personnel hospitalier

Do hospital staff feel prepared?

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Marie Bossard, a specialist in the social psychology of health, has been studying the feeling of preparedness among hospital staff in the face of exceptional health situations in her PhD since 2018. She explores the factors that may influence this feeling to better understand the dynamics of preparation in health systems.

The Covid-19 crisis is a case in point: our care system must sometimes confront exceptional health situations. Hospital staff are trained to respond to such situations, but there is little scientific literature on the way in which those concerned perceive their preparation. So how do caregivers, medical doctors, administrative staff and medical center directors feel in the face of these exceptional situations? This is the subject of Marie Bossard’s PhD at IMT Mines Alès and the University of Nîmes.

When she began her work in 2018, the Covid-19 crisis and pandemics were not yet a major concern. Exceptional health situations include anything that goes beyond the usual functioning of healthcare services. “We originally had in mind the emergency services being overwhelmed after an attack”, explains Gilles Dusserre, a researcher in risk sciences at IMT Mines Alès and joint supervisor of Marie Bossard with Karine Weiss at the University of Nîmes. Whatever the cause, this research fits into a global reflection on the current problems in emergency medicine. This is what the researchers want to understand better in order to provide operational responses to special users or hospital staff.

The feeling of “preparedness“

“The idea is to start with the individual and study how each person perceives his or her level of preparedness, and then develop these reflections on a collective scale,” says Marie Bossard. The aim is to measure the feeling of “preparedness” and identify the factors that influence it, as well as to apply psychosocial models to the level of preparedness of hospital staff. The PhD student is exploring the social representations of hospital staff through interviews with medical doctors, paramedics, health executives and administrative employees in different French university hospitals.

“We can differentiate the feeling of preparedness, the perception of our preparation, and the reported preparation”, explains Marie Bossard. If hospital staff consider that exceptional health situations are only linked to an attack, for example, they might never be prepared for a fire,” she continues.

And, although the preparation received has an influence on the feeling of preparedness, she insists that “there are many other aspects to take into account. The feeling of self-efficacy is important, in particular.” This psycho-social concept represents, in a way, the power to act: the individual perception of having sufficient skills to manage a situation and knowing how to apply them. The perception of preparation, whether positive or negative, also affects the feeling of preparedness. The role of the collective is also undeniable. “A common response is that, individually, the person doesn’t feel ready, but they still have confidence in the collective, she adds. There’s a certain resignation”, says the joint PhD supervisor. “Hospital systems are already going through a difficult time and are coping, so collectively they feel capable of facing one more challenge.”

In a second phase, the aim is to propose hypotheses on the structure and content of these social representations. For example, health executives do not give the same type of spontaneous responses as paramedics when asked to list words in connection with exceptional health situations. The former generally talk about the practice of preparation (logistics, influx), while the second generally mention everyday examples or emotion (danger, serious, disaster).

The context of the Covid crisis

Given that the development of an exceptional health situation was completely unforeseeable, it initially seemed impossible to carry out a field study. However, the pandemic caused by the new coronavirus in early 2020 provided a characteristic field of study for the researchers. Marie Bossard and her joint supervisors reorganized their methodology and two new studies were prepared. The first before the arrival of the virus in France, which studied the preparedness of more than 400 participants among personnel and collectives. The second after the first peak of the epidemic and before a potential second wave, which was still an uncertainty at the time. The questionnaires from the study carried out among 534 participants provide a comparison between the feeling of readiness before and after Covid-19.

The post-Covid study confirmed that the feeling of preparedness depends on psycho-social variables and not just the level of preparation. Age and years of professional experience also influence this feeling, as do the profession and any previous experience of managing an exceptional health situation. These are individual variables, but the role of the collective was also confirmed. “The more ready and prepared others are, the higher the perception of personal preparedness, says Marie Bossard. Similarly, perceiving the hospital as ready, with sufficient human and material resources, has a great influence.” The PhD student is currently studying the results of the latest study conducted in September.

The situation, although difficult, provides “a context for the answers given during the first interviews,” says the PhD student. For example, it confirms that all hospital staff are involved, not just those considered on the front line. Indeed, the mobilization affects every hospital department. She admits that “the Covid-19 health crisis has given us a new perspective on this PhD subject, which is now topical and concretely demonstrates the need for a better understanding in this field“. It is also an opportunity to explore the effect of this exceptional health situation on the feeling of preparedness among those first concerned and the factors that influence this feeling with a concrete application of the subject.

“We haven’t found any previous studies that have explored this subject from the same angle, says Marie Bossard. We’re starting from scratch. The aim is to remain as open-minded as possible to identify initial indicators, and then dig deeper into more specific questions,” she concludes. It could lead to new studies, for example to understand why the feeling of auto-efficacy plays such an important role in the feeling of preparedness.

 Tiphaine Claveau

planetary boundaries, urgence climatique, planet's limits

Covid-19 Epidemic: an early warning signal that we’ve reached the planet’s limits?

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Natacha Gondran, Mines Saint-Étienne – Institut Mines-Télécom and Aurélien Boutaud, Mines Saint-Étienne – Institut Mines-Télécom

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This article was published for the Fête de la Science (Science Festival, held from 2 to 12 October 2020 in mainland France and from 6 to 16 November in Corsica, overseas departments and internationally), in which The Conversation France is a partner. The theme for this year’s festival is “Planète Nature”. Read about all the events in your region at Fetedelascience.fr.

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[dropcap]W[/dropcap]hen an athlete gets too close to the limits of his body, it often reacts with an injury that forces him to rest. What athlete who has pushed himself past his limits has not been reined in by a strain, tendinitis, broken bone or other pain that has forced him to take it easy?

In ecology, there is also evidence that ecosystems send signals when they are reaching such high levels of deterioration that they cannot perform the regulatory functions that allow them to maintain their equilibrium. These are called early warning signals.

Several authors have made the connection between the Covid-19 epidemic and the decline of biodiversity, urging us to see this epidemic as an early warning signal. Evidence of a link between the current emerging zoonoses and the decline of biodiversity has existed for a number of years and that of a link between infectious diseases and climate change is emerging.

These early warning signals serve as a reminder that the planet’s capacity to absorb the pollution and deterioration to which it is subjected by humanity is not unlimited. And, as is the case for an athlete, there are dangers in getting too close to these limits.

Planetary boundaries that must not be transgressed

For over ten years, scientists from a wide range of disciplines and institutions have been working together to define a global framework for a Safe Operating Space (SOS), characterized by physical limits that humanity must respect, at the risk of seeing conditions for life on Earth become much less hospitable to human life. This framework has since been added to and updated through several publications.

These authors highlight the holistic dimension of the “Earth system”. For instance, the alteration  of land use and water cycles makes systems more sensitive to climate change. Changes in the three major global regulating systems have been well-documented – ozone layer degradation, climate change and ocean acidification.

Other cycles, which are slower and less visible, regulate the production of biomass and biodiversity, thereby contributing to the resilience of ecological systems – the biogeochemical cycles of nitrogen and phosphorous, the freshwater cycle, land use changes and the genetic and functional  integrity of the biosphere. Lastly, two phenomena present boundaries that have not yet been quantified by the scientific community: air pollution from aerosols and the introduction of novel entities (chemical or biological, for example).

These biophysical sub-systems react in a nonlinear, sometimes abrupt way, and are particularly sensitive when certain thresholds are approached. The consequences of crossing these thresholds may be irreversible and, in certain cases, could lead to huge environmental changes..

Several planetary boundaries have already been transgressed, others are on the brink

According to Steffen et al. (2015), planetary boundaries have already been overstepped in the areas of climate change, biodiversity loss, the biogeochemical cycles of nitrogen and phosphorous, and land use changes. And we are getting dangerously close to the boundaries for ocean acidification. As for the freshwater cycle, although W. Steffen et al. consider that the boundary has not yet been transgressed on the global level, the French Ministry for the Ecological and Inclusive Transition has reported that the threshold has already been crossed in France.

These transgressions cannot continue indefinitely without threatening the equilibrium of the Earth system – especially since these processes are closely interconnected.  For example, overstepping the boundaries of ocean acidification as well as those of the nitrogen and phosphorous cycles will ultimately limit the oceans’ ability to absorb atmospheric carbon dioxide. Likewise, the loss of natural land cover and deforestation reduce forests’ ability to sequester carbon and thereby limit climate change. But they also reduce local systems’ resilience to global changes.

Representation of the nine planetary boundaries (Steffen et al., 2015):

Steffen, W. et al. “A safe operating space for humanity”. Nature 461, pp. 472–475

 

Taking quick action to avoid the risk of drastic changes to biophysical conditions

The biological resources we depend on are undergoing rapid and unpredictable transformations within just a few human generations. These transformations may lead to the collapse of ecosystems,  food shortages and health crises that could be much worse than the one we are currently facing.  The main factors underlying these planetary impacts have been clearly identified: the increase in resource consumption, the transformation and fragmentation of natural habitats, and energy consumption.

It has also been widely established that the richest countries are primarily responsible for the ecological pressures that have led us to reach the planetary boundaries, while the poorer countries of the Global South, are primarily victims of the consequences of these degradations.

Considering the epidemic we are currently experiencing as an early warning signal should prompt us to take quick action to avoid transgressing planetary boundaries. The crisis we are facing has shown that strong policy decisions can be made in order to respect a limit – for example, the number of beds available to treat the sick. Will we be able to do as much when it comes to planetary boundaries?

The 150 citizens of the Citizens’ Convention for Climate have proposed that we “change our law so that the judicial system can take account of planetary boundaries. […] The definition of planetary boundaries can be used to establish a framework for quantifying the climate impact of human activities.” This is an ambitious goal, and it is more necessary than ever”.

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Aurélien Boutaud and Natacha Gondran are the authors of Les limites planétaires (Planetary Boundaries) published in May of 2020 by La Découverte.

Natacha Gondran is a research professor in environmental  assessment at Mines Saint-Étienne – Institut Mines-Télécom and Aurélien Boutaud, holds a PhD in environmental science and engineering from Mines Saint-Étienne – Institut Mines-Télécom.

This article has been republished from The Conversation under a Creative Commons license. Read original article (in French).

contact tracing applications

COVID-19: contact tracing applications and new conversational perimeter

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The original version of this article (in French) was published in the quarterly newsletter of the Values and Policies of Personal Information Chair (no. 18, September 2020).

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[dropcap]O[/dropcap]n March 11, 2020, the World Health Organization officially declared that our planet was in the midst of a pandemic caused by the spread of Covid-19. First reported in China, then Iran and Italy, the virus spread critically and quickly as it was given an opportunity. In two weeks, the number of cases outside China increased 13-fold and the number of affected countries tripled [1].

Every nation, every State, every administration, every institution, every scientist and every politician, every initiative and every willing public and private actors were called on to think and work together to fight this new scourge.

From the manufacture of masks and respirators to the pooling of resources and energy to find a vaccine, all segments of society joined altogether as our daily lives were transformed, now governed by a large-scale deadly virus. The very structure of the way we operate in society was adapted in the context of an unprecedented lockdown period.

In this collective battle, digital tools were also mobilized.

As early as March 2020, South Korea, Singapore and China announced the creation of contact tracing mobile applications to support their health policies [2].

Also in March, in Europe, Switzerland reported that it was working on the creation of the “SwissCovid” application, in partnership with EPFL University in Lausanne and ETH University in Zurich. This contact tracing application pilot project was eventually implemented on June 25. SwissCovid is designed to notify users who have been in extended contact with someone who tested positive for the virus, in order to control the spread of the virus. To quote the proponents of the application, it is “based on voluntary registration and subject to approval from Swiss Parliament.” Another noteworthy feature is that it is “based on a decentralized approach and relies on application programming interfaces (APIs) from Google and Apple.”

France, after initially dismissing this type of technological component through the Minister of the Interior, who stated that it was “foreign to French culture,” eventually changed is position and created a working group to develop a similar app called “StopCovid”.

In total, no less than 33 contact tracing apps were introduced around the world [3]. With a questionable success.

However, many voices in France, Europe and around the world, have spoken out against the implementation of this type of system, which could seriously infringe on basic rights and freedoms, especially regarding individual privacy and freedom of movement. Others have voiced concern about the possible control of this personal data by the GAFAM or States that are not committed to democratic values.

The security systems for these applications have also been widely debated and disputed, especially the risks of facing a digital virus, in addition to a biological one, due to the rushed creation of these tools.

The President of the CNIL (National Commission for Information Technology and Civil Liberties) Marie-Laure Denis, echoed the key areas for vigilance aimed at limiting potential intrusive nature of these tools.

  • First, through an opinion issued on April 24, 2020 on the principle of implementing such an application, the CNIL stated that, given the exceptional circumstances involved in managing the health crisis, it considered the implementation of StopCovid feasible. However, the Commission expressed two reservations: the application should serve the strategy of the end-of-lockdown plan and be designed in a way that protects users’ privacy [4].
  • Then, in its opinion of May 25, 2020, urgently issued for a draft decree related to the StopCovid mobile app [5], the CNIL stated that the application “can be legally deployed as soon as it is found to be a tool that supports manual health investigations and enables faster alerts in the event of contact cases with those infected with the virus, including unknown contacts.” Nevertheless, it considered that “the real usefulness of the device will need to be more specifically studied after its launch. The duration of its implementation must be dependent on the results of this regular assessment.”

From another point of view, there were those who emphasized the importance of digital solutions in limiting the spread of the virus.

No application can heal or stop Covid. Only medicine and a possible vaccine can do this. However, digital technology can certainly contribute to health policy in many ways, and it seems perfectly reasonable that the implementation of contact tracing applications came to the forefront.

What we wish to highlight here is not so much the arguments for or against the design choices in the various applications (centralized or decentralized, sovereign or otherwise) or even against their very existence (with, in each case, questionable and justified points), but the conversational scope that has played a part in all the debates surrounding their implementation.

While our technological progress is impressive in terms of scientific and engineering accomplishments, our capacity to collectively understand interactions between digital progress and our world has always raised questions within the Values and Policies of Personal Information research Chair.

It is, in fact, the very purpose of its existence and the reason why we share these issues with you.

In the midst of urgent action taken on all levels to contain, manage and–we hope–reverse the course of the pandemic, the issue of contact tracing apps has caused us to realize that the debates surrounding digital technology have perhaps finally moved on to a tangible stage involving collective reflection that is more intelligent, democratic and respectful of others.

In Europe, and also in other countries in the world, certain issues have now become part of our shared basis for conversation. These include personal data protection, individual privacy, technology that should be used, the type of data collected and its anonymization, application security, transparency, the availability of their source codes, their operating costs, whether or not to centralize data, their relationship with private or State monopolies, the need in duly justified cases for the digital tracking of populations, independence from the GAFAM [6] and United States [7] (or other third State).

In this respect, given the altogether recent nature of this situation, and our relationship with technological progress, which is no longer deified nor vilified, nor even a fantasy from an imaginary world that is obscure for many, we have progressed. Digital technology truly belongs to us. We have collectively made it ours, moving beyond both blissful techno-solutionism and irrational technophobia.

If you are not yet familiar with this specific subject, please reread the Chair’s posts on Twitter dating back to the start of the pandemic, in which we took time to identify all the elements in this conversational scope pertaining to contact tracing

The goal is not to reflect on these elements as a whole, or the tone of some of the colorful and theatrical remarks, but rather something we see as new: the quality and wealth of these remarks and their integration in a truly collective, rational and constructive debate.

It was about time!

On August 26, 2020, French Prime Minister Jean Castex made the following statement: “StopCovid did not achieve the desired results, perhaps due to a lack of communication. At the same time, we knew in advance that conducting the first full-scale trial run of this type of tool in the context of this epidemic would be particularly difficult.” [8] Given the human and financial investment, it is clear that the cost-effectiveness ratio does not help the case for StopCovid (and similar applications in other countries) [9].

Further revelations followed when the CNIL released its quarterly opinion on September 14, 2020. While, for the most part, the measures implemented (SI-DEP and Contact Covid data files, the StopCovid application) protected personal data, the Commission identified certain poor practices. It contacted the relevant agencies to ensure they would become compliant in these areas as soon as possible.

In any case, the conclusive outcome that can be factually demonstrated, is that remarkable progress has been made in our collective level of discussion, our scope for conversation in the area of digital technology. We are asking (ourselves) the right questions. Together, we are setting the terms for our objectives: what we can allow, and what we must certainly not allow.

This applies to ethical, legal and technical aspects.

It’s therefore political.

Claire Levallois-Barth and Ivan Meseguer
Co-founders of the Values and Policies of Personal Information research chair

 

 

silent cities project

Locked-down world, silent cities

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Last spring, France decided to impose a lockdown to respond to the health crisis. Our cities came to a standstill and cars disappeared from the streets, allowing residents to rediscover quieter sounds like birdsong. A team of researchers decided to take advantage of this calm that suddenly settled over our lives to better understand the impacts of sound pollution, and created the Silent Cities project.

 

When the lockdown was announced and France was getting ready to come to a halt, a team of researchers launched a collaborative, interdisciplinary project: Silent Cities. The team includes Samuel Challéat,¹ Nicolas Farrugia,² Jérémy Froidevaux³ and Amandine Gasc,4 researchers in environmental geography, artificial intelligence, biology and ecology, respectively. The aim of their project is to record the sounds heard in cities around the world to study the impacts that lockdown and social distancing measures may have on noise pollution. The project also seeks to assess the effects of the variation of our activities on other animal species as our lives gradually return to normal.

Listening to cities

“We had to develop a standard protocol to obtain high-quality recordings for the analyses, but they also had to be light and easy to implement during the lockdown,” explains Nicolas Farrugia, a researcher in machine learning and deep learning at IMT Atlantique. Due to the lockdown, it was not possible to go directly into the field to carry out these acoustic surveys. A collaborative system was set up to allow  a large number of participants around the world to take part in the project by making recordings from their homes. The four researchers provided a collaborative platform so that the participants could then upload their recordings.

Interactive map of the Silent Cities project participants around the world.

The researchers analyzed and compared recordings at different sites using what they call ecoacoustic indices. These are mathematical values. The higher they are, the more they show the diversity and complexity of sounds in an acoustic survey. “Still using an open-access approach, we used a code base  to develop an algorithm that would automatically calculate these ecoacoustic indices in order to catalogue our recordings” explains Nicolas Farrugia.

“The goal is to run audio-tagging algorithms to automatically recognize and tag different sounds heard in a recording,” he adds. This makes it possible to obtain a fairly accurate identification of sound sources, indicating, for example, the presence of a car, a raven’s caw or a discussion between several people in a sound survey.

This type of algorithm based on deep neural networks has become increasingly popular in recent years. For acoustic ecologists, they provide recognition that is relatively accurate, and more importantly, multi-targeted: the algorithm is able to seek many different sounds at the same time to tag all the acoustic surveys. “We can also use them as a filter if we want to find all the recordings where we hear a raven. That could be useful for measuring the appearance of a species, by visualizing the time, date or location,” says Nicolas Farrugia.

The contribution of artificial intelligence is also a help to estimate the frequency of different categories of sounds  — for automobile traffic for example — and visualize the increase or decrease. During the lockdown, the researchers clearly observed a drop in automobile traffic and now expect to see it go back up as our lives are gradually returning to normal. What they are interested in is being able to visualize how this may disturb the behavior of other animal species.

What changes?

“Some studies have shown that in urban environments, birds can change the frequency or time of day at which they communicate, due to ambient noise,” says Nicolas Farrugia. The sound of human activities, saturating the urban environment can, for example, make it difficult for certain species to reproduce. “That said, it’s hard to talk about causality since, in normal times, we can’t listen to urban ecosystems without the contribution of human activities.”  It is therefore usually difficult for eco-acoustics researchers to fully understand the biodiversity of our cities.

In this respect, the Silent Cities project provides an opportunity to directly study the variation in human activity and how it impacts ecosystems. Some of the measures put in place to respond to the health crisis could subsequently be promoted for ecological reasons. One such example is cycling, which is now being encouraged  through financial assistance to repair old bicycles and creating new cycle paths. Another example is initiatives to establish staggered working hours, which would also limit the associated noise pollution. One of the possible prospects of the project is to inform discussions about how urban environments should be organized.

” Samuel Challéat, the researcher who initiated this project, works on light pollution and what we can be done to limit artificial light,” he adds. For example — like “green and blue belts,” which seek to promote the preservation of so-called “ordinary” biodiversity including in urban environments — he is currently working on an emerging planning tool, the “black belt,” which aims to restore nocturnal ecological continuity which has been harmed by artificial light. Since we know that the sounds created by human activities disturb certain ecological processes, this reasoning on ecological continuity could be transferred to the field of eco-acoustics, where the challenge would be to work to maintain or restore spaces free from any noise pollution. The data and results of the Silent Cities project could help provide insights in this area.

By Tiphaine Claveau

 

¹Samuel Challéat, Environmental Geography, University of Toulouse 2, CNRS, GEODE (guest researcher), Toulouse, France

²Nicolas Farrugia, Machine Learning & Deep Learning, IMT Atlantique, CNRS, Lab-STICC, Brest, France

³Jérémy Froidevaux, Conservation Biology, University of Bristol, School of Biological Sciences, Bristol, UK

4Amandine Gasc, Conservation Ecology, Aix Marseille University, Avignon University, CNRS, IRD, IMBE, Marseille, France

 

masks

Protective masks: towards widespread reuse?

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How can protective masks be recycled and reused without risking safety? Scientists, medical practitioners and manufacturers have teamed up to explore different treatment methods. As part of this consortium, IMT Atlantique researchers are studying the impact of decontamination processes on mask performance.

 

Surgical and FFP2 masks are intended for single use. Thrown away after just a few hours of use, they are designed to protect the wearer from inhaling infectious agents spread through the air. The question of recycling these masks has not been raised before, but high demand for masks to protect healthcare workers and the general public has been a game-changer. To help find a solution to the current shortage, an interdisciplinary consortium bringing together nearly 25 laboratories and manufacturers throughout France was created in early March, led by professor Philippe Cinquin from Grenoble University Hospital, the CNRS and the CEA. Its goal is to find a treatment process that makes it possible to reuse masks.

Currently, various decontamination methods recognized for both their virucidal and bactericidal effects are being explored: among others, gamma or beta irradiation, thermal decontamination with steam at 121 °C; an ethylene oxide treatment, and wet or dry heating methods at 70°C or higher. These methods must able to reduce the bioburden of protective masks, without reducing filtration efficiency or breathability.

At IMT Atlantique, which is a member of the research consortium, Laurence Le Coq and her colleagues Aurélie Joubert and Yves Andrès are working mainly on this second aspect of the project.  The researchers are drawing on their research on filtration applied to air treatment — for industrial waste applications, for example, or indoor air treatment in ventilation networks. The team has been able to quickly shift its focus and adapt its expertise to work on recycling used masks. “The contribution and dedication of researchers and technical staff, who were called on to respond to an urgent need to develop technical solutions and establish experimental conditions, has been instrumental,” says Laurence Le Coq.

By mid-March, the scientists had set up an initial test bed to closely reflect the AFNOR standards for masks in order to test their performance following decontamination. “If the masks are normally intended for single use, it’s also because they first undergo a treatment process which gives them a certain level of efficiency, as well as their mechanical strength and specific shape. When they are decontaminated, part of this pre-treatment is removed, depending on the type of decontamination and its conditions. What’s more, depending on how a mask has been put on, worn and taken off, it may be damaged and its structure could be altered,” explains the researcher.

Preliminary findings    

So, how can effective decontamination be combined with a sufficient level of protection?  “We compare how performance is maintained between new treated masks and used treated masks. More precisely, we measure the changes brought about by decontamination treatments, in particular their level of breathability and their filtration efficiency for particles with a diameter ranging from 0.3 to 3 µm, since the virus is spread by microdroplets,” explains Laurence Le Coq.

After ruling out certain methods, the scientists were able to determine favorable treatment conditions for decontaminating the masks without having too much of an effect on their inherent qualities. “Dry heat treatments, for example, are promising but we can’t move forward for the time being. Certain findings are encouraging following irradiation or washing at 95°, but only for surgical masks. For now, our findings do not allow us to converge on a single treatment, a single protocol. And most importantly, there is a huge difference between what we do in good laboratory conditions and what could be done on a greater quantity of masks in a hospital environment, or at home,” says Laurence Le Coq.

The researchers are currently trying to clarify and confirm these preliminary findings. Their goal is now to quickly establish treatment conditions that are effective for all surgical and FFP2 masks, regardless of the manufacturer.

Is widespread mask recycling possible?

The majority of masks provided for the “general public” during the lockdown are reusable after being washed at 60°C for 30 minutes. This is not yet the case for professional masks.

Lockdown measures have been accompanied by efforts to raise public awareness about the importance of wearing masks. In French departments classified as red due to a high number of cases, masks intended for the “general public” are mandatory on public transportation and in high schools. These fabric masks are less effective than professional protective masks, but they are easily reusable and can be washed at least five times. “What is lost in effectiveness is made up for by widespread mask-wearing and ease of use,” says Laurence Le Coq.

For the researcher, this unprecedented research project could also be an opportunity to consider recycling protective masks in the long term, even when there is not a shortage. “Is it really appropriate to have single-use masks if at some point we are required to use them to a greater extent, or even on a daily basis? How should the environmental costs of this medical waste be weighed? Of course, what happens next will depend on the treatment we’re able to develop.”

 

By Anne-Sophie Boutaud

digital simulation

In the midst of a crisis, hospitals are using digital simulation to organize care

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Thierry Garaix and Raksmey Phan are systems engineering researchers at Mines Saint-Étienne[1]. In response to the current health crisis, they are making digital simulation and digital twins available to health services to inform their decision-making. This assistance is crucial to handling the influx of patients in hospitals and managing the post-peak period of the epidemic.

 

The organization of the various departments within a hospital is a particular concern in the management of this crisis. Based on the number of incoming patients and how many of them require special care, certain departments must be turned into dedicated wards for Covid-19 patients. Hospitals must therefore decide which departments they can afford to close in order to allocate beds and resources for new patients. “We’re working on models to simulate hospitalizations and intensive care units,” says Thierry Garaix, a researcher in healthcare systems engineering at Mines Saint-Étienne.

“Cardiac surgery operating rooms are already equipped with certain resources needed for Covid wards, such as respirators,” explains the researcher. This makes them good candidates for receiving Covid patients in respiratory distress. These simulations give caregivers a clearer view in order to anticipate the need for hospital and intensive care beds. “At the peak of the epidemic, all possible resources are reassigned,” he explains. “Once the peak has passed, the number of cases admitted to the hospital begins to drop, and the hospital must determine how to reallocate resources to the usual activities.”

Visualizing the hospital

It is essential for hospitals to have a good understanding of how the epidemic is evolving in order to define their priorities and identify possibilities. Once the peak has passed, fewer new patients are admitted to the hospital every day but those that remain still require care. These simulations make it possible to anticipate how long these departments will remain occupied by Covid patients and estimate when they will be available again.

“The tool I’m developing makes it possible to visualize how the flow of Covid patients will progress over time to help the university hospital make decisions,” says Thierry Garaix. The researcher provides the model with data about the length of hospital stays, time spent in the hospital or intensive care unit and the capacity of each hospital unit. The model can then digitally simulate patient pathways and visualize flows throughout the hospital. “It’s important to understand that the progression isn’t necessarily linear,” he adds, emphasizing that “if we see a drop in the number of cases, we have to consider the possibility that there could then be a rise in the epidemic.”

But even if a hospital unit could be freed up and reallocated to its regular activities, it may be more cautious to keep it available to handle new cases. “At the beginning of the epidemic, health services had to rush to allocate resources and set up Covid units quickly,” says Thierry Garaix. “The benefit of these simulations is that they make it easier to anticipate the management of resources, so that resources can be allocated gradually depending on how the epidemic evolves.”

“Strictly speaking, it is not a digital twin since the model does not directly interact with reality,” says the researcher. “But if a digital twin of all of the hospital’s departments had been available, it would have been of great help in planning how resources should be allocated at the beginning of the epidemic.” 

Visualizing people

A digital twin could help assess a number of complex aspects, including the effects of isolation on the health of elderly people. “It’s a project we’ve been working on for a while, but it has taken on new importance in light of the lockdown measures,” says Raksmey Phan, who is also a healthcare systems researcher at Mines Saint-Étienne. The AGGIR scale is generally used to measure an individual’s  loss of autonomy. It breaks health status into different categories   ̶̶  autonomous, at risk, fragile, dependent   ̶̶  in order to propose appropriate care. The digital twin would be used to anticipate changes in health status, identify at-risk individuals and prevent them from moving towards a situation of dependence.

“It’s important to point out that a fragile individual can, with appropriate physical activity, return to a category corresponding to a better health status. However, once an individual enters into a situation of dependence,  there’s no going back,” explains Raksmey Phan. The aim of this new digital twin project is to predict this progression in order to propose appropriate activities before it is too late. At present, the lack of physical activity as a result of the lockdown raises the risk of adverse health outcomes since it implies a loss of mobility.

In the context of lockdown, this digital twin therefore makes it possible to estimate the impact of lack of physical activity for elderly people. Before the lockdown period, researchers installed sensors in homes of volunteers, on doors, objects such as refrigerators, front doors etc. to evaluate their presence and level of activity at home. “With fairly simple sensors, we have a model that is well-aligned with reality and is effective for measuring changes in an individual’s health status,” he adds.

These sensors evaluate the time spent in bed, on the couch, or indicate if, on the other hand, individuals spend a lot of time standing up, moving around, or if he leaves the house often. With this data, the digital twin can extrapolate new data about a future situation, and therefore predict how an individual’s health status will progress over time. “The goal is essentially to analyze troubling changes that may lead to a risk of fragility, and react in order to prevent this from occurring,” explains the researcher.

The researchers, who are working with the insurance company EOVI MCD, could then propose appropriate activities to maintain good health. Even in the midst of a pandemic, and taking social distancing measures and an effort to limit contact into account, it is possible to propose activities to be done at home, in front of the TV for example. “The insurance provider could propose activities and home services or potentially direct them to a retirement home,” says Thierry Garaix. “The key focus is providing an opportunity to act before it’s too late by estimating the future health status of the individuals  concerned, and reacting by proposing appropriate structures or facilities,” say the two researchers.

[1] Thierry Garaix and Raksmey Phan are researchers at the Laboratory of Informatics, Modeling and Optimization of Systems (LIMOS), a joint research unit between Mines Saint-Étienne/CNRS/University of Clermont-Auvergne.

 

Tiphaine Claveau

surgical masks

Testing the efficiency of protective masks

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A Mines Saint-Étienne and Jean-Monnet University laboratory has been accredited to certify the bacterial filtration efficiency of surgical masks. Jérémie Pourchez, a researcher in healthcare engineering at Mines Saint-Étienne, describes this specific aspects of this expertise. He also explains why it is worth considering opening these tests up to the fabric masks worn by general public.

 

The Covid-19 pandemic has led to growing demand for surgical masks, and therefore a greater need for tests to assess this type of protective equipment. Since May 2020, a Mines Saint-Étienne and Jean-Monnet University laboratory¹ has been accredited by the French National Agency for Medicines and Health Products (ANSM) to certify the bacterial filtration efficiency of surgical masks.

The agency has specified “that no such facility is available in the country” and that it is therefore highly valuable in the context of the COVID 19 epidemic. Jérémie Pourchez, a researcher at Mines Saint-Étienne, adds that this expertise is also rare at the international level and that this accreditation is temporary. “We’re operational at the scientific level but under normal circumstances, this accreditation requires several months of additional inspection to ensure the COFRAC standards for the quality approach.” In other words: the laboratory environment.

Pathogen aerosols

Surgical masks are medical devices which must meet strict specifications regulated by a European standard(EN 14683). Three parameters must be verified to validate compliance with this standard: microbial cleanliness relating to a mask’s packaging and storage conditions, breathability, and bacterial filtration. The test bench developed by the laboratory is used to verify the latter parameter. “A surgical mask protects the environment from the wearer. It is usually used to protect the patient when the masked surgeon operates. So we try to measure the efficiency of the mask being worn toward the environment,” says Jérémie Pourchez.

“We place the surgical mask between a bioaerosol generator (which produces microdroplets of water measuring 3 micrometers containing a pathogenic bacterium, a Staphylococcus aureus) and a cascade impactor (which makes it possible to collect aerosols in petri dishes depending on their size),” explains the researcher. This allows the scientists to analyze which sizes of particles are not filtered by the mask. These dishes are then incubated at 37°C for at least 24 hours to determine whether they can make a culture. “It isn’t enough to simply show that the pathogen passes through the mask, we have to demonstrate that it is viable and cultivable to determine whether the pathogen that has passed through the mask could infect a host,” says the researcher.

Surprising findings for fabric masks

For the researchers, it is also important to perform these efficiency tests on fabric masks (masks for non-medical purposes) now intended for the general public. In the Loire department, many textile industries have started making fabric masks to help combat the pandemic, but until now these masks for the general public have not undergone bacterial filtration tests with a pathogen. “They don’t have to meet the same standards, but they must meet specification SPEC76 defined by AFNOR, and masks for the general public are divided into two major filtration categories, higher than 70% or 90%, whereas surgical masks are higher than 95% or 98%,” adds the Saint-Etienne researcher. Still, some manufacturers are interested in determining the efficiency of their fabric masks by having access to a test with pathogen aerosols.

“Out of the masks that we test here at the laboratory, 15 to 20 percent are fabric masks,” says Jérémie Pourchez, “and certain manufacturers make masks of excellent quality which, in terms of bacterial filtration, are almost equivalent to the least efficient surgical masks.”  The researcher stresses the potential benefits of these fabric masks if they are shown to have good bacterial filtration efficiency. As it stands today, surgical masks, which are made of plastic materials, are much more widely-used. Unfortunately, masks are often disposed of in nature, and this has significant environmental implications.

Reusable, washable masks with bacterial filtration efficiency almost equivalent to that of surgical masks would be beneficial in terms of sustainable development. “And as far as the washable, reusable aspect is concerned, it would be useful to determine methods for washing these masks in a more environmentally-friendly, convenient way than a long cycle at 60°C,” adds Jérémie Pourchez. “We’re working with colleagues from Jean-Monnet University to look for other solutions, and one of the solutions we are considering, for example, is using microwaves to decontaminate masks”. This approach could complement that of the international ReUse consortium, of which the Mines Saint-Étienne team is a member, along with a team from IMT Atlantique. The consortium is working on finding methods for decontaminating and reusing surgical masks.

¹ The laboratory corresponds to two joint research units (UMR), UMR INSERM U1059 Sainbiose and UMR EA 3064 GIMAP.

Tiphaine Claveau for I’MTech

Reducing the duration of mechanical ventilation with a statistical theory

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A team of researchers from IMT Atlantique has developed an algorithm that can automatically detect anomalies in mechanical ventilation by using a new statistical theory. The goal is to improve synchronization between the patient and ventilator, thus reducing the duration of mechanical ventilation and consequently shortening hospital stays. This issue is especially crucial for hospitals under pressure due to numerous patients on respirators as a result of the Covid-19 pandemic.

 

Dominique Pastor never imagined that the new theoretical approach in statistics he was working on would be used to help doctors provide better care for patients on mechanical ventilation (MV). The researcher in statistics specializes in signal processing, specifically anomaly detection. His work usually focuses on processing radar signals or speech signals. It wasn’t until he met Erwan L’Her, head of emergencies at La Cavale Blanche Hospital in Brest, that he began focusing the application of his theory, called Random Distortion Testing, on mechanical ventilation. The doctor shared a little known problem with the researcher, which would become a source of inspiration: a mismatch that often exists between patients’ efforts while undergoing MV and the respirator’s output.

Signal anomalies with serious consequences

Respirators–or ventilators–feature a device enabling them to supply pressurized air when they recognize demand from the patient. In other words, the patient is the one to initiate a cycle. Many adjustable parameters are used to best respond to an individual’s specific needs, which change as the illness progresses. These include inspiratory flow rate and number of cycles per minute. Standard settings are used at the start of MV and then modified based on flow rate/ pressure curves–the famous signal processed by the Curvex algorithm, which resulted from collaboration between Dominique Pastor and Erwan L’Her.

Patient-ventilator asynchronies are defined as time lags between the patient’s inspiration and the ventilator’s flow rate. For example, the device cannot detect a patient’s demand for air because the trigger threshold level is set too high. This leads to ineffective inspiratory effort. It can also lead to double triggering when the ventilator generates two cycles for one patient inspiratory effort. The patient may also not have time to completely empty their lungs before the respirator begins a new cycle, leading to dynamic hyperinflation of the lungs, also known as intrinsic PEEP (positive end-expiratory pressure).

Effort inspiratoire inefficace : la demande du patient n’aboutit pas à une insufflation

Example of ineffective inspiratory effort: patient demand does not result in insufflation.

 

Double déclenchement : un seul effort inspiratoire aboutit à deux insufflations rapprochées

Example of double triggering: a single inspiratory effort results in two ventilator insufflations within a short time span.

 

PEP intrinsèque : l’insufflation suivante survient alors que le débit n’est pas nul à la fin de l’expiration

Example of positive end expiratory pressure: the next ventilator insufflation occurs before the flow has returned to zero at the end of expiration.

 

These patient-ventilator anomalies are believed to be very common in clinical practice. They have serious consequences, ranging from patient discomfort to increased respiratory efforts that can lead to invasive ventilation–intubation. They involve an increase in the duration of mechanical ventilation, with an increase in weaning failure (end of MV) and therefore longer hospital stays.

However, the number of patients in need of mechanical ventilation has skyrocketed with the Covid-19 pandemic, while the number of health care workers, respirators and beds has only moderately increased, which at times gives rise to difficult ethical choices. A reduction in the duration of ventilation would therefore be a significant advantage, both for the current situation and in general, since respiratory diseases are becoming increasingly common, especially with the aging of the population.

A statistical model that adapts to various signals

Patient-ventilator asynchronies result in visible anomalies in air flow rate and pressure curves. These curves model the series of inspiratory phases, when pressure increases and expiratory phases, when it decreases, with inversion of the air flow. Control monitors for most next-generation devices display these flow rate and pressure curves. The anomalies are visible to the naked eye, but this requires regular monitoring of the curves, and a doctor to be present who can adjust the ventilator settings. Dominique Pastor and Erwan L’Her had a common objective: develop an algorithm that would detect certain anomalies automatically. Their work was patented under the name Curvex in 2013.

The detection of an anomaly represents a major deviation from the usual form for a signal. “We chose an approach called supervised learning by mathematical modeling,” Dominique Pastor explains. One characteristic of his Random Distorsion Testing theory is that it makes it possible to detect signal anomalies with very little prior knowledge. “Often, the signal to be processed is not well known, as in the case of MV, since each patient has unique characteristics, and it is difficult to obtain a large quantity of medical data. The usual statistical theories have difficulty taking into account a high degree of uncertainty in the signal. Our model, on the other hand, is generic and flexible enough to handle a wide range of situations.” 

Dominique Pastor first worked with intrinsic PEEP detection algorithms with PhD student Quang-Thang Nguyen, who helped to find solutions. “The algorithm is a flow rate signal segmentation method used to identify the various breathing phases and calculate models for detecting anomalies. We introduced an adjustable setting (tolerance) to define the deviation from the model used to determine whether it is an anomaly,” Dominique Pastor explains. According to the researcher from IMT Atlantique, this tolerance is a valuable asset. It can be adjusted by the user, based on their needs, to alter the sensitivity and specificity.

The Curvex platform not only processes flow data from ventilators, but also a wide range of physiological signals (electrocardiogram, electroencephalogram). A ventilation simulator was included, with settings that can be adjusted in real-time, in order to test the algorithms and perform demonstrations. By modifying certain pulmonary parameters (compliance, airway resistance, etc.) and background noise levels, different signal anomalies (intrinsic PEEP, ineffective inspiratory effort, etc.) appear randomly. The algorithm detects and characterizes them. “In terms of methodology, it is important to have statistical signals that we can control in order to make sure it is working and then move on to real signals,” Dominique Pastor explains.

The next step is to create a proof of concept (POC) by developing electronics to detect anomalies in ventilatory signals, to be installed in emergency and intensive care units and used by health care providers. The goal is to provide versatile equipment that could adapt to any ventilator. “The theory has been expanding since 2013, but unfortunately the project has made little progress from a technical perspective due to lack of funding.  We now hope that it will finally materialize, in partnership with a laboratory, or designers of ventilators, for example. I think this a valuable use of our algorithms, both from a scientific and medical perspective,” says Dominique Pastor.

By Sarah Balfagon for I’MTech.

Learn more:

– Mechanical ventilation system monitoring: automatic detection of dynamic hyperinflation and asynchrony. Quang-Thang Nguyen, Dominique Pastor, François Lellouche and Erwan L’Her

Illustration sources:

Curves 1 and 2

Curve 3

 

Capture d'écran des cartes du Tarn pour visualiser l'épidémie de Covid-19, crisis management

Covid-19 crisis management maps

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The prefecture of the Tarn department worked with a research team from IMT Mines Albi to meet their needs in managing the Covid-19 crisis. Frédérick Benaben, an industrial engineering researcher, explains the tool they developed to help local stakeholders visualize the necessary information and facilitate their decision-making.

 

“The Covid-19 crisis is original and new, because it is above all an information crisis,” says Frédérick Benaben, a researcher in information system interoperability at IMT Mines Albi. Usually, crisis management involves complex organization to get different stakeholders to work together. This has not been the case in the current health crisis. The difficulty here lies in obtaining information: it is important to know who is sick, where the sick people are and where the resources are. The algorithmic crisis management tools that Frédérick Benaben’s team have been working on are thus incompatible with current needs.

“When we were contacted by the Tarn prefecture to provide them with a crisis management tool, we had to start almost from scratch,” says the researcher. This crisis is not so complex in its management that it requires the help of artificial intelligence, but it is so widespread that it is difficult to display all the information at once. The researchers therefore worked on using a tool that ensures both the demographic visualization of the territory and the optimization of volunteer workers’ routes.

The Tarn team was able to make this tool available quickly and thus save a considerable amount of time for stakeholders in the territory. The success of this project also lies in the cohesion at the territorial level between a research establishment and local stakeholders, reacting quickly and effectively to an unprecedented crisis. The prefecture wanted to work on maps to visualize the needs and resources of the department, and that is what Frédérick Benaben and his colleagues, Aurélie Montarnal, Julien Lesbegueries and Guillaume Martin provided them with.

Visualizing the department

The first requirement was to be able to visualize the needs of the municipalities in the department. It was then necessary to identify the people most at risk of being affected by the disease. Researchers drew on INSEE’s public data to pool information such as age or population density. “The aim was to divide the territory into municipalities and cantons in order to diagnose fragility on a local scale,” explains Frédérick Benaben. For example, there are greater risks for municipalities whose residents are mostly over 65 years of age.

The researchers therefore created a map of the department with several layers that can be activated to visualize the different information. One showing the fragility of the municipalities, another indicating the resilience of the territory – based, for example, on the number of volunteers. By identifying themselves on the prefecture’s website, these people volunteer to go shopping for others, or simply to keep in touch or check on residents. “We can then see the relationship between the number of people at risk and the number of volunteers in a town, to see if the town has sufficient resources to respond,” says the researcher.

Some towns with a lot of volunteers appear mostly in green, those with a lack of volunteers are very red. “This gives us a representation of the Tarn as a sort of paving with red and green tiles, the aim being to create a uniform color by associating the surplus volunteers with those municipalities which need them” specifies Frédérick Benaben.

This territorial visualization tool offers a simple and clear view to local stakeholders to diagnose the needs of their towns. With this information in hand it is easier for them to make decisions to prepare or react. “If a territory is red, we know that the situation will be difficult when the virus hits,” says the researcher. The prefecture can then allocate resources for one of these territories, for example by requisitioning premises if there is no emergency center in the vicinity. It may also include decisions on communication, such as a call for volunteers.

Optimizing routes

This dynamic map is continuously updated with new data, such as the registration of new volunteers. “There is a very contemplative aspect and a more dynamic aspect that optimizes the routes of volunteers,” says Frédérick Benaben. There are many parameters to be taken into account when deciding on routes and this can be a real headache for the employees of the prefecture. Moreover, these volunteer routes must also be designed to limit the spread of the epidemic.

The needs of people who are ill or at risk must be matched with the skills of the volunteers. Some residents ask for help with errands or gardening, but others also need medical care or help with personal hygiene that requires special skills. It is also necessary to take into account the ability of volunteers to travel, whether by vehicle, bicycle or on foot. With regard to Covid-19, it is also essential to limit contact and reduce the perimeter of the routes as much as possible.

“With this information, we can develop an algorithm to optimize each volunteer’s routes,” says the researcher. This is of course personal data to which the researchers do not have access. They have tested the algorithm with fictitious values to ensure functionality when the prefecture enters the real data.

“The interest of this mapping solution lies in the possibilities for development,” says Frédérick Benaben. Depending on the available data, new visualization layers can be added. “Currently we have little or no data on those who are contaminated or at risk of dangerous contamination and remain at home. If we had this data we could add a new layer of visualization and provide additional support for decision making. We can configure as many layers of visualizations as we want.

 Tiphaine Claveau for I’MTech

EHPAD, Covid19, Coronavirus, nursing homes

In French nursing homes, the Covid-19 crisis has revealed the detrimental effects of austerity policies

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This article was originally published (in French) in the Conversation. 
By Laura Nirello, IMT Lille Douai, and Ilona Delouette, University of Lille.

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[dropcap]W[/dropcap]ith apocalyptic accounts of conditions in French nursing homes, where deaths have soared (over 9,000 estimated as of 3 May 2020), the Covid-19 pandemic has revealed, more than ever, the hardships facing this sector.

For years, care providers who work in France’s nursing homes (known as EHPADs in French) have been sounding the alarm about the crisis facing such facilities, underscoring the pitfalls of austerity policies and budgeting when applied to healthcare and care for dependent persons.

The ‘EHPAD’ nursing home status was created in 1997 when, after twenty years of discussions, the government approved the idea of covering care for dependent persons through the national Social Security program. At the time, the decision was based on a number of technical aspects, and in particular, uncertainty with respect to how the cost of providing care for dependent persons would develop in the future, and therefore, how it would be budgeted over time.

In 1997, a welfare allowance, managed by the departments, was therefore put in place (PSD, (assistance allowance), which has since been replaced with the APA (personal care allowance)).

Impossible to separate ‘cure’ from ‘care’?

This theoretical separation between healthcare, funded by Social Security, and care for dependent persons, funded by the departments, is at odds with the reality of care situations. Indeed, how can that which pertains to health (cure) be separated from that which pertains to assisting dependent persons (care)?

It is even more difficult to separate the two aspects in the case of highly dependent persons who require medical care in an institutional setting. The ‘EHPAD’ nursing home status was created precisely to cope with the influx of highly dependent persons: it makes facilities eligible for funding from both the public health insurance program and the departments.

Funding for nursing homes is therefore based on a three-part pricing system according to a theoretical categorization of costs (medical care, dependent care, living expenses). This funding is provided by public authorities, all of whom have limited budgets.

Living expenses are paid for by residents and their families. ‘Medical care’ is 100% funded through public health insurance, through the Regional Health Agency (ARS) while ‘dependent care’ is primarily funded by Departmental Councils. The Regional Health Agencies are limited to the fixed budgets voted upon annually through the Social Security Financing Act, while the Departmental Councils are limited to the funds transferred from the State through the personal care allowance (APA).

Medical care for the lowest possible cost

As part of the austerity policies imposed on the hospital sector, healthcare regulators gradually sought to remove expenditure for dependent elderly persons from hospital accounts. As such, according to IGAS, over a ten-year period (2006-2016) more than half of the beds in long-term care units (USLD) filled by highly dependent persons whose condition requires constant medical supervision were converted to places in nursing homes. Elderly people suffering from a loss of independence had no choice but to follow this trend and were sent to nursing homes. The State also invested in home care services and independent living facilities for the most independent individuals. This made it possible to limit the number of new places created in nursing homes.

The funding for nursing homes is negotiated through multi-year performance and resource contracts (CPOM) that determine an average level of dependency and severity of medical conditions for residents for a five-year period: the institutions are responsible for remaining within these averages and controlling resident admissions and discharges based on their level of dependency.

In this way, the authorities who fund the nursing homes pushed them to specialize in highly-dependent residents by taking in individuals excluded from the hospital setting and no longer independent enough to live at home or at intermediate living facilities. Nursing homes also tend to provide care for a community with an increasing number of medical conditions: more than a third of residents suffer from Alzheimer’s disease and struggle to perform everyday tasks (90% of residents need help with bathing and grooming); residents are admitted at an increasingly advanced age (85 years and 8 months) and stays in nursing homes are shorter (2 years and 5 months), according to data from the DREES (Directorate for Research, Studies, Evaluation and Statistics, a directorate of the central administration of health and social ministries).

But nursing homes’ resources have not kept pace with this changing profile of the residents receiving care. According to the DREES, while nursing homes now provide care for residents whose needs closely resemble those in long-term care units (USLD), the caregiver to patient ratio is .62 full-time equivalent employees per resident compared to 1.1 full-time equivalent employee per patient in long-term care units.

Moreover, while the staff of long-term care units are primarily made up of nurses, geriatric medicine specialists and nursing aids, in nursing homes there is only a single coordinating physician. And this physician is only present on a part-time basis, since they work at several facilities. Likewise, there are few nurses (5.8 for 100 residents) and they are not on site at night, whereas nurses are present 24 hours a day in long-term care units. Nursing home staff are primarily made up of nursing assistants and auxiliary staff, who are undoubtedly extremely devoted to their work, but are not adequately trained for the tasks they carry out and certainly underpaid as a result.

Deteriorating work and care conditions

Nursing homes find themselves facing a chronic lack of public funding. It therefore comes as no surprise that faced with emergency situations and endless needs, employees inevitably perform tasks that extend beyond their job description: they have no choice but to carry out tasks that are essential, but for which they are not qualified, to provide residents with the care and assistance they need (auxiliary staff help with grooming while nursing aids provide medical care). There is a disconnect between the work performed and salary levels, which remain low, making the sector unappealing and as a result, most nursing homes struggle to recruit staff, therefore exacerbating the already low caregiver-to-resident ratio in these facilities.

Working conditions have become even more difficult as changes in managerial practices have changed, as a result of efforts to control public spending, and have led to a demand for cost-effectiveness in nursing homes. These changes run counter to the founding principles of the facilities. As a successor to retirement homes, these institutions are also living communities, with a great number of interpersonal needs relating to accommodation (laundry, dining services), individual relationships and social life (care).

But in an effort to streamline operations, which goes hand in hand with cutting costs, work is “industrialized,” tasks are standardized and must be completed at a faster pace. The goal is to cut back on time considered to be “unproductive” – meaning saying “Good morning” and, “How are you today?” to residents in the morning and talking with them calmly in the evening – which ultimately amounts to all interpersonal aspects.

As far as indicators for funding institutions are concerned, public authorities prioritize tasks meant to accurately reflect operational productivity: the number of patients assisted with bathing and grooming or number of meals served! This intensifies the trend toward the dehumanization of living conditions in nursing homes, which are gradually turning in to “places to die.”

Dependence, a challenge for Social Security to recover from the crisis

This situation is alarming under normal circumstances, in particular from an ethical and social justice perspective, but it becomes tragic in the event of a health crisis. This is especially true today during the Covid-19 crisis. As the virus is wreaking havoc in these institutions, nursing homes lack medical staff to prescribe and administer the medications needed to keep patients alive and maintain their cognitive functions, or provide end-of-life care (Midazolam, Perfalgan). Staff members who are not considered caregivers had to wait for public authorities to decide to provide them with protective equipment, although it is critical to protecting high-risk residents. And while these residents are isolated in their rooms and visits are prohibited, employees do not have the time to comfort and support them at this difficult time.

These tragic circumstances call for a drastic rethinking of the nursing home model as many reports have suggested (Mission Flash Iborra-Fiat in 2018, Libault report in 2019). The fact is that these issues are related to the way the sector is funded.

While the various studies have assessed funding requirements for nursing homes at €7 and 10 billion, establishing a way to cover care for dependent persons within the healthcare sector, accompanied by increased resources based on needs, would have the advantage of doing away with the impossible separation between ‘cure’ and ‘care’, which has been maintained up to now for budgetary reasons, but which has shown its limitations, both in terms of managing hospitals and caring for dependent persons.

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Laura Nirello, Assistant Professor in economics, IMT Lille Douai – Institut Mines-Télécom and Ilona Delouette, PhD student in economics, University of Lille

This article has been republished from The Conversation under a Creative Commons license. Read original article (in French).