[Perinatal care: advantages and disadvantages of network functioning. Analysis and point-of-view of public health physicians].
Explore the source record for details and available documents.
Attitude of Health Personnel↗
Biomedical subjects
P Lombrail
Publications and source records attributed to P Lombrail.
[Social problems encountered during prenatal care in a Paris maternity ward].
In 1993, about 2,600 children are born in Robert Debré Hospital (RDH), a hospital specialized in pediatrics and obstetrics located in Paris. One hundred and seventy nine of the mothers contacted the hospital social service during pregnancy. The main goal of this study was to describe the social problems encountered by these women and the solutions proposed by the social service of RDH. The second aim was to describe the socio-demographic profile and medical problems of this population. At first contact, 45% of the women had no social coverage, and only 18% had a steady job. Most social problems were related to administrative procedures. Financial and housing problems were more difficult to solve in this context. These figures reflect the growing problem of precarity, with its consequences. A hospital social service is not the right place to solve these very complex problems. The most worrisome point is that the living conditions of newborn children are often unknown after delivery.
Adult↗
[Reconstruction of bladder exstrophy: retrospective study of 57 patients with evaluation of criteria in favor of the acquisition of continence].
In order to evaluate the results of staged surgical reconstruction in terms of urinary continence, spontaneous voiding and preservation of the upper urinary tract, we reviewed the charts of 42 boys and 15 girls treated at Hôpital Saint-Joseph for bladder exstrophy between 1965 and 1995. All patients underwent staged repair, associating bladder closure, bladder neck plasty, then genitoplasty, including bladder augmentation in 7 cases (12%). Criteria for good outcome in terms of continence are defined and factors influencing outcomes are reviewed. A total of 38 patients (67%) achieved good or acceptable urinary continence (22 or 39% and 16 or 28%, respectively). Outcome was poor in 19 patients, including 13 (23%) who underwent secondary urinary diversion. Bladder stones, which developed in 13 patients (23%), were the commonest long-term complication of bladder exstrophy reconstruction. Ten patients who underwent pelvic osteotomies ultimately had better continence and 9 are dry. Bladder neck reconstruction was performed at a later age overall (mean 10 years). Repeat bladder neck reconstruction was generally associated with poor results. The technique of bladder neck reconstruction did not appear to influence outcome. This retrospective study confirms that a carefully planned surgical reconstruction for bladder exstrophy can lead to satisfactory long-term urinary continence in most patients. Factors contributing to successful results include early bladder closure, pelvic osteotomy, adequate bladder neck reconstruction with bladder neck suspension in girls, and a motivated child and family. Alternatives to surgical reconstruction should be discussed. Ultimate predictors of outcome in bladder exstrophy repair are difficult to ascertain.
Adolescent↗
[Esophageal pH-metry. Evaluation of prescriptions at the Robert-Debré Hospital (Paris)].
OBJECTIVES: To record orders for esophageal pH-metry at the Robert-Debré hospital in Paris and to assess the quality and pertinence on the order. METHODS: A prospective survey of all children who underwent pH-metry during the month of February 1996 was conducted. There were 11 children included in the study. RESULTS: Half of the pH-metries were performed in inpatients and half in outpatients including 18% scheduled directly by the exploration unit. The order did not provide any reason for the exploration in 15% of the cases (42% of those scheduled by the unit). When a reason was explained, the order described the clinical context in 86% of the cases but did not give any information on ongoing treatment in 40%. Clinical indications mentioned respiratory or ear-nose-throat disease in 70% of the cases and regurgitations or vomiting in 42%. Pathological reflux was diagnosed in one-third of the explorations. An anti-reflux treatment was prescribed for half of the patients. In reference to the official prescription guidelines in France (Référence Médicale Opposable, RMO), 72% of the orders were pertinent, 10% were questionable, 10% did not comply to official guidelines, and 8% could not be classified due to lack of information. CONCLUSION: These findings point out that the official guidelines may be of questionable value in the hospital setting.
Adolescent↗
Prolongation of hospital stay and extra costs due to hospital-acquired infection in a neonatal unit.
A case-control study to evaluate the mean extra stay and corresponding cost of neonates acquiring a hospital-acquired infection (HAI) was performed on all patients admitted to a neonatology unit and discharged alive in 1994. Cases were identified from medical records. Controls were matched to cases for birthweight, gestational age, mode of admission to the unit, previous stay in an intensive care unit and presence of a central venous catheter. Costs were taken as those of the extra days attributable to HAI, i.e. the mean difference in the length of stay between cases and controls. Among a cohort of 616 neonates, 34 (5.5%) had one or more HAIs (average = 1.1). The mean extra cost per infected case was 52,192 FF (US$10,440), corresponding to 5.2 extra days in hospital.
Birth Weight↗
Another look at emergency room overcrowding: accessibility of the health services and quality of care.
PURPOSE: To describe both the social characteristics and the health needs of the medical users of a pediatric hospital Emergency Room with special emphasis on frequent use. STUDY SELECTION: Observational study on health services utilization and health care needs of young children consulting at a teaching hospital's Emergency Room. DATA SOURCES: Mother interview and medical record review. RESULTS OF DATA SYNTHESIS: Children from underprivileged strata are more often high Emergency Room users. Their preventive needs are satisfied but adequate follow-up of their medical problems is more often lacking. CONCLUSION: To understand why some achievable benefits are not achieved it is necessary to evaluate the varying performance of health services according to the social origin of the users.
Child, Preschool↗
Predicting the outcome in elderly patients of hospital admission for acute care in Paris, France: construction and initial validation of a simplex index.
OBJECTIVE: To develop a simple index able to identify at an early stage those elderly patients at high risk of requiring discharge to a residential or nursing home after admission to hospital for acute care. For these patients, early discharge planning might lead to a more effective management and reduce the length of hospitalisation. DESIGN, SETTING, AND PATIENTS: This was a prospective study conducted in two teaching hospitals in Paris, France. A total of 510 consecutive patients was included. They were aged 75 years or more and had been admitted to acute medical care units through the emergency department. MEASUREMENTS: Demographic data, social support, physical disability, mental disability, and pathologic status were assessed shortly after admission (within 24-48 hours). MAIN OUTCOME MEASURES: Outcome of hospitalisation was defined as discharge to home or residential/nursing home. RESULTS: The index, developed by multiple logistic regression, included six variables: the wish of patients' principal career about their returning home after acute hospitalisation, presence of a chronic condition, ability to perform toileting, ability to know the name of the hospital or the city, their age, and their living arrangements. The sensitivity of the index in identifying patients at high risk of requiring discharge to a residential/nursing home was 74.4%, the specificity 63.8% the positive predictive value was 57.8%, and the negative predictive value was 80.6%. CONCLUSIONS: The simple index, using data available very early in the course of hospitalisation, provides an accurate prediction of the hospitalisation outcome. The performance of the index should be tested in other populations and the practical benefits of risk screening should be assessed in a controlled trial to evaluate whether the intervention is useful and without any adverse effects.
Activities of Daily Living↗
Bladder exstrophy: evaluation of factors leading to continence with spontaneous voiding after staged reconstruction.
PURPOSE: We performed a long-term retrospective review of patients with bladder exstrophy to evaluate the results of staged surgical reconstruction in regard to urinary continence, spontaneous voiding and preservation of the upper urinary tract. MATERIALS AND METHODS: We reviewed the charts of 42 boys and 15 girls treated at Hôpital St. Joseph for bladder exstrophy between 1965 and 1995. All patients underwent staged repair, including bladder augmentation in 7 (12%) and secondary urinary diversion in 13 (23%). Criteria for good outcome in terms of continence are defined and factors influencing outcomes are reviewed. RESULTS: A total of 38 patients (67%) achieved good or acceptable urinary continence (22 or 39% and 16 or 28%, respectively). Outcome was poor in 19 patients, including 13 (23%) who underwent secondary urinary diversion. Bladder stones, which developed in 13 patients (23%), were the most common long-term complication of bladder exstrophy reconstruction. Ten patients who underwent pelvic osteotomies ultimately had better continence and 9 are dry. Bladder neck reconstruction was performed at a later age overall (mean 10 years). Repeat bladder neck reconstruction was generally associated with poor results. The technique of bladder neck reconstruction did not appear to influence outcome. CONCLUSIONS: A carefully planned surgical reconstruction for bladder exstrophy can lead to satisfactory long-term urinary continence in most patients. Factors contributing to successful results include early bladder closure, pelvic osteotomy, adequate bladder neck reconstruction with bladder neck suspension in girls, and a motivated child and family. Alternatives to surgical reconstruction should be discussed. Ultimate predictors of outcome in bladder exstrophy repair are difficult to ascertain.
Adolescent↗
Incidence and preventability of adverse events in the emergency room of an orthopaedic traumatologic surgery unit.
This paper reviews the nature and the frequency of adverse events in the everyday functioning of a French trauma emergency unit, and evaluates the feasibility of their detection by the means of a daily record review. A senior surgeon identified the adverse events by reviewing the complete record with a minimal 6-months follow-up for every patient attending the emergency unit during a 10-week period. To test the reliability of this review, a blind re-review of all records corresponding to the detected adverse events, mixed with an equal number of controls, was carried out by two independent experts. The review of the 2604 records identified 210 medical adverse events, most of them occurring early in the care process. Sixty-seven per cent of the adverse events involved prevention failure, mainly for tetanus but also for thrombosis and rabies. For the other 33% it was possible to determine two situations with a high risk of adverse event: body contusions following a traffic accident and metacarpo-phalangeal thumb sprains. The re-review evaluated the positive predictive value of the initial review to be 97.5% and its negative predictive value to be 96%. It is concluded that the review of the initial record by a single senior is effective in detecting the adverse events. Prevention of two-thirds of them could be possible by the implementation and monitoring of protocols.
Aftercare↗
Returning home after acute hospitalization in two French teaching hospitals: predictive value of patients' and relatives' wishes.
Identifying elderly patients who are unable to return home immediately after acute hospitalization is difficult. For these patients, early planning of discharge might reduce the length of hospitalization. We conducted a cohort study to investigate the roles of patients' characteristics and patients' and principal carers' wishes about patients returning home in predicting the outcome of hospitalization for 510 patients aged 75 years or more admitted to acute medical care units via the emergency departments of two teaching hospitals in Paris (France). Patients' characteristics and patients' and principal carers' wishes were investigated within 24-48 hours of admission. The outcome of hospitalization was defined as discharge to home or residential/nursing home. The opposition of the principal carer to a patient returning home was the most powerful predictor of discharge to a residential/nursing home. Advanced age, living alone, disability in Activities of Daily Living, altered mental state and presence of a chronic condition fatal within 4 years were also independently associated with discharge to a residential/nursing home. The patient's wishes were predictive in univariate but not in multivariate analysis. These results suggest that the principal carer's wishes about a patient returning home might be taken into consideration early in a hospital stay for more effective discharge planning.
Activities of Daily Living↗
[Hospital discharge planning and length of hospital stay in elderly patients admitted through the emergency department].
A prospective study was organized in two teaching hospitals in Paris, including 426 elderly patients aged 75 and more, who had been hospitalized through the medical emergency department. The goal of the study was to assess the influence of difficulties of orientation at discharge on the length of stay, independently of other risk factors. The mean length of stay was 18.3 +/- 15.4 days. Orientation at discharge toward a social or a nursing care institution was associated with a 12 days longer mean length of stay than a home discharge. A longer length of stay was also associated with: a strictly social problem at admission, the diagnoses of dementia, confusion, social problem, fall or general health impairment, a short or long-term fatal prognosis, a poor mental status, refusal of home discharge as expressed by the referent person. Multivariate analysis showed that discharge toward a social or a nursing care institution was the first explanatory factor, explaining 12% of variance. These results suggest that the hospital discharge management has a major influence on the elderly length of hospital stay. Therefore, an interdisciplinary care management, including social and geriatric evaluation as soon as the patient is admitted at the emergency department, should be evaluated, in order to avoid problems of orientation that may occur at discharge.
Age Factors↗
The impact of a comprehensive multi-dimensional geriatric assessment programme on duration of stay in a French acute medical ward.
The impact of a multi-dimensional geriatric assessment (MDGA) programme on the reorientation of the elderly person at discharge is described. One hundred and six elderly persons from a hospital catchment area identified for its poor level of social services, poor living conditions and high prevalence of dependency were allocated to either an experimental or control group. The experimental group was given the multi-dimensional assessment in the first three days of admission while the control group was subject to the usual hospital procedures. The study shows that the provision to the medical staff of easily obtained information relating to the individual's level of dependency and living conditions, in conjunction with recommendations for possible post-discharge placement, significantly reduced prolongation of stay due to non-medical reasons, albeit without a measurable impact on the whole duration of hospital stay.
Activities of Daily Living↗
[Prospective Payment Information Systems and epidemiology: a difficult link to establish].
This paper reviews the epidemiologic limitations to take into account when using data produced within the frame of the French Prospective Payment System for planning or medical evaluation purposes. Problems in describing medical data include completeness, reliability, granularity (precision) and sequencing. Referral bias hamper morbidity data collected at the institutional level. Differences in the case-mix may be due to the characteristics of the reference population but also to available equipment and variations in medical practice.
Bias↗
[Evaluation of the screening strategy for lead poisoning in 1-to-3-year-old children monitored in maternal-child welfare centers in Paris].
A procedure for screening for lead poisoning was implemented since 1987 in the maternal and child health centers of 6 Paris "arrondissements". It relies on a screening of the children through environmental and clinical information. Our study aimed at evaluating this procedure and at estimating the prevalence of lead poisoning in the children aged 1 to 3 years old attending free maternal and child health centers in Paris. We did a cross-sectional survey of a sample of 512 children. A questionnaire concerning each child's risk factors was answered by the paediatric nurses of the clinics. Potential lead poisoning cases were detected by capillary determining of free erythrocyte protoporphyrins (FEP). Blood lead level (PbB) was measured in children with FEP > or = 350 micrograms/l. The prevalence rate of lead poisoning was estimated at 1.9% +/- 1.7% for a PbB threshold > or = 250 micrograms/l and at 9.6% +/- 3.5% for a PbB threshold > or = 150 micrograms/l. The detection procedure identified 4 children out of 5 with a PbB > or = 250 micrograms/l and 2 children out of 3 with a PbB > or = 150 micrograms/l.
Child, Preschool↗
[Analysis of emergency recruitment in a pediatric hospital. Effect on the organization of available care].
BACKGROUND: The increasing demand on the emergency wards of pediatric hospitals raise the question of whether the services delivered are adequate for the explicit and implicit needs of outpatients. POPULATION AND METHODS: The files of all the 334 children consulting at the medical emergency ward of Robert-Debré hospital in Paris between April 19 and April 26, 1989 were analyzed. Socio-demographic data, reasons for visit and final diagnosis were collected. Each outpatient was assigned to one of 3 categories: 1) severe emergency; 2) simple emergency; 3) consultation. Further data on the events leading to the visit were obtained by a second survey covering 213 children seen between May 11 and May 14, 1991 from 8 hrs to 20 hrs. RESULTS: The mean age of the 334 children in the first survey was 3.2 years. Half of the mothers were unemployed. Half of the families was of foreign extraction. 3.4% of the children had no social insurance. Ten percent of the patients were frequent users of the emergency ward. Infectious diseases were the most prevalent reason for visit. Severe emergencies were 28%, simple emergencies 44% and consultations 28%. Among the 213 children of the second survey, half of the families had seen (43%) or attempted to see (7%) a physician outside the hospital before coming to the emergency ward. CONCLUSION: The needs of the children could best be met by performing a true medico-social examination at the medical emergency ward, enhancing access for children and revitalizing a partnership with the community to provide continuous care for those children in need of it.
Child, Preschool↗
Effectiveness of the daily record review at the medical emergency room department in a French teaching children's hospital.
We evaluate the effectiveness of the daily record review (DRR) of 4393 ambulatory medical patients seen at the emergency room department of a teaching pediatric hospital in Paris between 8th January and 11 March 1991. For these patients, 137 potential quality problems were found, 117 of them remaining after discussion with the junior. For 80 of the 117 confirmed problems (68.4%), the reviewing senior estimated that sufficient advice had been given to the child's usual caretaker or health care provider and (or) the children returned to seek medical advice when indicated. Experts proved the procedure to be reliable: they detected a problem for 36% of the cases with potential quality problems and for only 2% of a sample of control records considered without potential quality problems after the DRR.
Emergency Service, Hospital↗
[Causes and modalities of pediatric ambulatory care in ten hospitals in the Ile-de-France region].
BACKGROUND: The increasing shortage of financial resources requires optimal use of hospital care by patients. However, the studies carried out to date in France have been limited to patients who are hospitalized, and have not included those seen as out-patients. POPULATION AND METHODS: All patients seen as out-patients in 10 hospitals in the Paris district (3 pediatric hospitals and 7 pediatric departments located in hospitals for adults and children), during the week of 19-26 April 1989, were given a questionnaire on the age, sex, nationality, socio-cultural and economic features of the family, history of earlier medical visits or admissions, the existence of pediatrician or practitioner, and the means and time taken to get to the hospital. Medical diagnosis was established for each patient following the WHO International Classification of Diseases (9th edition). RESULTS: 2,365 out of 2,675 questionnaires were usable. The main features were: 50% of patients were less than 3 years old, 55% were of French origin; 78% belonged to families with relatively low socio-economic status. Both parents had professional activities in 49% of families, 7% of mothers did not speak or write French. The ratio of patients aged less than 3 years admitted to the emergency ward was higher than the average. The most frequent diseases presented by these patients were respiratory (23%), infectious (14%), gastro-intestinal (10%) and neurological (7%); 14% of the patients were seen for symptoms that could not be assigned to a specific disease. 39% of patients were seen in out-patient clinics and 61% in emergency wards. 40% were sent by a health professional to out-patient clinics and only 25% to emergency wards. CONCLUSIONS: Despite the fact that this study is subject to particular conditions, i.e., relative frequency of infectious diseases due to seasonal causes, it suggests that the hospital is becoming the primary source of health care with an increasing percentage of patients seen in "emergency", even though this emergency is often more apparent than real. Health care networks should be established.
Ambulatory Care↗
Alcohol: an underscored risk factor for diabetes mellitus.
OBJECTIVE: To investigate the link between alcohol consumption and glycoregulation. PATIENTS AND METHODS: Cross-sectional study during the annual occupational health check-up at the work site, concerning 7402 workers, excluding known diabetic persons and pregnant women. Alcohol consumption was recorded as the number of glasses of alcoholic beverage per day as stated by the subjects. A proxy for the glycoregulation was the level of capillary blood glucose measured with a reflectance meter (Reflolux) at the time of the visit. The association of alcohol consumption with impaired glycoregulation was assessed by multivariate analysis including potential confounders. RESULTS: Mean capillary blood glucose increased with increasing alcohol consumption, in both men and women. This association remained significant (p < 0.001) after adjustment for risk factors (multiple linear regression). Among 366 subjects with a fasting glycaemia or an oral glucose tolerance test, 26 were diabetic. Alcohol consumption was found independently associated by logistic regression with diabetes mellitus. CONCLUSION: Alcohol consumption might be a target for primary and secondary prevention of impaired glycoregulation and diabetes mellitus.
Adult↗