Validation of an evaluation instrument for responders in tactical casualty care simulations / Validação de um instrumento de avaliação para a prática de cuidados de saúde estratégicos / Validación de un instrumento de evaluación para la práctica de la atención sanitaria táctica

Objective: to construct and validate a tool for the evaluation of responders in tactical casualty care simulations. Method: three rubrics for the application of a tourniquet, an emergency bandage and haemostatic agents recommended by the Hartford Consensus were developed and validated. Validity and reliability were studied. Validation was performed by 4 experts in the field and 36 nursing participants who were selected through convenience sampling. Three rubrics with 8 items were evaluated (except for the application of an emergency bandage, for which 7 items were evaluated). Each simulation was evaluated by 3 experts. Results: an excellent score was obtained for the correlation index for the 3 simulations and 2 levels that were evaluated (competent and expert). The mean score for the application of a tourniquet was 0.897, the mean score for the application of an emergency bandage was 0.982, and the mean score for the application of topical haemostats was 0.805. Conclusion: this instrument for the evaluation of nurses in tactical casualty care simulations is considered useful, valid and reliable for training in a prehospital setting for both professionals who lack experience in tactical casualty care and those who are considered to be experts.

Objetivo: construir e validar um instrumento de avaliação da prática, por meio da simulação, nos cuidados de saúde estratégicos. Método: três instrumentos para práticas de avaliação de aplicação do torniquete, bandagem de emergência e agente hemostático recomendados pelo Consenso de Hartford foram desenvolvidos e validados. A validade e a confiabilidade foram estudadas. A validação foi realizada por quatro especialistas da área e trinta e seis enfermeiros participantes selecionados por amostragem por conveniência. Três instrumentos de avaliação com 8 itens foram avaliados (com exceção da bandagem de emergência, que tinha 7 itens para avaliar). Cada prática foi avaliada por três especialistas. Resultados: uma pontuação excelente foi obtida no cálculo do índice de correlação para as três práticas e nos dois níveis avaliados (competente e especialista). A pontuação média para a aplicação do torniquete foi de 0,897, para o curativo de emergência foi de 0,982 e para a aplicação de agentes hemostáticos tópicos foi de 0,805. Conclusão: este instrumento de avaliação da prática por meio de simulação nos cuidados de saúde estratégicos é considerado útil, válido e confiável para o treinamento no contexto pré-hospitalar tanto dos profissionais que não possuem experiência nos cuidados estratégicos quanto nos considerados peritos.

Objetivo: construir y validar un instrumento de evaluación de la práctica, mediante simulación, en la atención sanitaria táctica. Método: se construyeron y validaron tres rúbricas de las prácticas de aplicación del torniquete, vendaje de emergencia y agente hemostático recomendadas por el Consenso Hartford. Se estudió la validez y fiabilidad. La validación se realizó por cuatro expertos en la materia y treinta y seis participantes enfermeros que fueron la muestra de conveniencia. Se evaluaron tres rúbricas con 8 ítems (excepto para el vendaje de emergencia que fueron 7 ítems a evaluar). Cada práctica fue evaluada por tres expertos. Resultados: se ha obtenido una excelente puntuación en el cálculo del índice de correlación para las tres prácticas y en los dos niveles evaluados (competente y experto). La puntuación media para la rúbrica de aplicación del torniquete fue de 0.897, la del vendaje de emergencia 0.982 y para la aplicación de hemostáticos tópicos 0.805. Conclusión: este instrumento de evaluación de la práctica mediante simulación en la atención sanitaria se considera útil, válido y fiable para la formación en el entorno prehospitalario tanto de profesionales que carecen de experiencia en atención táctica como de aquellos considerados como expertos.

Satisfacción con la atención en urgencias pediátricas: influencia del funcionamiento familiar y la alteración emocional / Satisfaction with care received in pediatric emergency services: impact of family interaction and emotional disturbance

Resumen Este estudio aborda la relación entre dos elementos clave en la satisfacción con los servicios sanitarios de urgencias pediátricas: la afectación emocional y el funcionamiento familiar. El objetivo general es determinar si la cohesión, la adaptabilidad familiar y la ira pueden asociarse a niveles diferenciales de satisfacción en progenitores cuyos hijos eran atendidos en urgencias pediátricas. Se trata de un estudio descriptivo transversal para el que se trabajó con una muestra de 711 progenitores que habían sido atendidos en 6 servicios de urgencias pediátricas. Se utilizaron respectivamente las versiones españolas del Inventado de Expresión de Ira Estado-Rasgo-2 (STAXI-2), la Escala de Satisfacción con los Servicios Sanitarios y la Escala de Evaluación de la Cohesión y Adaptabilidad Familiar (Faces). El análisis de datos incluyó un análisis de correlaciones bivariadas de Spearman, pruebas de Kruskal Wallis, pruebas de Mann-Whitney y un path-analysis mediante un modelo de ecuaciones estructurales. Los resultados soportan la idea de que mayores niveles de cohesión y adaptabilidad familiar así como menores niveles de ira, se asocian a mayores niveles de satisfacción en los padres. Nuestros datos no reflejan diferencias significativas en ira entre padres y madres.

Abstract This study addresses the relationship between two key elements in satisfaction with pediatric emergency services, namely emotional disturbance and family interaction. The main goal is to determine whether family cohesion and adaptability and anger may be associated with differential levels of satisfaction among parents whose children were attended in pediatric emergency units. It is a descriptive study for which a sample of 711 parents whose children were attended in 6 pediatric emergency services was studied. The Spanish version of the State-Trait Anger Expression Inventory-2 (Staxi-2), the Satisfaction with Healthcare Services Scale and the Family Adaptability and Cohesion Evaluation Scale (Faces) were used respectively. Data analysis included a Spearman bivariate correlations analysis, Kruskal Wallis, Mann-Whitney test and path-analysis using a structural equations model. The results support the hypothesis that higher levels of family cohesion and adaptability as well as lower levels of anger are associated with higher levels of satisfaction among parents.

[Studying the time of response and results of delay in emergency medical system's [EMS] missions in Shiraz]

Prehospital Emergency Medical System is one of the critical parts in health care sector which has been usually unnoticed. Delivering quick, efficient and high quality care in this system has a large impact on mortality and morbidity of patients. In this descriptive and cross-sectional study, 20662 cases in 4 months in the middle of the year 2008. Missions over 8 minutes from when the time of call receiving to arrival on the scene were detected and survived For statistical analysis ANOVA was used. Most of the missions were done between 8 to10 minutes. Nine reasons were detected for this arrival delay:1] destruction of the road, 2] Traffic, 3] Rainy weather, 4] Long way to the scene, 5] Scarcity of ambulance in the center near the scene, 6] Wrong address, 7] Cannot find the address, 8] Delay in dispatching the ambulance, 10] Delay in arrival because of technicians. In Shiraz Emergency Medical system the most important reasons for missions over 8 minutes were scarcity of ambulance in the center near the scene, traffic, long way to the scene. Quick arrival on the scene has a large effect on patients, though, health ministry and emergency centers should pay more attention on this sector and deliver financial support for equipped emergency centers due to the population and demand for emergency centers.

Reduced frequency of cardiopulmonary arrests by rapid response teams / Redução de paradas cardiorrespiratórias por times de resposta rápida

OBJECTIVE: To evaluate the impact of the implementation of a rapid response team on the rate of cardiorespiratory arrests in mortality associated with cardiorespiratory arrests and on in-hospital mortality in a high complexity general hospital. METHODS: A retrospective analysis of cardiorespiratory arrests and in-hospital mortality events before and after implementation of a rapid response team. The period analyzed covered 19 months before intervention by the team (August 2005 to February 2007) and 19 months after the intervention (March 2007 to September 2008). RESULTS: During the pre-intervention period, 3.54 events of cardiorespiratory arrest/1,000 discharges and 16.27 deaths/1,000 discharges were noted. After the intervention, there was a reduction in the number of cardiorespiratory arrests and in the rate of in-hospital mortality; respectively, 1.69 events of cardiorespiratory arrest/1,000 discharges (p<0.001) and 14.34 deaths/1,000 discharges (p=0.029). CONCLUSION: The implementation of the rapid response team may have caused a significant reduction in the number of cardiorespiratory arrests. It was estimated that during the period from March 2007 to September 2008, the intervention probably saved 67 lives.

OBJETIVO: Avaliar o impacto da implementação de um time de resposta rápida na incidência de paradas cardiorrespiratórias, na mortalidade associada à parada cardiorrespiratória e na mortalidade hospitalar em um hospital geral, de alta complexidade. MÉTODOS: Análise retrospectiva dos eventos de paradas cardiorrespiratórias e mortalidade hospitalar, antes e depois da implementação de um time de resposta rápida. O período analisado compreendeu 19 meses antes da intervenção desse time (agosto de 2005 a fevereiro de 2007) e 19 meses após sua intervenção (março 2007 a setembro 2008). RESULTADOS: No período pré-intervenção, observaram-se 3,54 eventos de parada cardiorrespiratória/1.000 altas e 16,27 mortes/1.000 altas. Após a intervenção, observou-se redução no número de paradas cardiorrespiratórias e na taxa de mortalidade hospitalar: respectivamente 1,69 eventos de parada cardiorrespiratória/1.000 altas (p<0,001) e 14,34 mortes/1.000 altas (p=0,029). CONCLUSÃO: A implementação do time de resposta rápida, pode ter trazido uma redução significativa no número de paradas cardiorrespiratórias. Estimou-se que, no período de março de 2007 a setembro de 2008, a intervenção provavelmente salvou 67 vidas.

Protocolo de cuidados de enfermagem no ambiente aeroespacial a pacientes traumatizados: cuidados antes do voo / Protocol of nursing care to traumatized patients in the aerospace environment: care before flight / Protocolo de cuidados de enfermería en el ambiente aeroespacial a pacientes traumatizados: cuidados antes del vuelo

Teve-se como objetivo apresentar um protocolo de cuidados de enfermagem na pré-remoção aeroespacial de pacientes adultos vítimas de trauma. Trata-se de uma pesquisa qualitativa, convergente assistencial, realizada na Divisão de Operações Aéreas, em São José-SC, entre abril a junho de 2010. Baseou-se nos princípios do Prehospital Trauma Life Support. Utilizou-se de entrevista individual e de encontros em grupo. Participaram os oito enfermeiros do serviço. O protocolo contempla os cuidados relativos à segurança no embarque; desembarque; avaliação da cena; avaliação primária; avaliação secundária e estabilização do paciente. O protocolo propiciará uma prática de cuidado mais segura aos pacientes aerorremovidos.

The study aimed to present a protocol for nursing care in pre aerospace removing of adult victims of trauma. A qualitative convergent care research was performed at the Division of Air Operations in the municipality of San Jose-SC, Brazil, from April to June 2010. The study was based on the principles of the Pre-hospital Trauma Life Support. Individual interviews and group meetings were used. Eight nurses participated in the service. The proposed protocol includes safety boarding, disembarking, assessment of the scene, primary assessment, secondary assessment and stabilization of the patient. The protocol will provide a safer nursing practice care to patients aero removed.

Este estudio tuvo como objetivo presentar un protocolo para la atención de enfermería en la remoción pre aeroespacial de las víctimas adultas de trauma. Se trata de una investigación cualitativa, convergente asistencial, levada a cabo en la División de Operaciones Aéreas, en San José-SC, de abril a junio de 2010. La investigación levó en cuenta los principios del Prehospital Trauma Life Support. Para su elaboración, realizó-se entrevistas individuales y reuniones de grupo. Ocho enfermeras participaron en el estudio. El propuesto protocolo cubre los cuidados relativos a la seguranza durante el embarque y el desembarque; a la evaluación de la escena; a la evaluación primaria; a la evaluación secundaria y la estabilización del paciente. El protocolo servirá a una atención de enfermería más segura para los pacientes aerotransportados.

Epidemiological findings of ocular trauma in childhood

PURPOSE: To describe epidemiological findings of ocular trauma in childhood in an emergency unit. METHODS: A retrospective study was carried out including patients under 16 years old who were treated for ocular trauma at the emergency unit of the Federal University of São Paulo from September 2001 to September 2004. Age, sex, involved eye, place, circumstance and mechanism of injury, initial visual acuity and immediate management were recorded. RESULTS: A total of 273 patients were included in the study. The age group comprising most cases was 7 to 10 years (39.9 percent). The most frequent cause of ocular injury was traumatism by external agents like stone, iron and wood objects (27.9 percent). The commonest place was the home (53.1 percent). Initial visual acuity was over 20/40 in 63.4 percent of cases. Closed globe injury occurred in 201 (73.6 percent) accidents. Seventy-six children (27. 8 percent) were treated with medicines and in forty-eight (17.6 percent) cases surgery was necessary. CONCLUSION: Ocular trauma in childhood was more frequent in the male schoolchild and was due mostly to traumatism with agents like stone, wood and iron pieces, domestic utensils and leisure objects. The injuries occurred most frequently at home. Closed globe injuries predominated. Programs of education and prevention for ocular trauma in childhood are necessary.

OBJETIVO: Descrever os achados epidemiológicos do trauma ocular na infância em uma unidade de emergência. MÉTODOS: Em estudo retrospectivo, foram analisados prontuários de pacientes menores que 16 anos que foram atendidos por trauma ocular no Pronto-Socorro de Oftalmologia da Universidade Federal de São Paulo de setembro de 2001 a setembro de 2004. Foram coletadas informações a respeito da idade, sexo, olho envolvido, local, circunstância e mecanismo do trauma, acuidade visual inicial e conduta imediata. RESULTADOS: Um total de 273 pacientes foi incluído no estudo. A faixa etária com maior número de casos foi a de 7 a 10 anos (39,9 por cento). A causa mais freqüente de lesão ocular foi traumatismo com objetos externos como pedra, ferro ou madeira (28,9 por cento) e o local mais comum foi a própria casa (53,1 por cento). A acuidade visual inicial foi melhor que 20/40 em 63,4 por cento dos casos. Houve trauma ocular fechado em 201 (73,6 por cento) acidentes. Setenta e seis pacientes (27,8 por cento) foram tratadas com medicamentos e em quarenta e oito (17,6 por cento) casos foi necessário procedimento cirúrgico. CONCLUSÃO: O trauma ocular na infância foi mais freqüente no sexo masculino, em escolares e foi associado a objetos tais como pedra, madeira, ferro, utensílios domésticos e brinquedos. Os acidentes aconteceram mais freqüentemente em casa e trauma fechado foi a lesão predominante. São necessários programas de educação e prevenção do trauma na infância.

Oncological emergencies--management guidelines for clinicians.

The authors in the present article have given a brief outline of oncological emergencies and discussed the management guidelines from clinical stand point.

Influence of time elapsed from end of emergency surgery until admission to intensive care unit, on Acute Physiology and Chronic Health Evaluation II (APACHE II) prediction and patient mortality rate

CONTEXTO E OBJETIVO: Com freqüência os doentes são admitidos nas unidades de terapia intensiva com atraso em relação ao momento da indicação deste atendimento. Objetivamos verificar, nos doentes operados de urgência, se esse atraso interfere na letalidade hospitalar, na permanência na unidade e no hospital, e na predição do escore APACHE II. TIPO DE ESTUDO E LOCAL: De acurácia, prospectivo, na unidade de terapia intensiva da Santa Casa de Misericórdia de São Paulo, hospital terciário e universitário. MÉTODOS: Foram avaliados todos os 94 doentes admitidos de agosto/2002 a julho/2003, após operações de urgência. As variáveis estudadas foram: APACHE II, risco de óbito, permanência na unidade e no hospital e letalidade hospitalar. Foram comparados dois grupos de doentes divididos conforme o intervalo de tempo entre o fim da operação e a admissão na unidade: até 12 h e após 12 h. RESULTADOS: Os grupos eram semelhantes quanto ao sexo, idade, diagnóstico, APACHE II, tempo de internação, bem como de hospitalização. Os fatores de risco de óbito foram idade, APACHE II e tempo de retardo na internação (p < 0,02). A letalidade do grupo após 12 h foi maior (54.9 por cento x 26.1 por cento; p = 0,018). A letalidade observada foi maior que a esperada no grupo após 12 h (p = 0,015), enquanto a letalidade observada no grupo até 12 h foi semelhante à esperada (p = 0,288). CONCLUSÕES: O APACHE II previu melhor a letalidade do grupo de doentes que entraram mais rapidamente na unidade de cuidados intensivos, enquanto a letalidade hospitalar foi maior nos doentes que demoraram mais para a admissão na unidade de terapia intensiva.

Epidemiological and Trauma Injury and Severity Score (TRISS) analysis of trauma patients at a tertiary care centre in India.

BACKGROUND: An observational study was done to obtain the epidemiological profile of Indian trauma patients. We used the Trauma Injury and Severity Score (TRISS) and survival evaluation methodologies to compare the mortality with norms established by the Major Trauma Outcome Study of the USA to assess the quality of emergency medical care provided to trauma patients at our centre. This would allow comparisons and may help propagate the routine use of trauma scales. METHODS: An instrument to collect detailed epidemiological and TRISS data was created and validated. All patients with trauma who were admitted to the surgery service were included in the study. The details of all patients were recorded and they were followed till discharge or death during a 6-week period. RESULTS: Of the 180 trauma patients studied, 123 were men (70.3%) with a mean age of 24.7 years; 143 patients had blunt injuries while 32 patients had penetrating injuries. A nearly equal percentage of men were injured on the road (39.8%) as at home (39.0%), while most women (65.4%) were injured at home. The mortality rate was 31.4%. TRISS methodology was applied to 88.6% of patients. All the 113 survivors had a probability of survival > or = 0.5 and were considered expected survivors. Among the 42 deaths, 32 had a probability of survival > or = 0.5 and were considered unexpected deaths, while 10 of the deaths had a probability of survival <0.5 and were expected deaths. The reasons for the unexpected deaths were septicaemia, mannitol nephrotoxicity, aspiration and a direct result of the injury, especially in patients with burns. CONCLUSIONS: Our centre has a high rate of unexpected deaths. Although it is the major trauma referral centre in the region, the care provided to trauma patients needs to be improved.

Implementation of the national asthma management guidelines in the emergency department

The national protocol for asthma management was released in 1995. There has been no national investigation to compare the actual care delivered at the Emergency Department to those recommended by these guidelines: To compare the documented management of acute bronchial asthma at the Emergency Room [ER] with the Saudi National Guidelines Retrospective analyses of a total of 150 ER records, of patients with a diagnosis of asthma over a one year period [January through to December 2000], at King Abdul-Aziz Medical City, King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia. Documentation of the history, indices of severity, treatment given, pre-discharge assessment and prescriptions were compared to the nationally recommended management. History of the present attack, its duration, frequency of b-agonist use and nocturnal symptoms were documented in less than 50% of patients. Previous ER visits and hospitalization, peak flow rate and accessory muscle use were similarly recorded in less than 50% of patients whereas intensive care unit admission and intubation were documented in less than 15% of asthmatics. Steroids were given to only 46% of patients with acute asthma who visited the Emergency Department. Pre-discharge clinical assessment and peak flow readings were documented in 48% and 29%. Only 64% of patients were given a follow up appointment. The documented treatment of patients with an acute asthmatic episode at the ER varies significantly from what is recommended by the National and International Asthma Management Guidelines. Failure to implement Asthma Guidelines probably results in an inadequate care of asthmatic patients and raises the urgent need for a National Physician Asthma Education Program

Primeiro atendimento ao paciente queimado / Initial management of burns patients

O atendimento ao paciente portador de queimadura de qualquer etiologia merece, pela sua complexidade, uma rotina previamente conhecida, para que seja executada com bases já determinadas, respeitando-se sempre a emergêncal que envolve estas situações. Saber classificar, calcular superfície corporal queimada, hidratar e promover a adequada analgesia constitui necessidade na prática médica de qualquer serviço de urgência ou emergência.

Study on performance following Key Performance Indicators for trauma care: Khon Kaen Hospital 2000.

This study was conducted in 2000-2001 in order to improve the quality of trauma care by establishing the Key Performance Indicators (KPIs) as a guideline in providing trauma care service and to study the personnel's performance following 27 indexes of KPIs for trauma care in Khon Kaen Hospital. After the implementation of the KPIs by the method of participatory action research (PAR), the trauma preventable death rate was decreased to 1.3 per cent which was statistically different from the preventable death rate in 1997 (2.0%).

Recent advances in management of diabetic ketoacidosis.

Diabetic ketoacidosis is the most common endocrine emergency in children and frequently it is the initial presentation of insulin dependent diabetes mellitus. Despite sophisticated technology and our improved understanding of the pathophysiology of this disease, the mortality from intracranial complications remains constant over the past two decades. Several management protocols are used all over the world but the recent trend in opinion seems to be one of the slower rates of initial hydration aimed at matching the osmolarity of the infusion solutions with the patient's serum osmolarity. It remains to be seen if widespread use of this rehydration strategy will improve morbidity in the future. A protocol for managing diabetic ketoacidosis is suggested.