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Background: Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent medication errors., Objectives: The objectives were to describe interventions performed by a clinical pharmacist integrated into clinical wards with CPOE, to assess the acceptance of interventions by prescribers, and to describe factors associated with acceptance., Methods: A 3-week prospective study was conducted in five wards of a 2000-bed French teaching hospital., Results: During pharmacist review of medication orders and participation on physician rounds, six resident pharmacists provided interventions either conveyed orally to prescribers, using the computer system, or combining both methods. There were 221 pharmacist interventions concerning drug-drug interactions (27%), drug monitoring (17%) and computer-related problems (16%). Pharmacist interventions consisted of change of drug choice or dose adjustment (49%), drug monitoring (17%) and administration modality optimisation (14%). Interventions were provided solely via computer systems in 67% of cases. The rate of intervention acceptance was 47.1%. In multivariate analysis, acceptance was significantly associated with oral transmission (odds ratio [OR] = 6.46; 95% confidence interval [95% CI] [1.65-25.24]; p < 0.01), change of drug choice or dose adjustment recommendations (OR = 3.81; 95% CI [1.63-8.86]; p < 0.01) and administration modality optimisation recommendations (OR = 9.51; 95% CI [3.02-29.93]; p < 0.01)., Conclusion: Communication method and nature of recommendation are factors associated with pharmacist intervention acceptance. CPOE is necessary to develop clinical pharmacy practice. However, only the integration of the pharmacist on the ward can guarantee a high level of acceptance of pharmacist interventions by prescribers.

Susceptibility to quinolones of aerobic gram-negative bacilli was assessed in a 2000-bed university hospital from 1992 to 2000. There was a significant downward trend in the rate of susceptibility to nalidixic acid (Nal) for Enterobacteriaceae as a whole from 1992 to 2000 (86% vs 82%), and E. coli (92% vs 84%), and an upward trend for K. pneumoniae (74% vs 82%), the latter being related to the control of the spread of epidemic ESBL producing strains. The overall susceptibility of Enterobacteriaceae to ciprofloxacin (Cip) paralleled the susceptibility to Nal: decreased susceptibility for Enterobacteriaceae as a whole (96% vs 89%) and E. coli (99% vs 91%). A clear decrease in the level of susceptibility to Cip occurred during the study period among the Nal-resistant strains as demonstrated by the decrease in the median zone diameter (D) observed among the Nal-resistant strains of E. coli (26 mm in 1992 vs 19 mm in 1998-2000). The zone diameter distribution pattern changed from an unimodal distribution in 1992 to a trimodal distribution in 2000 secondary to the occurrence of a population of resistant strains (D = 13 mm) and of a highly resistant population (D = 6 mm). Finally, the susceptibility to Cip of P. aeruginosa strains remained stable around 62% throughout the study period.

All hospitals in Switzerland will have to set up and run a quality management system, according to legal and contract requirements. However, their context and characteristics are quite different, and will have an impact on the type of system they will select and implement. The University Hospital in Lausanne and the Hôpital Orthopédique de la Suisse Romande are neighbour hospitals, which run an orthopaedic ward on both locations. Despite their different sizes, they need a common philosophy and collaboration to set up and run their quality management system. The different stages, strengths and difficulties of both projects are described and compared. The illustrate how coherent the two projects can be despite their initial diversity.

Isolation rates of multiple-drug resistant (MDR) bacteria were evaluated retrospectively in a psychiatric care facility. Over the six-year study period, 66 MDR bacterial strains were found. Methicillin-resistant Staphylococcus aureus contributed half of all MDR strains and 31% of all S. aureus strains. Among Pseudomonas aeruginosa strains, 22% were resistant to ticarcillin or imipenem, and among Enterobacteriaceae, 4.1% were MDR strains (production of a derepressed cephalosporinase or of an extended-spectrum beta-lactamase). Although most MDR strains were probably acquired during hospitalizations in short-term care facilities outside our institution, patient-to-patient transmission, either direct or via other individuals, cannot be ruled out. These data indicate that psychiatric care facilities should adopt the MDR strain monitoring strategies already used in other hospitals.

An acute care hospital was closed by the British Columbia Ministry of Health in 1993. A research study was conducted to investigate the ways closure of the hospital affected hospital employees and to identify ways to facilitate the closure/reorganization process. Unstructured interviews were conducted with 25 employees around the time of closure and six months after the closure. In the category Living with Closure, six themes arose from the qualitative analysis. They related to (1) provision of information; (2) effect of closure on the working environment and colleagues; (3) perceived stress; (4) recognition of one's worth; (5) provision of support services; and (6) the process of having a new job. The authors offer recommendations stemming from the analysis, which are intended to assist others planning for future hospital reorganizations or closures.

A multidisciplinary group from two medical floors at the Royal Victoria Hospital chose the Managed Care Appropriateness Program (MCAP) to evaluate the appropriateness of the days of stay for their patients. Of 100 charts of consecutive patients examined by the nurse reviewer (comprising 1,095 patient days), 33 percent of the days were deemed inappropriate. The reasons for each of these inappropriate days were documented, and strategies were implemented to address the issues. The major outcome of the study was a change in the culture of the health professionals to a more positive approach to defining and carrying out efficient patient care.

This paper illustrates the importance of giving emotional support and education to patients, families, staff and managers at The Queen Elizabeth Hospital, Toronto during the Spring 1992 downsizing effort. The Queen Elizabeth Hospital is a 601-bed, two-site facility which provides complex specialized rehabilitative and supportive care, teaching and research, as well as specialty programs in rehabilitation, geriatric service, geriatric psychiatry and long-term care. Downsizing at The Queen Elizabeth Hospital meant the consolidation and closure of 82 long-term beds, on one nursing unit at each site, to offset a projected budget deficit of $5.4 million. Internal restraint over the past year and during the budget process reduced this deficit to $2.8 million, thus necessitating further downsizing consideration. Background information includes a review of the recent downsizing literature. This paper describes the informal and formalized support activities that took place during the two-month process and the educational sessions that were provided on a regular basis. It gives specific attention to methodology and rationale. The authors also make recommendations for the successful implementation of a downsizing process which can be beneficial to any health care setting involved in bed closure.

Hospitals developed over the period of time when positivism become a predominant world view. Positivism was founded by four Western trends: preponderance of hierarchy and autocracy, popularization of bureaucracy, extensive application of a machine orientation to work and predominance of "scientific" inquiry. Organizational theory developed largely from quantitative research findings arising from a positivistic world view. A case study, analyzing a current nursing organizational structure at one large hospital, is presented. Nursing management was found to be based upon the positivistic paradigm. The predominance of a machine orientation, and an autocratic and bureaucratic structure are evidence of this. A change to shared governance had been attempted, indicating a shift to a more modern organizational structure based on a different paradigm. The article concludes by emphasizing that managers are largely responsible for facilitating change; change that will meet internal human resource needs and the cost-effectiveness crises of hospitals today through more effective use of human resources.

After two years of difficult financial times, the Kitchener-Waterloo Hospital was faced with another upcoming year of tight fiscal constraint. In February 1991, the hospital implemented a program review process to align its services with the hospital's long-term strategy and economic realities. The authors present a thorough review of the literature pertaining to downsizing decisions. From a practical perspective they demonstrate a downsizing process, its implications and lessons to be learned so that a "rightsizing" exercise can be implemented to minimize the effects of the program and staff reductions while focusing on the positive long-term benefits of strategic planning. Although downsizing is a difficult process, the Kitchener-Waterloo Hospital was able to develop and implement a plan that minimized the impact on the hospital services and its staff. A reduction in expenses of over $2 million was achieved without having to lay off any permanent hospital staff. This was achieved by streamlining programs, reducing management supervisory positions and eliminating 50 full-time equivalent positions through attrition. Ultimately, the hospital's board, senior management, medical staff and employees felt that a rightsizing decision had been made, one which minimized the negative impact of restructuring on service delivery, hospital employees and the community served.

Sunnybrook Medical Centre, Toronto, has designed a written, multidisciplinary program of care for elderly patients in acute care. The program includes specific community outreach activities that support the in-hospital program and addresses the challenges presented by an increasingly aged population. Some of its objectives are to develop a measurement for length of stay patterns, a reduction in the number of patients waiting for relocation to a long-term care institution (commonly and derogatorily referred to as "placement problems") and an increase in patient, family and staff satisfaction. A method for program evaluation is being designed. The program takes a three-level approach to care: (1) the non-problematic elderly patient, (2) the more complex elderly patient and (3) the care of patients who have finished treatment for their acute illness but who require long-term care institutionalization.

Medical technologists from four clinical laboratories in a large teaching hospital were surveyed for their perceptions of occupational stress or job dissatisfaction concomitant with the advent of major technological and procedural change. Overall the data support the interpretation of excessive stress and job dissatisfaction. More than one-third (37.7%) of the laboratory personnel experienced psychological symptoms of occupational stress; 46.4% had experienced physical symptoms of stress. There was a marked and significant increase in reports of adverse effects among the group of laboratory workers subjected to the most extensive technological changes. Main components of the stress difference related to work overload, feelings of uncertainty in the face of new technology, lack of direction from supervisors and lack of influence on management. Age, type of shift worked and years of employment were associated with physical and psychological manifestations of stress. Implications and recommendations for laboratory workers, hospital administrators and educators are discussed.

Traditionally, hospitals have denied the true intricacy of their organization by forcing all reporting relationships into a single structure. To address this complexity, Sunnybrook has developed three independent, yet interrelated, organization dimensions. Three structures--the traditional, the clinical unit and the programmatic dimension--provide a better link of accountability by holding departments responsible for the efficiency of their operations, holding physicians accountable for the resource implication of volume and case mix, and ensuring that the activities of the hospital's departments and clinical units are in line with hospital's overall mission and programs.