Bakterien Clostridium difficile er en av de hyppigste årsakene til  sykehusrelatert diaré. Symptomene skyldes endringer av tarmens normale  bakterieflora på grunn av antibiotikabehandling. Pasienter med svekket  immunforsvar er spesielt utsatt og spredning av bakterien i en  helseinstitusjon vil være særlig uheldig – men dette er mulig å  forebygge.

Amerikansk rapport

Ifølge en ny  rapport utgitt av amerikanske Agency for Healthcare Research and Quality (AHRQ) kan probiotika og en dose av en annen persons avføring  (fecestransplantasjon) gjenopprette normal tarmflora og derved forebygge infeksjon med Clostridium difficile. Standardbehandling er fortsatt  antibiotika.

Rapporten (1), «Early diagnosis, prevention, and treatment of Clostridium difficile: Update»,  oppsummerer forskning om ulike tester for å diagnostisere, forebygge og behandle Clostridium difficile-infeksjoner hos voksne pasienter.  Oversikten er en oppdatering av tilsvarende arbeid publisert i 2011.

Flere nye publikasjoner

Den amerikanske rapporten er blant åtte publikasjoner som  videreformidles av avdeling for kvalitet og pasientsikkerhet i  Folkehelseinstituttet. Dette er temaer for de andre rapportene:

• Pasientsikkerhet og kvalitet i svangerskapsomsorgen (2)
• Sykepleierens rolle i forebygging og retting av legemiddelfeil (3)
• Simuleringstrening innenfor anestesien (4)
• Tiltak for bedre diagnostikk (5,7)
• Nødvendig kompetanse innenfor pasientsikkerhet og kvalitetsforbedring (6)
• Farmasøyter bidrar til bedre legemiddelforskrivning til eldre pasienter (8)

Se kriteriene for formidling av disse publikasjonene i høyre kolonne.

De åtte artiklene:

1. Early diagnosis, prevention, and treatment of clostridium difficile: Update, Butler M, Olson A, Drekonja D, Shaukat A, Schwehr N, Shippee N, et al., Rockville, MD: Agency for Healthcare Research and Quality, 2016. (Comparative Effectiveness Review No. 172. AHRQ Publication No. 16-EHC012-EF).

Research  on diagnostic testing for and interventions to treat Clostridium difficile infections (CDI) expanded considerably in 4 years. Nucleic acid amplification tests have high sensitivity and specificity for CDI.  Vancomycin is more effective than metronidazole for initial CDI, while fidaxomicin is more effective than vancomycin for the prevention of recurrent CDI. FMT and lactobacillus probiotics to restore colonic biodiversity and improve patient resistance to CDI or recurrence have  low-strength but relatively consistent positive evidence for efficacy.

Key Questions

KQ1: How do different methods for detection of toxigenic C. difficile to  assist with diagnosis of CDI compare in their sensitivity, specificity,  and predictive values?

a. How do they differ overall?

b. Do performance measures vary with sample characteristics?

c. Does testing strategy impact patient health or health system outcomes?

KQ2: What are effective prevention strategies?

a. What is the effectiveness of current prevention strategies?

b. What are the harms associated with prevention strategies?

c. How sustainable are prevention practices in health care (outpatient,  hospital inpatient, extended care) and community settings?

KQ3: What are the comparative effectiveness and harms of different antibiotic treatments?

a. Does effectiveness vary by disease severity?

KQ4: What are the effectiveness and harms of other interventions?

a. How do they differ overall?

b. In patients with relapse/recurrent CDI?

2. Triggers, bundles, protocols, and checklists - what every maternal care provider needs to know, Arora KS, Shields LE, Grobman WA, D'Alton ME, Lappen JR, Mercer BM, Am J Obstet Gynecol 2016;214(4):444-451

The rise in maternal morbidity and mortality has resulted in national and  international attention at optimally organizing systems and teams for  pregnancy care. Given that maternal morbidity and mortality can occur unpredictably in any obstetric setting, specialists in general  obstetrics and gynecology along with other primary maternal care providers should be integrally involved in efforts to improve the safety  of obstetric care delivery. Quality improvement initiatives remain vital to meeting this goal.

The evidence-based utilization of triggers, bundles, protocols, and checklists can aid in timely diagnosis and treatment to prevent or limit the severity of morbidity as well as  facilitate interdisciplinary, patient-centered care.

3. Nurses' role in medical error recovery: An integrative review, Gaffney TA, Hatcher BJ, Milligan R, J Clin Nurs 2016;25(7-8):906-917

Patient harm can be reduced or prevented by adequate recovery processes that include identifying, interrupting and correcting medical errors in a  timely fashion. Both medical error prevention and recovery are critical components in advancing patient safety, yet little is known about nurses' role in medical error recovery.

The medical error recovery rate varied across specialty nursing populations with nurses recovering, on average, as many as one error per shift to as few as one error per week. Nurses rely on knowing the patient, environment and plan  of care to aid in medical error recovery.

Greater understanding of nurse characteristics and organisational factors that influence error  recovery can foster the development of effective strategies to detect and correct medical errors and enable organisations to reduce negative  outcomes.

4. Improving patient safety through simulation training in anesthesiology: Where are we?, Green M, Tariq R, Green P, Anesthesiology research and practice 2016;2016:4237523

This  paper gives a brief overview of the history and evolution of use of simulation in anesthesiology and highlights some of the more recent studies that have advanced simulation-based training.

Over the years, the use of simulation has gone from low fidelity to high fidelity  models that mimic human responses in a startlingly realistic manner,  extremely life-like mannequin that breathes, generates E.K.G, and has  pulses, heart sounds, and an airway that can be programmed for different  degrees of obstruction. Simulation in anesthesiology is no longer a  research fascination but an integral part of resident education and one of ACGME requirements for resident graduation.

5. Dual-process cognitive interventions to enhance diagnostic reasoning: A systematic review, Lambe KA, O'Reilly G, Kelly BD, Curristan S, BMJ quality & safety 2016

Diagnostic  error incurs enormous human and economic costs. The dual-process model reasoning provides a framework for understanding the diagnostic process and attributes certain errors to faulty cognitive shortcuts (heuristics). The literature contains many suggestions to counteract these and to enhance analytical and non-analytical modes of reasoning.

This  review aims to identify, describe and appraise studies that have  empirically investigated interventions to enhance analytical and  non-analytical reasoning among medical trainees and doctors, and to  assess their effectiveness. Twenty-eight studies were included under  five categories: educational interventions, checklists, cognitive forcing strategies, guided reflection, instructions at test and other interventions.

Results to date are promising and this relatively young field is now close to a point where these kinds of cognitive interventions can be recommended to educators.

6. Competencies for patient safety and quality improvement: A synthesis of recommendations in influential position papers, Moran KM, Harris IB, Valenta AL, Joint Commission journal on quality and patient safety / Joint Commission Resources 2016;42(4):162-169

There is limited conformity among patient safety and quality improvement (QI)  competencies of the knowledge, skills, and attitudes (KSA), by stage of skill acquisition, essential for all health professionals. A study was conducted to identify, categorize, critically appraise, and discuss implications of competency recommendations published in influential position papers.

The identified themes for competencies in patient  safety and QI have implications for curriculum development and  assessment of competence in education and practice. The findings in this  study demonstrate a need to discourage publication of recommendations of yet more competencies and to instead encourage development of an  international consensus on the essential KSA for patient safety and QI  across all health professions and all levels of skill acquisition.

7. The effectiveness of electronic differential diagnoses (DDX) generators: A systematic review and meta-analysis, Riches N, Panagioti M, Alam R, Cheraghi-Sohi S, Campbell S, Esmail A, et al., PLoS One 2016;11(3):e0148991

Diagnostic  errors are costly and they can contribute to adverse patient outcomes,  including avoidable deaths. Differential diagnosis (DDX) generators are electronic tools that may facilitate the diagnostic process. We conducted a systematic review and meta-analysis to investigate the efficacy and utility of DDX generators.

DDX generators did not  demonstrate improved diagnostic retrieval compared to clinicians but small improvements were seen in the before and after studies where clinicians had the opportunity to revisit their diagnoses following DDX generator consultation. Clinical utility data generally indicated high levels of user satisfaction and significant reductions in time taken to  use for newer web-based tools. Lengthy differential lists and their low relevance were areas of concern and have the potential to increase diagnostic uncertainty. Data on the number of investigations ordered and  on cost-effectiveness remain inconclusive.

8. Improving the appropriateness of prescribing in older patients: A  systematic review and meta-analysis of pharmacists' interventions in  secondary care, Walsh KA, O'Riordan D, Kearney PM, Timmons S, Byrne S, Age Ageing 2016;45(2):201-209

Potentially  inappropriate prescribing (PIP) in older hospitalised patients, and in  particular those with dementia, is associated with poorer health outcomes. PIP reduction is therefore essential in this population.

Multi-disciplinary teams involving pharmacists may improve prescribing appropriateness in  older inpatients, though the clinical significance of observed reductions is unclear. More research is required into the effectiveness of pharmacists' interventions in reducing PIP in dementia patients.  Additionally, easily assessed and clinically relevant measures of PIP  need to be developed.