The prevalence of acne in boys increased from 40% (75/189) at age 12 to 95% (108/114) at age 16, and in girls it increased from 61% (114/187) at age 12 to 83% (136/164) at age 16. On a scale of 0 to 10 only 18 boys (1.8%) and three girls (0.3%) had grades of acne of 1.0 or greater; most of the pupils had grade 0.05-0.375 (minimal) acne. Nine per cent of boys (88/973) and 14% of girls (145/1041) had visited their general practitioner specifically for advice on and treatment for acne; only five pupils (0.3%) had been referred to a dermatologist. CONCLUSIONS--Both the prevalence and severity of acne have decreased over the past 20 years. This has probably been due to improvement of treatment for acne by primary care doctors and the greater availability and use of over the counter preparations for acne.     

Multidrug-resistant Acinetobacter baumannii as an emerging concern in hospitals

Molecular Biology Reports - Acinetobacter baumannii has become a major concern for scientific attention due to extensive antimicrobial resistance. This resistance causes an increase in mortality...     

Adverse events among children in Canadian hospitals: the Canadian Paediatric Adverse Events Study

Background:

Limited data are available on adverse events among children admitted to hospital. The Canadian Paediatric Adverse Events Study was done to describe the epidemiology of adverse events among children in hospital in Canada.

Methods:

We performed a 2-stage medical record review at 8 academic pediatric centres and 14 community hospitals in Canada. We reviewed charts from patients admitted from April 2008 through March 2009, evenly distributed across 4 age groups (0 to 28 d; 29 to 365 d; > 1 to 5 yr and > 5 to 18 yr). In stage 1, nurses and health records personnel who had received training in the use of the Canadian Paediatric Trigger Tool reviewed medical records to detect triggers for possible adverse events. In stage 2, physicians reviewed the charts identified as having triggers and described the adverse events.

Results:

A total of 3669 children were admitted to hospital during the study period. The weighted rate of adverse events was 9.2%. Adverse events were more frequent in academic pediatric centres than in community hospitals (adjusted odds ratio [OR] 2.98, 95% confidence interval [CI] 1.65–5.39). The incidence of preventable adverse events was not significantly different between types of hospital, but nonpreventable adverse events were more common in academic pediatric centres (adjusted OR 4.39, 95% CI 2.08–9.27). Surgical events predominated overall and occurred more frequently in academic pediatric centres than in community hospitals (37.2% v. 21.5%, relative risk [RR] 1.7, 95% CI 1.0–3.1), whereas events associated with diagnostic errors were significantly less frequent (11.1% v. 23.1%, RR 0.5, 95% CI 0.2–0.9).

Interpretation:

More children have adverse events in academic pediatric centres than in community hospitals; however, adverse events in the former are less likely to be preventable. There are many opportunities to reduce harm affecting children in hospital in Canada, particularly related to surgery, intensive care and diagnostic error.Children are vulnerable to harm associated with medical care. Although there is a need to make health care safer,¹ transforming the system requires knowledge of the full scope and burden of health care–associated injury in pediatric medicine. Chart and administrative database reviews showing rates of adverse events of 3% or lower among children admitted to hospital^2–4 have been superseded by data from targeted studies using trigger tools to identify patient charts warranting review for adverse events.^5–7 Unfortunately, the absence of a comprehensive pediatric trigger tool has limited the understanding of the full burden of health care–associated harm.The Canadian Paediatric Trigger Tool was validated to identify adverse events in children admitted to hospital.⁸ Using this tool, we conducted the Canadian Paediatric Adverse Events Study to determine and compare the incidence, type, severity and preventability of adverse events among children admitted to academic pediatric centres with those admitted to community hospitals in Canada.