Bulgarian Hospitals Research Articles

In Vitro Antimicrobial Activity of Five Newly Approved Antibiotics against Carbapenemase-Producing Enterobacteria-A Pilot Study in Bulgaria.

To solve the problem with pan-drug resistant and extensively drug-resistant Gram-negative microbes, newly approved drugs such as ceftazidime/avibactam, cefiderocol, plazomicin, meropenem/vaborbactam, and eravacycline have been introduced in practice. The aim of the present study was to collect carbapenemase-producing clinical Enterobacterales isolates, to characterize their carbapenemase genes and clonal relatedness, and to detect their susceptibility to commonly used antimicrobials and the above-mentioned newly approved antibiotics. Sixty-four carbapenemase producers were collected in a period of one year from four Bulgarian hospitals, mainly including Klebsiella pneumoniae (89% of the isolates) and also single Proteus mirabilis, Providencia stuartii and Citrobacter freundii isolates. The main genotype was blaNDM-1 (in 61%), followed by blaKPC-2 (23%), blaVIM-1 (7.8%) and blaOXA-48 (7.8%). Many isolates showed the presence of ESBL (blaCTX-M-15/-3 in 76.6%) and AmpC (blaCMY-4 in 37.5% or blaCMY-99 in 7.8% of isolates). The most common MLST type was K. pneumoniae ST11 (57.8%), followed by ST340 (12.5%), ST258 (6.3%) and ST101 (6.3%). The isolates were highly resistant to standard-group antibiotics, except they were susceptible to tigecycline (83.1%), colistin (79.7%), fosfomycin (32.8%), and aminoglycosides (20.3-35.9%). Among the newly approved compounds, plazomicin (90.6%) and eravacycline (76.3%) showed the best activity. Susceptibility to ceftazidime/avibactam and meropenem/vaborbactam was 34.4% and 27.6%, respectively. For cefiderocol, a large discrepancy was observed between the percentages of susceptible isolates according to EUCAST susceptibility breakpoints (37.5%) and those of CLSI (71.8%), detected by the disk diffusion method. This study is the first report to show patterns of susceptibility to five newly approved antibiotics among molecularly characterized isolates in Bulgaria. The data may contribute to both the improvement of treatment of individual patients and the choice of infection control strategy and antibiotic policy.

How Sensitive and Specific are Rapid Antigen Tests for SARS-CoV-2 – The Experience of One of the Biggest Bulgarian Hospitals

Abstract Rapid point-of-care tests that detect antigens specific for SARS-CoV-2 are less expensive and faster than the standard molecular methods. However, their accuracy varies widely between tests, populations and settings. We decided to assess the diagnostic precision of antigen tests for SARS-CoV-2 in a real-life hospital environment. In a cohort of 2677 hospitalized patients, we found a sensitivity of 60.2% (95% CI 57.1%-63.4%) and a specificity of 98.1% (95% CI 97.4%-98.7%) for the antigen tests when compared to RT-PCR. The accuracy of antigen testing could be acceptable in a hospital setting, especially when the result is consistent with the clinical and epidemiological context. When there is discordance between the antigen test result and the patient’s symptoms, a confirmation with molecular methods is needed.

Molecular Epidemiology of Bulgarian Clinically Significant Staphylococcus aureus Isolates.

Severe infections due to highly virulent and resistant Staphylococcus aureus pose a serious health threat in Bulgaria and worldwide. The purpose of this study was to explore the clonal spread of recent clinically significant methicillin-susceptible S. aureus (MSSA) isolates from inpatients and outpatients treated in three university hospitals in Sofia, Bulgaria, during the period 2016-2020 and evaluate the relationship between their molecular epidemiology, virulence profiling, and antimicrobial resistance. A total of 85 isolates (invasive and noninvasive) were studied using RAPD analysis. Ten major clusters (A-K) were identified. The first major cluster A (31.8%) was found to be predominant during 2016 and 2017 and was widespread in two hospitals, unlike its case in the following years, when it was found to be replaced by newer cluster groups. All MSSA members of the second most common cluster F (11.8%) were recovered from the Military Medical Academy, mainly during 2018-2020, and were determined to be susceptible to all other groups of antimicrobials, except for penicillins without inhibitors because they harboured the blaZ gene. The newer cluster I, with 9.4% of the isolates absent in 2016-2017, showed significantly higher virulence and macrolide resistance (42.9%) due to ermB and ermC. All the isolated MSSA in groups F and I were nosocomial and mostly invasive. In conclusion, this 5-year study demonstrates the molecular epidemiology of MSSA infections in three Bulgarian hospitals. Findings can be helpful for the understanding of staphylococcal infection distribution in hospital settings and their prevention.

A survey of the knowledge, perceptions of and attitudes to digital health of healthcare professionals in 14 Bulgarian hospitals: First large-scale study on digital health in Bulgarian inpatient facilities.

To explore the knowledge, perceptions of and attitudes to digital health of Bulgarian hospital professionals in the first study of digital health in this professional group. A paper-based questionnaire was administered to doctors, trainee doctors, nurses, midwives, and laboratory assistants working in multiprofile or specialized hospitals. Topics included the following: state, objectives, benefits, and future of digital health; data storage, access, security, and sharing; main software used; patient-held Personal Information System (PIS); and telemedicine. A total of 1187 participants from 14 hospitals completed the survey in two phases: September 2013-April 2014 and May 2015-April 2017. Data were analyzed through descriptive statistics and multilevel logistic regression. Three-quarters of participants evaluated the state of development of digital health in Bulgaria as subpar (36.0% negative; 38.9% passable; 24.5% positive). 27.2% (323) endorsed patients having unconditional access to their data. In contrast, 89.5% (1062) of participants considered it appropriate to have full access to patient data recorded by colleagues. Doctors were more likely to endorse patients having access to their data than healthcare specialists (OR = 1.79 at facility, OR = 1.77 at location). The largely negative or lukewarm attitudes toward the state of development of digital health in Bulgaria are likely to result from the high number of failed projects, unmet expectations, misunderstood benefits, and unforeseen challenges. This study provides a much-needed stimulus and baseline for researching the ways in which the digital health landscape in Bulgaria has matured-or not.

Patient Safety Culture in Bulgarian Hospitals – A Web-Based Survey

Establishing a high culture of patient safety in hospitals is one of the main ways to prevent or reduce errors and improve the overall quality of healthcare. The aim of the study is to assess the perceptions on patient safety culture among healthcare specialists in Bulgarian hospitals. A national cross-sectional survey was conducted among 620 healthcare specialists. The study was conducted using the web-based Bulgarian Version of the Hospital Survey on Patient Safety Culture Questionnaire (B-HSOPSC). The B-HSOPSC includes 42 questions, grouped in 12 different dimensions measuring patient safety culture. No personal identification was possible of the participations in the survey using the e-platform. The data was analyzed with descriptive statistics and non-parametric tests. The results of the study show in general that the respondents demonstrate a positive attitude regarding patient safety culture. The dimensions “Staffing” and “Non-punitive response to error” are most problematic, as their percentage of positive response rates (PRRs) are lowest - 35.16% and 39.62%, respectively. However, “Handoffs and transitions” and “Overall perceptions of safety“ show the highest PRRs – 66.65% and 65.48%, respectively. From all participants, 74.7% have never reported an adverse event or error. Non-parametric tests did not find significant statistical differences in “Patient safety grade” between physicians and other health care specialists. Based on the evidence, the hospital managements need to focus on improving problem areas.

Antibiotic Resistance And Monitoring Of Antibiotic Consumption In Hospital Settings

Introduction: Antibiotics are one of the key discoveries in human history. Unfortunately, the global rise in antimicrobial drug resistance has become one of the most pressing medical problems. Monitoring of antibiotic consumption is one of the most important components of all programs aimed at controlling the problem with the rising antimicrobial resistance. Aim: The aim of this article is to present a free and internationally standardized electronic-based method for calculating the consumption of antibiotics in hospitals and in society. Methodology: The system for classification of antibiotic agents ATC/DDD (Anatomical Therapeutic Chemi-cal/Defined Daily Dose), which is an international standard for calculation of antibiotic consumption in a univer-sal technical unit of measurement—defined daily dose, is used. Practical Examples and Recommendations: The problem with the increasing antibiotic resistance was first discussed internationally at The Microbial Threat conference in Copenhagen in 1998. Monitoring antibiotic consumption is one of the key components of The European Community Strategy Against Antimicrobial Re-sistance from 2001. For the convenience of the users, open-source free software programs, incorporating the ATC/DDD system, such as ABC Calc and AMC Tool have been created for easy calculation of antimicrobial consumption. Discussion: According to the latest ECDC report, total antibiotic consumption in EU countries has been decreasing since 2014, with data for 2020 showing that antimicrobial consumption has decreased further during the first year of the COVID-19 pandemic. The only exception is Bulgaria, where it has doubled. Conclusion: ECDC data show that our country lags significantly behind other EU countries and immediate strict measures and actions are needed to combat the rising tide of antimicrobial resistance. Given the availabil-ity of free open-source programs for monitoring antimicrobial consumption, it would be very helpful to use them more widely in Bulgarian hospitals, and hospital pharmacists should play a key role in this process.

Comparative Assessment of the Level of Patient Safety Culture between Surgical and Nonsurgical Units in Bulgarian Hospitals

Patient safety culture is a key component of the organizational culture and a critical measure of the quality of healthcare. The aim of this study was to gain an insight into the problems concerning patient safety culture, based on the analysis of data, collected after interviewing healthcare specialists working in surgical and nonsurgical units in selected Bulgarian hospitals. This was a cross-sectional online study using a web-platform and the Bulgarian Version of Hospital Survey on Patient Safety Culture. It was conducted among healthcare workers (n = 620) in 2021. The B-HSOPSC incudes 42 scales grouped in 12 different domains. We compared the percentage of positive ratings and outcome dimensions between surgical and other hospital departments with the nonparametric Mann–Whitney U test, χ2 tests, Fisher’s Exact Test, and OR. The results showed that there are no statistically significant differences between the ratings on Patient Safety Culture given by the surgical and the nonsurgical staff except for the dimension “Hospital management support for patient safety”. Results from the study highlighted that the most important aspect of hospital patient safety is the shortage of medical staff in both surgical and nonsurgical hospital units. Communication, work shift organization, handoffs and transitions between shifts and among different hospital units, as well as communication with line managers were rated as satisfactory in Bulgarian hospitals.

Cerebral vasospasm after subarachnoid hemorrhage from intracranial aneurysm rupture in SARS-CoV-2 positive patients. A retrospective review from two Bulgarian hospitals

Intracranial aneurysms are acquired lesions resulting from hemodynamic stress on the vascular wall. Their rupture usually presents as a subarachnoid hemorrhage (SAH) with a high mortality rate. Cerebral vasospasm follows, which leads in many cases to delayed brain ischemia and even death. We aimed to explore the relationship between cerebral perfusion and coronavirus disease (COVID-19) in aneurysmal SAH. We analyzed 42 cases that underwent treatment for proven SAH due to ruptured cerebral aneurysms between January 2020 and December 2021. The patients were treated adhering to a standard protocol. The cerebral vasospasm was assessed by measuring the difference in the mean arterial pressure of the carotid artery relative to the internal cerebral artery (Lindegaard’s ratio) by transcranial Doppler ultrasound for 12 consecutive days. Twenty-three patients showed no signs of an acute respiratory syndrome associated with COVID-19 but tested positive for the SARS-coronavirus 2 (SARS-CoV-2). The control group included 19 SARS-CoV-2 negative cases. The mean age was 59.7 ± 8.4 years (range 44-72), with 29 males and 13 females. The mean arterial pressure was without a significant difference of 89.3 ± 3.3 to 89.7 ± 3.7 mmHg in SARS-CoV-2 negative to positive patients. When viral infection was evident, we observed a higher Lindegaard’s ratio of 2.12 ± 0.36 than the control, with a value of 1.43 ± 0.33 (p < 0.01). Thus, brain perfusion was 32.5% better in negative patients. We suggest that SARS-CoV-2 positive patients, without acute COVID-19, are more likely to have worse brain perfusion after SAH from cerebral aneurysm rupture.

In vitro Investigation of Antibiotic Combinations against Multi- and Extensively Drug-Resistant Klebsiella pneumoniae

Objectives: Community and hospital acquired K. pneumoniae infections have become a ubiquitous medical issue due to the limited treatment options and high mortality rate therefore the aims of this study are in vitro investigation of double antimicrobial combinations against multidrug resistant (MDR) and extensively drug resistant (XDR) isolates.&#x0D; Materials and Methods: Antimicrobial susceptibility of twelve isolates from eight Bulgarian hospitals was determined to study the interaction effect of selected double combinations in accordance to fractional inhibitory concentration (FIC) method. Furthermore, the isolates were subjected to genotyping by Multilocus sequence typing (MLST) and detection of carbapenemase genes by multiplex PCR. The results were assessed by groups of strains with either NDM or KPC carbapenemase.&#x0D; Results: Nine antimicrobial combinations: meropenem-colistin, meropenem-fosfomycin, meropenem-gentamicin, meropenem-rifampicin, meropenem-tigecycline, colistin-fosfomycin, colistin-gentamicin, colistin-rifampicin and colistin-tigecycline were tested for synergism on twelve K. pneumoniae, producing either KPC-2 (KPC-KP, 41.7%, 5/12) or NDM-1 (NDM-KP, 58.3%, 7/12). The isolates were distributed in three sequence types: ST11 (58.3%, 7/12), ST15 (25%, 3/12) and ST258 (16.7%, 2/12). All KPC-KP (ST258 and ST15) originated from three hospitals. The rest were NDM-1 carriers isolated from six hospitals and belonged to ST11. The highest synergistic effect was determined for MER-GEN (83.3%, 10/12) and COL-RIF (83.3%, 10/12). The MER-FOS combination was most efficient against NDM-KP, opposite to the KPC strains. Antagonism was not observed for any combinations.&#x0D; Conclusions: The evaluated joint synergistic effect of the MER-GEN and COL-RIF may facilitate the treatment options for patients infected with NDM- and KPC-KP, whereas MER-FOS is highly synergetic against NDM-KP.

Fecal Carriage and Epidemiology of Extended-Spectrum Beta-Lactamase/Carbapenemases Producing Enterobacterales Isolates in Bulgarian Hospitals.

The gastrointestinal tract is an important reservoir of extended spectrum beta-lactamase (ESBL)/carbapenemase-producing Enterobacterales isolates. This study included patients from two Bulgarian hospitals. Overall, 98 ESBL producers (including 68 Escherichia coli and 20 Klebsiella pneumoniae isolates) were detected among 99 hospitalized patients, 212 patients at admission, and 92 hospital staff in 42.4%, 24.5%, and 4%, respectively. We observed blaCTX-M-15 in 47% of isolates, blaCTX-M-3 in 39% and blaCTX-M-14 in 11%. Three blaCTX-M-15 positive isolates were also blaKPC-2 positive. High transferability was detected for blaCTX-M-3 carrying plasmids (55%) with L/M and I1 replicon plasmids, followed by CTX-M-14 (36.4%) and CTX-M-15 (27.9%) with IncF plasmids. BlaKPC-2 was carried by FIIAs plasmids. Epidemiology typing revealed 8 K. pneumoniae ST types—ST15(8/20), ST17(4/20), ST37(2/20) and 9 E. coli ST types—ST131 (30.9%, 21/68), ST38 (8/68), ST95(7/68) and ST316(7/68). All ST131 isolates but one was from the highly virulent epidemic clone O25bST131. This is the first report in Bulgaria about ESBL/carbapenemase faecal carriage. We observed high ESBL/carbapenemases prevalence. A predominant number of isolates were members of highly epidemic and virulent PanEuropean clones ST15 K. pneumoniae and O25bST131 E. coli. High antibiotics usage during the COVID pandemic will worsen the situation. Routine screenings and strict infection control measures should be widely implemented.

BULGARIAN HEALTH SYSTEM COST ASSESSMENT METHODS APPLICATION FOR THE DECISION “MAKE OR BUY”

The application of cost assessment methods for the decision “make or buy” is very useful for the private enterprises and this can be traced by the published scientific experimental evidences about the future benefits. The subject, focused of the present research is to investigate whether it is appropriate for the Bulgarian health system cost assessment methods to be used. Most of the Bulgarian hospitals are not private and this is a challenge for the health mangers to lead the hospital on profit even if the financing is a mixed public-private and the regulatory issues do not allow them to take the decision “make or buy” on their own. The most important analyzed result is the impact of the decision “make or buy” on different kinds of costs that are common at the hospital activities. The present publication consists with the results from the first part of the conducted research.

Testing the Cost Assessment Methods Application at a Hospital for the Decision ‘Make or Buy’

The application of cost assessment methods for the decision “make or buy” is very useful for the private enterprises and this can be traced by the published scientific experimental evidences about the future benefits. The subject, focused of the present research is to investigate whether it is appropriate for the Bulgarian health system cost assessment methods to be used. Most of the Bulgarian hospitals are not private and this is a challenge for the health mangers to lead the hospital on profit even if the financing is a mixed public-private and the regulatory issues do not allow them to take the decision “make or buy” on their own. The most important analyzed result is the impact of the decision “make or buy” on different kinds of costs that are common at the hospital activities. The present publication consists with the results from the first part of the conducted research.

DIFFERENCES IN GENOTYPE OF E. FAECALIS AND E. FAECIUM CLINICAL ISOLATES REGARDING CYTOLYSIN AND GELATINASE PRODUCTION IN BULGARIAN PATIENTS

Purpose - compare the phenotype and genotype correlation of cytolysin and gelatinase production in clinical isolates Enterococcus spp. Materials and methods - 100 Enterococcus strains collected over a period of one year from inpatients of two Bulgarian university hospitals, were tested for phenotype production of cytolysin and gelatinase. Multiplex PCR was performed to screen the presence of gelE and cylA virulence genes. Results – 17% of the enterococcal isolates demonstrated only cytolysin production phenotypically. Gelatinase activity was found in 21% of the isolates. Only E. faecalis showed combined phenotypic production of cytolysin plus gelatinase (21%). Forty-five percent of the tested enterococci were identified negative for both hemolysin and gelatinase activity. GelE was the most prevalent virulent gene (48% of the isolates). CylA gene was present alone only in four non-invasive E. faecalis isolates. Twenty-six percent of the isolates possessed both cylA and gelE genes and 21% did not harbor any of the virulence factors genotypically. Conclusion - our results prove that it is appropriate to perform both phenotypic and genotypic analysis of the enterococci virulence profile in parallel in order to better characterize the strains, which in turn may serve to develop more effective methods to limit the spread of infections caused by these microorganisms.

Partnerships in Bulgarian Hospital Sector – Practice and Development

Introduction. In recent years, hospitals in Bulgaria have been operating in resource constraint and highly competitive environment, which hindered their operations. Collaboration in the hospital sector provides opportunities to address environmental challenges and facilitates the access to resources and new markets. The aim of this article is to analyze the partnerships between hospitals and other organizations and to evaluate their development in Bulgaria. Materials and Methods. The study was conducted in 2016 among senior managers of 71 hospitals in Bulgaria. Using the survey, the previous experience of hospital managers in the implementation of partnerships, attitudes and motives for cooperation with other organizations is analyzed. Results and Discussion. The results of the survey indicate that all hospitals participate in some form of partnership with other healthcare and health establishments or organizations outside the healthcare system. Most often, they cooperate with external service providers, other Bulgarian healthcare establishments, as well as with providers of medical equipment and supplies. Hospitals cooperate with other hospitals mainly to share necessary resources (specialists and equipment) for their medical activities. They tend to have limited cooperation with their direct competitors mainly to exchange staff and have more patients. Hospital managers define their partnerships as successful in terms of results achieved. Conclusion. In the hospital sector in Bulgaria, co-operation is widely used as an opportunity to share resources and risks with other organizations. Partnerships with foreign hospitals that have the potential to improve the competitiveness of Bulgarian hospitals have not yet been sufficiently developed.

Comparing patient safety culture in Bulgarian, Croatian and American hospitals - preliminary results.

Background and aimsPatient safety culture (PSC) is an essential component of the quality of healthcare. Improving PSC is considered a priority in many developed countries. A specialized software platform for registration and evaluation of hospital patient safety culture has been developed with the support of the Medical University Plovdiv Project №11/2017.The aim of the study is to assess the status of PSC in Bulgarian hospitals and to compare it to that in USA and Croatian hospitals.MethodsThe study was conducted from June 01 to July 31, 2018 using the web-based Bulgarian Version of the Hospital Survey on Patient Safety Culture Questionnaire (B-HSOPSC). Two hundred and forty-eight medical professionals from different hospitals in Bulgaria participated in the study. In order to quantify the differences of positive scores distributions for each of the 42 HSOPSC items between Bulgarian, Croatian and USA samples, the χ2-test was applied. The research hypothesis assumed that there were no significant differences between the Bulgarian, Croatian and US PSCs.ResultsThe results revealed 14 significant differences in the positive scores between the Bulgarian and Croatian PSCs and 15 between the Bulgarian and the USA PSC, respectively. Bulgarian medical professionals provided less positive responses to 12 items compared with Croatian and USA respondents. The Bulgarian respondents were more positive compared to Croatians on the feedback and communication of medical errors (Items - C1, C4, C5) as well as on the employment of locum staff (A7) and the frequency of reported mistakes (D1). Bulgarian medical professionals were more positive compared with their USA colleagues on the communication of information at shift handover and across hospital units (F5, F7). The distribution of positive scores on items: “Staff worry that their mistakes are kept in their personnel file” (RA16), “Things ‘fall between the cracks’ when transferring patients from one unit to another” (RF3) and “Shift handovers are problematic for patients in this hospital” (RF11) were significantly higher among Bulgarian respondents compared with Croatian and US respondents.ConclusionsSignificant differences of positive scores distribution were found between Bulgarian and USA PSC on one hand and between Bulgarian and Croatian on the other. The study reveals that distribution of positive responses could be explained by the cultural, organizational and healthcare system differences.

Combined Laboratory Approach to Detection of Parvovirus B19 and Coxiella Burnetii in Patients with Fever of Unknown Origin

Fever of unknown origin (FUO) is one of the greatest challenges for clinicians and patients. There are more than 200 etiological agents of FUO, among these the most common is the role of infection, neoplasms, and diseases of connective tissue. The aim of the present study is to investigate the role of the infectious agents parvovirus B19 (B19V) and Coxiella burnetii (C. burnetii) in the development of fever of unknown origin by a set of immunoenzymatic and molecular methods. The present study included a total of 70 adult patients diagnosed with FUO and hospitalized in Bulgarian Hospitals. A control group of 26 healthy people were also included. Serological (indirect enzyme immunoassay test for detection of B19V and C. burnetii Ph. II specific IgM/IgG) and molecular (extraction and detection of infectious nucleic acids) methods were used. From all patients with FUO, a positive result for B19V-IgM was obtained in 18/70 (25.71%, 95% CI: 15.47 - 35.95) and the highest percentage was found in age groups 0 - 9 and 10 - 19 years. Protective B19V immunity and past viral infection was reported in 41/70 (58.57%, 95% CI: 47.03 - 70.11), and this percentage corresponded with the control group 16/26 (61.54%, 95% CI: 42.84 - 80.24). Anti-C. burnetii Ph. II-IgM was demonstrated in 13/70 (18.57%, 95% CI: 9.46 - 27.68). A relatively high percentage of affected patients were ≤ 40 years. Anti-C. burnetii Ph. II-IgG was detected in 24/70 (34.29%, 95% CI: 23.17 - 45.41). The control group has a 100% negative result for acute B19V and C. burnetii infection. A positive B19V-DNA result was obtained in 12/70 (17.14%, 95% CI: 8.31 - 25.97) patients. In 11/12 (91.67%) it was in combination with positive B19V-IgM marker. Of the total 70 sera tested, a positive PCR results for C. burnetii-DNA were obtained in 11 (15.71%, 95% CI: 7.18 - 24.24). According to clinical manifestation and concomitant symptoms, a high percentage of B19V and C. burnetii positives were associated with FUO and fever, headache, chills, and rash. It is of particular importance for a correct diagnosis of FUO to use a combined laboratory approach to prove acute or persistent infection and to test for a set of etiological agents.

Socio-economic factors for the job satisfaction of the physicians in bulgarian hospitals

Socio-economic factors for the job satisfaction of the physicians in bulgarian hospitals

A taxonomy of healthcare supply chain management practices

ABSTRACTThis paper describes the classification of a sample of hospitals based upon the extent of supply chain management practices application. Data was collected from 63 Bulgarian hospitals. Scores of 14 measures of two dimensions of healthcare supply chain management (HSCM) – internal and external, were subjected to hierarchical cluster analysis. A detailed characterization of the resulting three clusters was made in terms of the applied HSCM practices. On the basis of the scores for these practices the clusters were labeled as ‘leading hospitals’, ‘developing hospitals’, ‘underdeveloped hospitals’. This research also explores the differences between the groups of hospitals in relation to their performance. The use of a cluster analysis helps in gaining an understanding of the patterns of HSCM. This will be useful for researchers who want to test the existence of these patterns in their countries and for healthcare practitioners as well who could formulate a HSCM strategy based on their level of HSCM development and choose to apply practices within the different HSCM patterns. Originality – The article investigates how HSCM practices create differences among hospitals, including their performance.

Work overload of nurses and midwives in Bulgarian hospitals and the need for provision of supporting care by health assistants

INTRODUCTION : Medical professionals face big problems in providing supporting care. Currently it is delivered by nurses and midwives, a huge challenge in terms of the constant work overload this kind of med­ical professionals face in Bulgaria. AIM : The aim is to explore the work overload among nurses and midwives in Bulgarian hospitals and the need for the recruitment of a separate group of additional staff - health assistants for the delivery of sup­porting care. MATERIALS AND METHODS : The study was conducted among the medical staff in nine hospitals in five cities of Northeastern Bulgaria. The total number of respondents was 463 including physicians, nurses and midwives. Data about the work overload of nurses and midwives, as well as the need for additional per­sonnel for supporting care was collected by a semi-structured questionnaire. Data was analyzed with IBM SPSS v. 19 - descriptive statistics and non-parametric tests (the Chi-square test was used for analyzing the independence of two categorical data). RESULTS : Results show that according to the medical staff, nurses and midwives are `permanently` and `frequently` overloaded with work due to the provision of supporting care for patients. There was no statistically significant relationship between `profession` and `work overload` (I‡2=9.188, p=0.163), i.e. - both nurses and midwives are considered as overloaded with work. Almost all respondents notify that med­ical orderlies also take part in delivering supporting care. Two thirds of the respondents acknowledge the need for hiring health assistants. CONCLUSION : There is an essential need for health assistants in Bulgarian health care. The new health professionals would be fully involved in providing supporting care which would improve quality of care and reduce the work overload of nurses and midwives.

Web based national patient dose survey in diagnostic and interventional radiology. Preliminary results and analysis of survey performance

Introduction According to the Bulgarian regulation for radiation protection of medical exposure, the National Centre of Radiobiology and Radiation Protection (NCRRP) is responsible for performing national dose surveys in diagnostic and interventional radiology and nuclear medicine and for establishing of national diagnostic reference levels (DRLs). Purpose In the period 2014–15 NCRRP have developed web based platform with main goal to establish new national DRLs by collecting data from most of the facilities in the country. Materials and methods In collaboration with software company centralized database was developed. The database can be accessed via internet browser, allowing pre-registered user remote sending of survey data. Electronic questionnaires with the necessary technical and dosimetric information were prepared. Short but clear manuals are also included to guide users, and to minimize errors. Since many of the X-ray systems in Bulgaria are still analogue, the platform at this stage also allows manually enter patient data by the user. Results Users from Bulgarian hospitals was trained and encouraged to enter data. During the test period more than 300 individual patient data sets, from 8 clinical departments, were sent in the database of platform. Currently medical physicists and radiographers from more than 20 clinical departments collect and enter data in the platform. Conclusion Patient data gathered from number of hospitals and different type of examination was used to test the platform. Every hospital or clinical department participated in the survey can establish the local DRLs and initiate optimization of their own protocol.