Instal·lacions de baix risc de proliferació i dispersió de legionel·la: anàlisi de circuits i eines de control

Legionel·la; Control oficial; Seguretat ambientalLegionela; Control oficial; Seguridad ambientalLegionella; Official control; Environmental securityAquesta Comunitat de Pràctica (CoP) es va crear amb l’objectiu de disposar d’uns documents, consensuats per tècnics de les diferents administracions implicades en el control i la prevenció de la legionel·losi (ASPCAT, DIBA, municipis, i, fins i tot, el Govern andorrà), perquè siguin una eina pràctica de treball. En un mateix model s’inclou la normativa, la informació ja disponible i les recomanacions tècniques per a aquells paràmetres que no conté ni la normativa ni la informació complementària ja disponible. D’una banda, aquests documents han de permetre la inspecció, tant als tècnics de l’ASPCAT com als tècnics municipals i/o a altres institucions encarregades de fer aquestes tasques. D’una altra banda, han de servir per donar suport a tots els agents implicats en la gestió i el control d’aquestes instal·lacions de baix risc. Presentem la documentació generada fins ara. Som conscients que no està del tot acabada i esperem que aquesta CoP tingui la continuïtat necessària per tal de concloure aquests documents i, si és possible, d’ampliar-los a altres instal·lacions de baix risc. Esperem que això ajudi a millorar l’estat higienicosanitari de les instal·lacions considerades de baix risc i a disminuir els brots i els casos de legionel·losi que, en els darrers anys, s’ha detectat que podrien ser les principals causants d’aquesta malaltia al nostre territori.Esta Comunidad de Práctica (CoP) se creó con el objetivo de disponer de unos documentos, consensuados por técnicos de las diferentes administraciones implicadas en el control y la prevención de la legionelosis (ASPCAT, DIBA, municipios, y, hasta y todo, el Gobierno andorrano), para que sean una herramienta práctica de trabajo. En un mismo modelo se incluye la normativa, información ya disponible y recomendaciones técnicas para aquellos parámetros que no contiene ni la normativa ni la información complementaria ya disponible. Por un lado, estos documentos deben permitir la inspección, tanto a los técnicos de la ASPCAT como a los técnicos municipales y/oa otras instituciones encargadas de realizar estas tareas. Por otro lado, deben servir para apoyar a todos los agentes implicados en la gestión y control de estas instalaciones de bajo riesgo. Presentamos la documentación generada hasta ahora. Somos conscientes de que no está del todo terminada y esperamos que esta CoP tenga la continuidad necesaria para concluir estos documentos y, si es posible, ampliarlos a otras instalaciones de bajo riesgo. Esperamos que esto ayude a mejorar el estado higiénico-sanitario de las instalaciones consideradas de bajo riesgo ya disminuir los brotes y los casos de legionelosis que, en los últimos años, se ha detectado que podrían ser las principales causantes de ésta enfermedad en nuestro territorio.This Community of Practice (CoP) was created with the aim of having some documents agreed upon by technicians from the different administrations involved in the control and prevention of legionellosis (ASPCAT, DIBA, municipalities, and, even and all, the Government Andorran), so that they are a practical work tool. The same model includes the regulations, information already available and technical recommendations for those parameters that neither the regulations nor the complementary information already available contain. On the one hand, these documents must allow inspection, both by ASPCAT technicians and by municipal technicians and/or other institutions in charge of carrying out these tasks. On the other hand, they must serve to support all the agents involved in the management and control of these low-risk facilities. We present the documentation generated so far. We are aware that it is not completely finished and we hope that this CoP will have the necessary continuity to finalize these documents and, if possible, extend them to other low-risk facilities. We hope this will help improve the hygienic-sanitary status of facilities considered low risk and reduce outbreaks and cases of legionellosis which, in recent years, have been found to be the main causes of this disease in our territory

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Prospective observational cohort study on grading the severity of postoperative complications in global surgery research

Background The Clavien–Dindo classification is perhaps the most widely used approach for reporting postoperative complications in clinical trials. This system classifies complication severity by the treatment provided. However, it is unclear whether the Clavien–Dindo system can be used internationally in studies across differing healthcare systems in high- (HICs) and low- and middle-income countries (LMICs). Methods This was a secondary analysis of the International Surgical Outcomes Study (ISOS), a prospective observational cohort study of elective surgery in adults. Data collection occurred over a 7-day period. Severity of complications was graded using Clavien–Dindo and the simpler ISOS grading (mild, moderate or severe, based on guided investigator judgement). Severity grading was compared using the intraclass correlation coefficient (ICC). Data are presented as frequencies and ICC values (with 95 per cent c.i.). The analysis was stratified by income status of the country, comparing HICs with LMICs. Results A total of 44 814 patients were recruited from 474 hospitals in 27 countries (19 HICs and 8 LMICs). Some 7508 patients (16·8 per cent) experienced at least one postoperative complication, equivalent to 11 664 complications in total. Using the ISOS classification, 5504 of 11 664 complications (47·2 per cent) were graded as mild, 4244 (36·4 per cent) as moderate and 1916 (16·4 per cent) as severe. Using Clavien–Dindo, 6781 of 11 664 complications (58·1 per cent) were graded as I or II, 1740 (14·9 per cent) as III, 2408 (20·6 per cent) as IV and 735 (6·3 per cent) as V. Agreement between classification systems was poor overall (ICC 0·41, 95 per cent c.i. 0·20 to 0·55), and in LMICs (ICC 0·23, 0·05 to 0·38) and HICs (ICC 0·46, 0·25 to 0·59). Conclusion Caution is recommended when using a treatment approach to grade complications in global surgery studies, as this may introduce bias unintentionally

The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis

© 2017 British Journal of Anaesthesia Background: The surgical safety checklist is widely used to improve the quality of perioperative care. However, clinicians continue to debate the clinical effectiveness of this tool. Methods: Prospective analysis of data from the International Surgical Outcomes Study (ISOS), an international observational study of elective in-patient surgery, accompanied by a systematic review and meta-analysis of published literature. The exposure was surgical safety checklist use. The primary outcome was in-hospital mortality and the secondary outcome was postoperative complications. In the ISOS cohort, a multivariable multi-level generalized linear model was used to test associations. To further contextualise these findings, we included the results from the ISOS cohort in a meta-analysis. Results are reported as odds ratios (OR) with 95% confidence intervals. Results: We included 44 814 patients from 497 hospitals in 27 countries in the ISOS analysis. There were 40 245 (89.8%) patients exposed to the checklist, whilst 7508 (16.8%) sustained ≥1 postoperative complications and 207 (0.5%) died before hospital discharge. Checklist exposure was associated with reduced mortality [odds ratio (OR) 0.49 (0.32–0.77); P\u3c0.01], but no difference in complication rates [OR 1.02 (0.88–1.19); P=0.75]. In a systematic review, we screened 3732 records and identified 11 eligible studies of 453 292 patients including the ISOS cohort. Checklist exposure was associated with both reduced postoperative mortality [OR 0.75 (0.62–0.92); P\u3c0.01; I2=87%] and reduced complication rates [OR 0.73 (0.61–0.88); P\u3c0.01; I2=89%). Conclusions: Patients exposed to a surgical safety checklist experience better postoperative outcomes, but this could simply reflect wider quality of care in hospitals where checklist use is routine

Critical care admission following elective surgery was not associated with survival benefit: prospective analysis of data from 27 countries

This was an investigator initiated study funded by Nestle Health Sciences through an unrestricted research grant, and by a National Institute for Health Research (UK) Professorship held by RP. The study was sponsored by Queen Mary University of London