Evaluation du dispositif d'urgences sociales EMUS

Le concept EMUS (équipe mobile d'urgences sociales) trouve son origine dans la réunion consacrée à l'urgence sociale qui s'est tenue en fin d'année 2009 et dans le rapport sur la création de l'équipe mobile d'urgence établi en été 2010 à la suite de cette réunion. Le Département de la santé et de l'action sociale (DSAS) a mandaté l'IUMSP pour effectuer une évaluation accompagnante du projet dans sa phase pilote pour: Accompagner le projet par des bilans intermédiaires dans le but d'effectuer des ajustements du projet ; Mesurer l'impact du projet ; Évaluer le dispositif en place ; Évaluer le fonctionnement du dispositif ; Évaluer ses interventions. Les résultats de cette évaluation sont présentés dans le présent rapport. Des résultats intermédiaires (quantitatifs et qualitatifs) ont également été présentés au comité de pilotage de l'évaluation sous forme orale (présentations PowerPoint suivies d'une discussion), et cela à deux reprises (septembre 2012 et juin 2013). Une synthèse de ces résultats intermédiaires peut être consultée à l'annexe 8.

Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study

Background During paravertebral block, the anterolateral limit of the paravertebral space, which consists of the pleura, should preferably not be perforated. Also it is possible that, during the block, the constant superior costotransverse ligament can be missed in the loss-of-resistance technique. We therefore aimed to develop a new technique for an ultrasound-guided puncture of the paravertebral space. Methods We performed 20 punctures and catheter placements in 10 human cadavers. A sonographic view showing the pleura and the superior costotransverse ligament was obtained with a slightly oblique scan using a curved array transducer. After inline approach, injection of 10 ml normal saline confirmed the correct position of the needle tip, distended the space, and enabled catheter insertion. The spread of contrast dye injected through the catheters was assessed by CT scans. Results The superior costotransverse ligament and the paravertebral space were easy to identify. The needle tip reached the paravertebral space without problems under visualization. In contrast, the introduction of the catheter was difficult. The CT scan revealed a correct paravertebral spread of contrast in 11 cases. Out of the remaining, one catheter was found in the pleural space, in six cases there was an epidural, and in two cases there was a prevertebral spread of contrast dye. Conclusions We successfully developed a technique for an accurate ultrasound-guided puncture of the paravertebral space. We also showed that when a catheter is introduced through the needle with the tip lying in the paravertebral space, there is a high probability of catheter misplacement into the epidural, mediastinal, or pleural space

Ultrasound-guided thoracic paravertebral puncture and placement of catheters in human cadavers: where do catheters go?†

Background Paravertebral regional anaesthesia is used to treat pain after several surgical procedures. This study aimed to improve on our first published ultrasound-guided approach to the paravertebral space (PVS) and to investigate a possible discrepancy between the needle, catheter, and contrast dye position. Methods In 10 cadavers, we conducted 26 ultrasound-guided paravertebral approaches combined with loss of resistance (LOR) and after an interim analysis performed 36 novel, pure ultrasound-guided (PUSG) paravertebral approaches. Needle-tip position was controlled by a first computed tomography (CT) scan. After placement of the catheters, the tips were assessed by a second CT and the spread of injected contrast dye was assessed by further CT scans. The part of the PVS near the intervertebral foramen was defined as the primary target to reach. Results The first CT scans assessing 62 needle tips revealed that: 13 (50%) of LOR and 34 (94%) of PUSG approaches were at the target; and two (8%) LOR and no PUSG approaches were outside the PVS. With the second CT scans 60 catheter-tip positions were analysed: three (12%) of LOR and five (14%) of PUSG approaches were at the target, three (12%) of LOR and two (6%) of PUSG approaches were outside the PVS. No catheters were detected in the epidural space. In two cases, insertion of the catheter was not possible. In cases with major epidural contrast, the widest contrast dye spread was 7.7 (3.5) [mean (sd)] vertebral segments. Conclusions Our new PUSG technique has a high success rate for paravertebral needle placement. Although needles were correctly positioned, catheters were usually found distant from the needle-tip positio

Ultrasound-guided percutaneous tracheal puncture: a computer-tomographic controlled study in cadavers

Background Ultrasound-guided techniques are increasingly used in anaesthetic practice to identify tissues beneath the skin and to increase the accuracy of placement of needles close to targeted structures. To examine ultrasound's usefulness for dilatational tracheostomy, we performed ultrasound-guided tracheal punctures in human cadavers followed by computer-tomographic (CT) control. Methods The trachea of nine cadavers was punctured using an in-plane approach with a longitudinal ultrasound visualization of the trachea. As soon as a loss of resistance was felt, or air/fluid could be aspirated into the attached syringe, the syringe was disconnected and the ultrasound transducer set aside. Thereafter, a cricothyroidotomy guidewire was inserted through the needle into the trachea. The needle was then removed, leaving the wire in place and a control CT imaging of the neck and the chest was performed. Primary outcome was successful wire insertion into the trachea. Results Tracheal puncture and wire insertion was successful in eight of nine cadavers at the first attempt and in one at the second attempt (total of 10 puncture attempts, nine successful). In eight of nine successfully inserted wires, the wire was placed on the defined midline. Conclusions Ultrasound guidance can facilitate successful tracheal puncture. However, combining an in-plane approach with a longitudinal ultrasound visualization of the trachea neither guarantees an exact midline puncture nor allows detection of a misplaced guidewir

Prevalence of multimorbidity in general practice: a cross-sectional study within the Swiss Sentinel Surveillance System (Sentinella).

To estimate the prevalence of multimorbidity using a list of 75 chronic conditions derived from the International Classification for Primary Care, Second edition and developed specifically to assess multimorbidity in primary care. Our aim was also to provide prevalence data for multimorbidity in primary care in a country in which general practitioners (GPs) do not play a gatekeeping role in the health system. A representative sample of GPs within the Swiss Sentinel Surveillance Network. 118 GPs completed a paper-based questionnaire about 25 consecutive patients of all ages between September and November 2015. There were no patient exclusion criteria. Recorded data included date of birth, gender and the patients' chronic conditions. We estimated the prevalence of multimorbidity, defined as ≥2, and ≥3 chronic conditions stratified by gender and age group, and adjusted for clustering by GPs. We also computed the prevalence of each chronic condition individually and grouped by system. Data from 2904 patients were included (mean age (SD)=56.5 (20.5) years; male=43.7%). Prevalence was 52.1% (95% CI 48.6% to 55.5%) for ≥2 and 35.0% (95% CI 31.6% to 38.5%) for ≥3 chronic conditions, with no significant gender differences. Prevalence of two or more chronic conditions was low (6.2%, 95% CI 2.8% to 13.0%) in those below 20 but affected more than 85% (85.8%, 95% CI 79.6% to 90.3%) of those above the age of 80. The most prevalent conditions were cardiovascular (42.7%, 95% CI 39.7% to 45.7%), psychological (28.5%, 95% CI 26.1% to 31.1%) and metabolic or endocrine disorders (24.1%, 95% CI 21.6% to 26.7%). Elevated blood pressure was the most prevalent cardiovascular condition and depression the most common psychological disorder. In a country in which GPs do not play a gatekeeping role within the health system, the prevalence of multimorbidity, as assessed using a list of chronic conditions specifically relevant to primary care, is high and increases with age

Comparing the self-perceived quality of life of multimorbid patients and the general population using the EQ-5D-3L.

To assess and compare the self-perceived Health Related Quality of Life (HRQoL) of multimorbid patients and the general population using health utilities (HU) and visual analogue scale (VAS) methods. We analyzed data (n = 888) from a national, cross-sectional Swiss study of multimorbid patients recruited in primary care settings. Self-perceived HRQoL was assessed using the EQ-5D-3L instrument, composed of 1) a questionnaire on the five dimensions of mobility, self-care, usual activities, pain/discomfort, and anxiety/depression (EQ-5D dimensions), and 2) a 0-100 (0 = worst- and 100 = best-imaginable health status) VAS. We described the EQ-5D dimensions and VAS and computed HU using a standard pan-European value set. HU and VAS are the two components of the overall HRQoL assessment. We examined the proportions of multimorbid patients reporting problems (moderate/severe) in each EQ-5D dimension, corresponding proportions without problems, and mean HU and VAS values across patient characteristics. To test differences between subgroups, we used chi-square tests for dichotomous outcomes and T-tests (ANOVA if more than two groups) for continuous outcomes. Finally, we compared observed and predicted HU and VAS values. All 888 participants answered every EQ-5D item. Mean (SD) HU and VAS values were 0.70 (0.18) and 63.2 (19.2), respectively. HU and VAS were considerably and significantly lower in multimorbid patients than in the general population and were also lower in multimorbid patients below 60 years old and in women. Differences between observed and predicted means (SD) were -0.07 (0.18) for HU and -11.8 (20.3) for VAS. Self-perceived HRQoL is considerably and significantly affected by multimorbidity. More attention should be given to developing interventions that improve the HRQoL of multimorbid patients, particularly women and those aged below 60 years old

Multimorbidity and patterns of chronic conditions in a primary care population in Switzerland: a cross-sectional study

To characterise in details a random sample of multimorbid patients in Switzerland and to evaluate the clustering of chronic conditions in that sample. 100 general practitioners (GPs) each enrolled 10 randomly selected multimorbid patients aged ≥18 years old and suffering from at least three chronic conditions. The prevalence of 75 separate chronic conditions from the International Classification of Primary Care-2 (ICPC-2) was evaluated in these patients. Clusters of chronic conditions were studied in parallel. The final database included 888 patients. Mean (SD) patient age was 73.0 (12.0) years old. They suffered from 5.5 (2.2) chronic conditions and were prescribed 7.7 (3.5) drugs; 25.7% suffered from depression. Psychological conditions were more prevalent among younger individuals (≤66 years old). Cluster analysis of chronic conditions with a prevalence ≥5% in the sample revealed four main groups of conditions: (1) cardiovascular risk factors and conditions, (2) general age-related and metabolic conditions, (3) tobacco and alcohol dependencies, and (4) pain, musculoskeletal and psychological conditions. Given the emerging epidemic of multimorbidity in industrialised countries, accurately depicting the multiple expressions of multimorbidity in family practices' patients is a high priority. Indeed, even in a setting where patients have direct access to medical specialists, GPs nevertheless retain a key role as coordinators and often as the sole medical reference for multimorbid patients

Ultrasound-guided paravertebral puncture and placement of catheters in human cadavers: an imaging study

BACKGROUND: During paravertebral block, the anterolateral limit of the paravertebral space, which consists of the pleura, should preferably not be perforated. Also it is possible that, during the block, the constant superior costotransverse ligament can be missed in the loss-of-resistance technique. We therefore aimed to develop a new technique for an ultrasound-guided puncture of the paravertebral space. METHODS: We performed 20 punctures and catheter placements in 10 human cadavers. A sonographic view showing the pleura and the superior costotransverse ligament was obtained with a slightly oblique scan using a curved array transducer. After inline approach, injection of 10 ml normal saline confirmed the correct position of the needle tip, distended the space, and enabled catheter insertion. The spread of contrast dye injected through the catheters was assessed by CT scans. RESULTS: The superior costotransverse ligament and the paravertebral space were easy to identify. The needle tip reached the paravertebral space without problems under visualization. In contrast, the introduction of the catheter was difficult. The CT scan revealed a correct paravertebral spread of contrast in 11 cases. Out of the remaining, one catheter was found in the pleural space, in six cases there was an epidural, and in two cases there was a prevertebral spread of contrast dye. CONCLUSIONS: We successfully developed a technique for an accurate ultrasound-guided puncture of the paravertebral space. We also showed that when a catheter is introduced through the needle with the tip lying in the paravertebral space, there is a high probability of catheter misplacement into the epidural, mediastinal, or pleural spaces

Determinants associated with deprivation in multimorbid patients in primary care-A cross-sectional study in Switzerland

Deprivation usually encompasses material, social, and health components. It has been shown to be associated with greater risks of developing chronic health conditions and of worse outcome in multimorbidity. The DipCare questionnaire, an instrument developed and validated in Switzerland for use in primary care, identifies patients subject to potentially higher levels of deprivation. To identifying determinants of the material, social, and health profiles associated with deprivation in a sample of multimorbid, primary care patients, and thus set priorities in screening for deprivation in this population. Secondary analysis from a nationwide cross-sectional study in Switzerland. A random sample of 886 adult patients suffering from at least three chronic health conditions. The outcomes of interest were the patients' levels of deprivation as measured using the DipCare questionnaire. Classification And Regression Tree analysis identified the independent variables that separated the examined population into groups with increasing deprivation scores. Finally, a sensitivity analysis (multivariate regression) confirmed the robustness of our results. Being aged under 64 years old was associated with higher overall, material, and health deprivation; being aged over 77 years old was associated with higher social deprivation. Other variables associated with deprivation were the level of education, marital status, and the presence of depression or chronic pain. Specific profiles, such as being younger, were associated with higher levels of overall, material, and health deprivation in multimorbid patients. In contrast, patients over 77 years old reported higher levels of social deprivation. Furthermore, chronic pain and depression added to the score for health deprivation. It is important that GPs consider the possibility of deprivation in these multimorbid patients and are able to identify it, both in order to encourage treatment adherence and limit any forgoing of care for financial reasons

The Intervisions cliniques continuing medical education program: A forum for exchange and mutual knowledge development between general practitioners and psychiatrists

Objective This article presents the Intervisions cliniques program, a continuing Medical Education (CME) initiative for psychiatrists and general practitioners which uses case discussion to foster the acquisition of mental health care knowledge. Method This project is a case study, using qualitative methods. An operational model of Intervisions Cliniques was drawn for analysis. Data mainly come from the program-related literature, direct observation and interviews with 9 key actors, assembled in 2 groups of promoters and participants of the program. Findings The findings help to define the context and vision in which the Intervisions cliniques program was set up and implemented, to identify the perceived benefits and disappointments with regard to the program. Set up in the Canadian public managed care system and university-affiliated hospital, the Intervisions cliniques program helps to create lines of communication and privileged exchanges between general practitioners and psychiatrists as well as to foster mutual knowledge and a crosscutting and interactive view within a shared clinical territory. Several benefits noted by the participants and the organizing committee demonstrate the importance and multimodal effects of this type of initiative. The case-discussion format used as a CME method meets the training needs of general practitioners and is widely appreciated. However, the pressing needs expressed by the general practitioners with regard to improving shared mental health care still pose many challenges. Conclusions Making the link with the duties of responding psychiatrists, who are now funded in Québec, seems to be part of the solution. Maintaining and disseminating the Intervisions Cliniques program will require provincial-wide system implementation strategies to train psychiatrist, support them and regional managers to monitor the quality of this innovative practice within a public managed care system. Clinical implications • In the context of Continuing Medical Education (CME), case discussions are valued because they help to address the full complexity of clinical situations. • In the development of shared mental health care, direct contacts between general practitioners and psychiatrists are an optimal way to foster mutual knowledge and a crosscutting and interactive view within a shared clinical territory. • The Intervisions cliniques program contributes to shared mental health care and is a CME strategy that should be reproduced. Limitations • The operational model presented cannot identify all the links which unite the structures, processes and effects of the Intervisions cliniques program. • Interviews with local and regional managers would have helped to better determine all the issues involved in maintaining and generalizing the Intervisions cliniques program. • Clinical examples illustrating experiences of shared mental health care following participation in the Intervisions cliniques program would have helped to better determine what contribution the Intervisions cliniques program has made to shared mental health care