Le corps des directeurs d'hôpital : Entre logique professionnelle et régulation d'Etat

International audienc

Etude évaluative de l'activité et de la réalisation du projet médical de l'Hôpital Yves Lanco de Belle-Ile.

International audienceAu printemps de l'année 1992, l'hôpital Yves Lanco avait fait appel à une équipe pluridisciplinaire de l'Ecole Nationale de la Santé Publique pour l'aider à élaborer son projet médical. Le rapport d'étude proposait deux lignes directrices : 1) répondre adéquatement aux problèmes de santé des Bellilois et des visiteurs de l'Ile ; 2) mettre l'hôpital au centre d'un réseau de services sociaux et sanitaires de qualité pour les résidents de Belle-Ile. Le projet d'établissement qui a été adopté s'est structuré autour de ces deux axes. Il a pris fin en 1998. Par un courrier du 24 février 1998, le directeur de l'hôpital Yves Lanco demandait à l'Ecole Nationale de la Santé Publique de "mesurer les effets" du projet médical et de "fixer les orientations de ce que pourrait être le futur projet d'établissement". Plus précisément, il a été demandé d'évaluer de façon objective en quoi les lignes directrices de 1992 ont été suivies, tout particulièrement pour ce qui a trait à la pratique soignante

Etude évaluative de l'activité et de la réalisation du projet médical de l'Hôpital Yves Lanco de Belle-Ile.

International audienceAu printemps de l'année 1992, l'hôpital Yves Lanco avait fait appel à une équipe pluridisciplinaire de l'Ecole Nationale de la Santé Publique pour l'aider à élaborer son projet médical. Le rapport d'étude proposait deux lignes directrices : 1) répondre adéquatement aux problèmes de santé des Bellilois et des visiteurs de l'Ile ; 2) mettre l'hôpital au centre d'un réseau de services sociaux et sanitaires de qualité pour les résidents de Belle-Ile. Le projet d'établissement qui a été adopté s'est structuré autour de ces deux axes. Il a pris fin en 1998. Par un courrier du 24 février 1998, le directeur de l'hôpital Yves Lanco demandait à l'Ecole Nationale de la Santé Publique de "mesurer les effets" du projet médical et de "fixer les orientations de ce que pourrait être le futur projet d'établissement". Plus précisément, il a été demandé d'évaluer de façon objective en quoi les lignes directrices de 1992 ont été suivies, tout particulièrement pour ce qui a trait à la pratique soignante

INDI 67. Developments of Indicators to improve monitoring of MSFD descriptors 6 and 7 (INDI67) : final report

Context To protect the marine environment more effectively, the European Union adopted the Marine Strategy Framework Directive (MSFD) in 2008, aiming to achieve the Good Environmental Status (GES) of the EU's marine waters by 2020 and to protect the resource base upon which marine-related economic and social activities depend. A major challenge in the implementation of the MSFD is to achieve the necessary scientific knowledge on the marine environment, its processes and the methods to monitor them. The focus of INDI67 is on the evaluation and development of indicators to monitor GES of descriptor 6 and 7. Seafloor integrity (descriptor 6) refers to the structure and functions of the benthic ecosystems. It relates to the comprises physical, chemical and biological properties as well as to spatial and temporal connectedness, avoiding artificial fragmentation of habitats or temporal sealing due to ephemeral sediment deposits or armouring. Hydrographic conditions (descriptor 7) imply that the nature and scale of any long-term changes to the prevailing hydrographical conditions resulting from anthropogenic activities (individual and cumulative), do not lead to significant negative impacts on the benthic and pelagic habitats, functioning or on hydro-geomorphological impacts on the seabed. Objectives The overall objective of INDI67 is to develop and evaluate tools and methods to support the monitoring of MSFD descriptors 6 and 7. The subject is the monitoring of seafloor integrity and hydrography using both modelling and measurements of hydro- and sediment dynamic processes and seabed characteristics. Three parameters have been selected as key indicator, i.e. turbidity, bottom shear stress and seabed/habitat type. These parameters are all related to sea floor dynamics and are strongly linked as changes in seafloor integrity and turbidity occur as a result of the combined force that waves and currents exert on the sea floor. Furthermore, they are witnesses of changes induced by human activities (dredging/disposal, aggregate extraction, constructions, fishery). Turbidity (used both in terms of suspended particulate matter(SPM) concentration and light availability) and bottom shear stress are currently measured and modelled. Bottom shear stress and seabed/habitat type are included in the Belgian MSFD monitoring programme, while turbidity is not yet included as GES indicator. Conclusions The major conclusion with respect to the measuring and modelling of the key indicators turbidity/SPMC, bottom shear stress and seabed/habitat type are: 1) Despite calibration to a reference solution and the use of ISO-normed optical turbidity sensors, model calibration may vary considerably in recorded turbidity for a same SPMC solution across different instruments resulting in instrument-specific turbidity-SPMC relation. Turbidity (or dB for acoustic sensors) should therefore not be used as it is not standardized and will diminish the comparability of the data. Instead, the optical and acoustic sensor output should be transformed into a mass concentration, a unit that is comparable in time and between regions. Monitoring in situ SPMC should follow common guidance and protocols to restrict their measurement uncertainties. The main challenge is now to evaluate model results uncertainty and improve the formulation of natural processes, such as flocculation and bottom shear stress, together with the effects of pressures in the models

Le moment RCB ou le rêve d’un gouvernement rationnel 1962-1978

Lancée en France en 1968, la rationalisation des choix budgétaires, dite RCB, constitue une séquence importante des politiques de réforme de l’État sous la Ve République. Elle est la première tentative d’une introduction généralisée du management dans la gestion des finances publiques. Croisant les approches d’historiens, de sociologues, de politistes et de juristes, cet ouvrage rassemble des enquêtes originales qui analysent les nombreuses dimensions de cette politique  : la genèse et le développement des savoirs et des techniques de rationalisation des choix budgétaires ; le processus de réforme, les coalitions et les luttes de pouvoir au sein de l’appareil d’État auxquelles il donne lieu ; enfin, son institutionnalisation dans l’administration française, ainsi que les appropriations variées dont la RCB a fait l’objet dans les différents ministères. Ce livre est le troisième volume d’une série d’ouvrages sur l’histoire de la gestion des finances publiques au xixe et au xxe siècle. Le premier volume (1815‑1914) étudiait le développement intriqué d’un droit public financier et des premiers instruments gestionnaires lui donnant corps dans l’administration. Le deuxième volume (1917‑1967) mettait en évidence la figure dominante du contrôle, sous toutes ses formes, appliqué à la dépense et à la gestion des services publics. En étudiant les dynamiques de réforme rangées sous le nom de rationalisation des choix budgétaires, le présent ouvrage montre comment la RCB se situe à la charnière de deux périodes et de deux conceptions du pilotage de l’État central : celle de la planification et des instruments de programmation de l’action publique ; celle du management public et du développement des méthodes modernes de gestion

Additional file 1 of Prevention of post-operative delirium using an overnight infusion of dexmedetomidine in patients undergoing cardiac surgery: a pragmatic, randomized, double-blind, placebo-controlled trial

Additional file 1. Table S1. Minimum and maximum dose of dexmedetomidine and its corresponding placebo administered every night (from 8 pm to 8 am) from Day 0 to Day 7. Table S2. All concomitant treatments administered from inclusion to Day 7 in both groups. Table S3. Main reason why CAM-ICU assessment and sleep quality evaluation were not performed or missing from Day 1 to Day 7. Table S4. Comparison of dexmedetomidine versus placebo on secondary outcomes: daily evaluation of sleep quality. Data are expressed as median and IQR. Table S5. Comparison of dexmedetomidine versus placebo on secondary outcomes: detailed sections of LSEQ during the 7 days of observation. Data are expressed as median and IQR. Table S6. Baseline creatinine level and daily renal component of the SOFA (Sequential Organ Failure Assessment) score. Table S7. Preplanned sub-group analysis for the primary outcome. Occurrence of PoD within the 7 days after surgery are expressed as number (%). Appendix 1. The cognitive failures questionnaire. Appendix 2. The PCL-5 standard form checklist. Appendix 3. The Leeds Sleep Evaluation Questionnaire (LSEQ). Each item is rated from -5 to +5. Negative score corresponded to negative effects on sleep quality

Impact of continuous hypertonic (NaCl 20%) saline solution on renal outcomes after traumatic brain injury (TBI): a post hoc analysis of the COBI trial

Abstract Background To evaluate if the increase in chloride intake during a continuous infusion of 20% hypertonic saline solution (HSS) is associated with an increase in the incidence of acute kidney injury (AKI) compared to standard of care in traumatic brain injury patients. Methods In this post hoc analysis of the COBI trial, 370 patients admitted for a moderate-to-severe TBI in the 9 participating ICUs were enrolled. The intervention consisted in a continuous infusion of HSS to maintain a blood sodium level between 150 and 155 mmol/L for at least 48 h. Patients enrolled in the control arm were treated as recommended by the latest Brain Trauma foundation guidelines. The primary outcome of this study was the occurrence of AKI within 28 days after enrollment. AKI was defined by stages 2 or 3 according to KDIGO criteria. Results After exclusion of missing data, 322 patients were included in this post hoc analysis. The patients randomized in the intervention arm received a significantly higher amount of chloride during the first 4 days (intervention group: 97.3 ± 31.6 g vs. control group: 61.3 ± 38.1 g; p < 0.001) and had higher blood chloride levels at day 4 (117.9 ± 10.7 mmol/L vs. 111.6 ± 9 mmol/L, respectively, p < 0.001). The incidence of AKI was not statistically different between the intervention and the control group (24.5% vs. 28.9%, respectively; p = 0.45). Conclusions Despite a significant increase in chloride intake, a continuous infusion of HSS was not associated with AKI in moderate-to-severe TBI patients. Our study does not confirm the potentially detrimental effect of chloride load on kidney function in ICU patients. Trial registration: The COBI trial was registered on clinicaltrial.gov (Trial registration number: NCT03143751, date of registration: 8 May 2017)

Prevention of post-operative delirium using an overnight infusion of dexmedetomidine in patients undergoing cardiac surgery: a pragmatic, randomized, double-blind, placebo-controlled trial

International audienceBackground: After cardiac surgery, post-operative delirium (PoD) is acknowledged to have a significant negative impact on patient outcome. To date, there is no valuable and specific treatment for PoD. Critically ill patients often suffer from poor sleep condition. There is an association between delirium and sleep quality after cardiac surgery. This study aimed to establish whether promoting sleep using an overnight infusion of dexmedetomidine reduces the incidence of delirium after cardiac surgery.Methods: Randomized, pragmatic, multicentre, double-blind, placebo controlled trial from January 2019 to July 2021. All adult patients aged 65 years or older requiring elective cardiac surgery were randomly assigned 1:1 either to the dexmedetomidine group or the placebo group on the day of surgery. Dexmedetomidine or matched placebo infusion was started the night after surgery from 8 pm to 8 am and administered every night while the patient remained in ICU, or for a maximum of 7 days. Primary outcome was the occurrence of postoperative delirium (PoD) within the 7 days after surgery.Results: A total of 348 patients provided informed consent, of whom 333 were randomized: 331 patients underwent surgery and were analysed (165 assigned to dexmedetomidine and 166 assigned to placebo). The incidence of PoD was not significantly different between the two groups (12.6% vs. 12.4%, p = 0.97). Patients treated with dexmedetomidine had significantly more hypotensive events (7.3% vs 0.6%; p &lt; 0.01). At 3 months, functional outcomes (Short-form 36, Cognitive failure questionnaire, PCL-5) were comparable between the two groups.Conclusion: In patients recovering from an elective cardiac surgery, an overnight infusion of dexmedetomidine did not decrease postoperative delirium. Trial registration This trial was registered on ClinicalTrials.gov (number: NCT03477344; date: 26th March 2018)