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5.
Intensive Care Med ; 47(3): 282-291, 2021 Mar.
Artículo en Inglés | MEDLINE | ID: covidwho-1092644

RESUMEN

Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients.


Asunto(s)
Cuidados Críticos/tendencias , Pandemias , Cuidados Críticos/organización & administración , Planificación en Desastres , Humanos , Unidades de Cuidados Intensivos/organización & administración , Monitoreo Fisiológico/instrumentación , Monitoreo Fisiológico/métodos , Equipo de Protección Personal , Capacidad de Reacción , Telemedicina , Flujo de Trabajo
7.
Pan Afr Med J ; 37(Suppl 1): 44, 2020.
Artículo en Inglés | MEDLINE | ID: covidwho-1069977

RESUMEN

Unlike developed countries which have purely intensivists also called critical care physicians or intensive care physicians to manage critically ill patients like those with severe forms of COVID-19, the practice of critical care medicine in Africa is coined to anaesthesiology. Hence, anaesthesiologist-intensivist physicians are the medical specialists taking care of critically ill COVID-19 patients in Africa. Likewise, unlike intensive care units (ICUs) in high income countries, those in most African countries face the challenge of a lack of emergency drugs and resuscitation equipment, limited health infrastructure and understaffed and underfunded health care systems. The COVID-19 pandemic is an unprecedented one faced by intensivists in high-income countries and anaesthesiologist-intensivist phycisians in Africa. Infected patients with severe forms of the disease like those having grave COVID-19 complications like massive pulmonary embolism, severe cardiac arrhythmias, cardiogenic shock, septic shock, acute kidney injury or acute respiratory distress syndrome require ICU admission for better management. Both intensivists or anaesthesiologist-intensivist physicians have the peculiarity of securing the airways of critically COVID-19 patients and providing respiratory support with mechanical ventilation after laryngoscopy and endotracheal intubation when needed. In so doing, they can easily be infected from respiratory droplets or aerosols expired by the COVID-19 patients. Hence, in Africa, anaesthesiologist-intensivist phycisians have a higher risk of contracting COVID-19 compared to other health professionals. It's worth to mention that the COVID-19 pandemic struck African anaesthesiologist-intensivist phycisians and ICUs when there were neither prepared skillfully or lacked the required ICU capacity to meet the demands of thousands of severe COVID-19 African patients. These further weakened the already strained health systems in Africa. It required a lot of creativity, engineering skills and courage for these ill prepared African anaesthesiologist-intensivist physicians to provide care to these critically ill patients and improve their outcomes as the pandemic progressed. However, despites the numerous efforts made in African anaesthesiologist-Intensivist phycisians to care for critically ill COVID-19 patients, the pandemic is spreading at a rapid rate across Africa. There is an urgent need for African health authorities to anticipate on how to scale up the future high ICU capacity needs and limited ICU workforce, infrastructure and equipment to manage severe forms of COVID-19 in future. It cannot be overemphasized that these severe forms of COVID-19 are potentially fatal and are a major contributor to the death toll of the COVID-19 pandemic.


Asunto(s)
Anestesiólogos/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Médicos/organización & administración , África , /transmisión , Cuidados Críticos/organización & administración , Enfermedad Crítica , Prestación de Atención de Salud/organización & administración , Países en Desarrollo , Humanos , Transmisión de Enfermedad Infecciosa de Paciente a Profesional , Enfermedades Profesionales/epidemiología , Enfermedades Profesionales/virología , Exposición Profesional
8.
Eur J Cardiothorac Surg ; 58(5): 875-880, 2020 11 01.
Artículo en Inglés | MEDLINE | ID: covidwho-1066299

RESUMEN

OBJECTIVES: Coronavirus disease 2019 is a new contagious disease that has spread rapidly across the world. It is associated with high mortality in those who develop respiratory complications and require admission to intensive care. Extracorporeal membrane oxygenation (ECMO) is a supportive therapy option for selected severely ill patients who deteriorate despite the best supportive care. During the coronavirus disease 2019 pandemic, extra demand led to staff reorganization; hence, cardiac surgery consultants joined the ECMO retrieval team. This article describes how we increased service provisions to adapt to the changes in activity and staffing. METHODS: The data were collected from 16 March 2020 to 8 May 2020. The patients were referred through a dedicated Web-based referral portal to cope with increasing demand. The retrieval team attended the referring hospital, reviewed the patients and made the final decision to proceed with ECMO. RESULTS: We reported 41 ECMO retrieval runs during this study period. Apart from staffing changes, other retrieval protocols were maintained. The preferred cannulation method for veno-venous ECMO was drainage via the femoral vein and return to the right internal jugular vein. There were no complications reported during cannulation or transport. CONCLUSIONS: Staff reorganization in a crisis is of paramount importance. For those with precise transferrable skills, experience can be gained quickly with appropriate supervision. Therefore, the team members were selected based on skill mix rather than on roles that are more traditional. We have demonstrated that an ECMO retrieval service can be reorganized swiftly and successfully to cope with the sudden increase in demand by spending cardiac surgeons services to supplement the anaesthetic-intensivist roles.


Asunto(s)
Betacoronavirus , Infecciones por Coronavirus/terapia , Cuidados Críticos/organización & administración , Oxigenación por Membrana Extracorpórea , Accesibilidad a los Servicios de Salud/organización & administración , Admisión y Programación de Personal/organización & administración , Neumonía Viral/terapia , Cirujanos/organización & administración , Adulto , Anciano , Cardiología/organización & administración , Cuidados Críticos/métodos , Enfermedad Crítica , Oxigenación por Membrana Extracorpórea/métodos , Femenino , Necesidades y Demandas de Servicios de Salud , Humanos , Masculino , Persona de Mediana Edad , Pandemias , Grupo de Atención al Paciente/organización & administración , Reino Unido
9.
J Nurs Adm ; 51(2): E1-E5, 2021 Feb 01.
Artículo en Inglés | MEDLINE | ID: covidwho-1066481

RESUMEN

AIM: To identify strategies that increase hospital bed capacity, material resources, and available nurse staffing during a national pandemic. BACKGROUND: The COVID-19 outbreak resulted in an influx of acutely ill patients requiring critical care. The volume and acuity of this patient population increased the demand for care and stretched hospitals beyond their capacity. While increasing hospital bed capacity and material resources are crucial, healthcare systems have noted one of the greatest limitations to rapid expansion has been the number of available medical personnel, particularly those trained in emergency and critical care nursing. EVALUATION: Program evaluation occurred on a daily basis with hospital throughput, focusing on logistics including our ability to expand bed volume, resource utilization, and the ability to meet staffing needs. CONCLUSION: This article describes how a quaternary care hospital in New York City prepared for the COVID-19 surge in patients by maximizing and shifting nursing resources to its most impacted services, the emergency department (ED) and the intensive care units (ICUs). A tier-based staffing model and rapid training were operationalized to address nurse-staffing shortages in the ICU and ED, identifying key factors for swift deployment. IMPLICATIONS FOR NURSING MANAGERS: Frequent communication between staff and leaders improves teamwork and builds trust and buy-in during normal operations and particularly in times of crisis.


Asunto(s)
/enfermería , Cuidados Críticos/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Personal de Enfermería en Hospital/provisión & distribución , Admisión y Programación de Personal/organización & administración , Capacidad de Camas en Hospitales , Humanos , Evaluación de Resultado en la Atención de Salud
10.
J Invasive Cardiol ; 33(2): E71-E76, 2021 02.
Artículo en Inglés | MEDLINE | ID: covidwho-1063668

RESUMEN

In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel.


Asunto(s)
Cateterismo Cardíaco/métodos , Servicio de Cardiología en Hospital , Unidades de Cuidados Coronarios , Cuidados Críticos , Control de Infecciones , Laboratorios de Hospital/organización & administración , Innovación Organizacional , Infarto del Miocardio con Elevación del ST , /epidemiología , Servicio de Cardiología en Hospital/organización & administración , Servicio de Cardiología en Hospital/tendencias , Unidades de Cuidados Coronarios/métodos , Unidades de Cuidados Coronarios/organización & administración , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Cuidados Críticos/tendencias , Humanos , Control de Infecciones/métodos , Control de Infecciones/organización & administración , Ciudad de Nueva York/epidemiología , Grupo de Atención al Paciente/organización & administración , Atención Perioperativa/métodos , Infarto del Miocardio con Elevación del ST/epidemiología , Infarto del Miocardio con Elevación del ST/terapia
11.
Am J Respir Crit Care Med ; 203(3): 287-295, 2021 02 01.
Artículo en Inglés | MEDLINE | ID: covidwho-1058133

RESUMEN

The burdens of the coronavirus disease (COVID-19) pandemic have fallen disproportionately on disadvantaged groups, including the poor and Black, Latinx, and Indigenous communities. There is substantial concern that the use of existing ICU triage protocols to allocate scarce ventilators and critical care resources-most of which are designed to save as many lives as possible-may compound these inequities. As governments and health systems revisit their triage guidelines in the context of impending resource shortages, scholars have advocated a range of alternative allocation strategies, including the use of a random lottery to give all patients in need an equal chance of ICU treatment. However, both the save-the-most-lives approach and random allocation are seriously flawed. In this Perspective, we argue that ICU triage policies should simultaneously promote population health outcomes and mitigate health inequities. These ethical goals are sometimes in conflict, which will require balancing the goals of maximizing the number of lives saved and distributing health benefits equitably across society. We recommend three strategies to mitigate health inequities during ICU triage: introducing a correction factor into patients' triage scores to reduce the impact of baseline structural inequities; giving heightened priority to individuals in essential, high-risk occupations; and rejecting use of longer-term life expectancy and categorical exclusions as allocation criteria. We present a practical triage framework that incorporates these strategies and attends to the twin public health goals of promoting population health and social justice.


Asunto(s)
/epidemiología , Cuidados Críticos/organización & administración , Disparidades en Atención de Salud/organización & administración , Triaje/organización & administración , Poblaciones Vulnerables/estadística & datos numéricos , Disparidades en el Estado de Salud , Humanos
12.
Crit Care ; 25(1): 40, 2021 01 28.
Artículo en Inglés | MEDLINE | ID: covidwho-1054831

RESUMEN

The current coronavirus pandemic has impacted heavily on ICUs worldwide. Although many hospitals and healthcare systems had plans in place to manage multiple casualties as a result of major natural disasters or accidents, there was insufficient preparation for the sudden, massive influx of severely ill patients with COVID-19. As a result, systems and staff were placed under immense pressure as everyone tried to optimize patient management. As the pandemic continues, we must apply what we have learned about our response, both good and bad, to improve organization and thus patient care in the future.


Asunto(s)
/terapia , Cuidados Críticos/organización & administración , Investigación sobre Servicios de Salud , Unidades de Cuidados Intensivos/organización & administración , /epidemiología , Humanos
14.
Ann Glob Health ; 87(1): 1, 2021 01 04.
Artículo en Inglés | MEDLINE | ID: covidwho-1043783

RESUMEN

Background: UC San Diego Health System (UCSDHS) is an academic medical center and integrated care network in the US-Mexico border area of California contiguous to the Mexican Northern Baja region. The COVID-19 pandemic deeply influenced UCSDHS activities as new public health challenges increasingly related to high population density, cross-border traffic, economic disparities, and interconnectedness between cross-border communities, which accelerated development of clinical collaborations between UCSDHS and several border community hospitals - one in the US, two in Mexico - as high volumes of severely ill patients overwhelmed hospitals. Objective: We describe the development, implementation, feasibility, and acceptance of a novel critical care support program in three community hospitals along the US-Mexico border. Methods: We created and instituted a hybrid critical care program involving: 1) in-person activities to perform needs assessments of equipment and supplies and hands-on training and education, and 2) creation of a telemedicine-based (Tele-ICU) service for direct patient management and/or consultative, education-based experiences. We collected performance metrics surrounding adherence to evidence-based practices and staff perceptions of critical care delivery. Findings: In-person intervention phase identified and filled gaps in equipment and supplies, and Tele-ICU program promoted adherence to evidence-based practices and improved staff confidence in caring for critically ill COVID-19 patients at each hospital. Conclusion: A collaborative, hybrid critical care program across academic and community centers is feasible and effective to address cross-cultural public health emergencies.


Asunto(s)
Centros Médicos Académicos , Cuidados Críticos/métodos , Hospitales Comunitarios , Comunicación Interdisciplinaria , Telemedicina , Algoritmos , California , Cuidados Críticos/organización & administración , Equipos y Suministros de Hospitales , Medicina Basada en la Evidencia , Personal de Salud/educación , Humanos , Control de Infecciones/métodos , Unidades de Cuidados Intensivos , Cooperación Internacional , México , Enfermería/métodos , Autoeficacia
15.
Ann Acad Med Singap ; 49(12): 1009-1012, 2020 12.
Artículo en Inglés | MEDLINE | ID: covidwho-1037619

RESUMEN

COVID-19 has spread globally, infecting and killing millions of people worldwide. The use of operating rooms (ORs) and the post-anaesthesia care unit (PACU) for intensive care is part of surge response planning. We aim to describe and discuss some of the practical considerations involved in a large tertiary hospital in Singapore. Firstly, considerations for setting up a level III intensive care unit (ICU) include that of space, staff, supplies and standards. Secondly, oxygen supply of the entire hospital is a major determinant of the number of ventilators it can support, including those on non-invasive forms of oxygen therapy. Thirdly, air flows due to positive pressure systems within the OR complex need to be addressed. In addition, due to the worldwide shortage of ICU ventilators, the US Food and Drug Administration has granted temporary approval for the use of anaesthesia gas machines for patients requiring mechanical ventilation. Lastly, planning of logistics and staff deployment needs to be carefully considered during a crisis. Although OR and PACU are not designed for long-term care of critically ill patients, they may be adapted for ICU use with careful planning in the current pandemic.


Asunto(s)
/terapia , Cuidados Críticos/organización & administración , Recursos en Salud/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Quirófanos/organización & administración , Centros de Atención Terciaria/organización & administración , /epidemiología , Cuidados Críticos/métodos , Enfermedad Crítica , Asignación de Recursos para la Atención de Salud/organización & administración , Accesibilidad a los Servicios de Salud/organización & administración , Humanos , Pandemias , Respiración Artificial , Singapur/epidemiología
16.
Lancet Respir Med ; 9(4): 430-434, 2021 04.
Artículo en Inglés | MEDLINE | ID: covidwho-1033502

RESUMEN

The COVID-19 pandemic strained health-care systems throughout the world. For some, available medical resources could not meet the increased demand and rationing was ultimately required. Hospitals and governments often sought to establish triage committees to assist with allocation decisions. However, for institutions operating under crisis standards of care (during times when standards of care must be substantially lowered in the setting of crisis), relying on these committees for rationing decisions was impractical-circumstances were changing too rapidly, occurring in too many diverse locations within hospitals, and the available information for decision making was notably scarce. Furthermore, a utilitarian approach to decision making based on an analysis of outcomes is problematic due to uncertainty regarding outcomes of different therapeutic options. We propose that triage committees could be involved in providing policies and guidance for clinicians to help ensure equity in the application of rationing under crisis standards of care. An approach guided by egalitarian principles, integrated with utilitarian principles, can support physicians at the bedside when they must ration scarce resources.


Asunto(s)
/terapia , Cuidados Críticos/organización & administración , Asignación de Recursos para la Atención de Salud/organización & administración , Pandemias/prevención & control , Triaje/organización & administración , Comités Consultivos/organización & administración , Comités Consultivos/normas , Cuidados Críticos/economía , Cuidados Críticos/normas , Cuidados Críticos/estadística & datos numéricos , Toma de Decisiones en la Organización , Salud Global/economía , Salud Global/normas , Asignación de Recursos para la Atención de Salud/economía , Asignación de Recursos para la Atención de Salud/normas , Política de Salud , Humanos , Colaboración Intersectorial , Pandemias/economía , Guías de Práctica Clínica como Asunto , Nivel de Atención/economía , Triaje/normas
17.
Crit Care ; 25(1): 22, 2021 01 08.
Artículo en Inglés | MEDLINE | ID: covidwho-1015894

RESUMEN

Providing optimal care to patients with acute respiratory illness while preventing hospital transmission of COVID-19 is of paramount importance during the pandemic; the challenge lies in achieving both goals simultaneously. Controversy exists regarding the role of early intubation versus use of non-invasive respiratory support measures to avoid intubation. This review summarizes available evidence and provides a clinical decision algorithm with risk mitigation techniques to guide clinicians in care of the hypoxemic, non-intubated, patient during the COVID-19 pandemic. Although aerosolization of droplets may occur with aerosol-generating medical procedures (AGMP), including high flow nasal oxygen and non-invasive ventilation, the risk of using these AGMP is outweighed by the benefit in carefully selected patients, particularly if care is taken to mitigate risk of viral transmission. Non-invasive support measures should not be denied for conditions where previously proven effective and may be used even while there is suspicion of COVID-19 infection. Patients with de novo acute respiratory illness with suspected/confirmed COVID-19 may also benefit. These techniques may improve oxygenation sufficiently to allow some patients to avoid intubation; however, patients must be carefully monitored for signs of increased work of breathing. Patients showing signs of clinical deterioration or high work of breathing not alleviated by non-invasive support should proceed promptly to intubation and invasive lung protective ventilation strategy. With adherence to these principles, risk of viral spread can be minimized.


Asunto(s)
Toma de Decisiones Clínicas/métodos , Cuidados Críticos/organización & administración , Ventilación no Invasiva , /terapia , Algoritmos , Humanos
18.
Thorax ; 76(3): 302-312, 2021 03.
Artículo en Inglés | MEDLINE | ID: covidwho-991868

RESUMEN

The surge in cases of severe COVID-19 has resulted in clinicians triaging intensive care unit (ICU) admissions in places where demand has exceeded capacity. In order to assist difficult triage decisions, clinicians require clear guidelines on how to prioritise patients. Existing guidelines show significant variability in their development, interpretation, implementation and an urgent need for a robust synthesis of published guidance. To understand how to manage which patients are admitted to ICU, and receive mechanical ventilatory support, during periods of high demand during the COVID-19 pandemic, a systematic review was performed. Databases of indexed literature (Medline, Embase, Web of Science, and Global Health) and grey literature (Google.com and MedRxiv), published from 1 January until 2 April 2020, were searched. Search terms included synonyms of COVID-19, ICU, ventilation, and triage. Only formal written guidelines were included. There were no exclusion criteria based on geographical location or publication language. Quality appraisal of the guidelines was performed using the Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and the Appraisal of Guidelines for Research and Evaluation Instrument Recommendation EXcellence (AGREE REX) appraisal tools, and key themes related to triage were extracted using narrative synthesis. Of 1902 unique records identified, nine relevant guidelines were included. Six guidelines were national or transnational level guidance (UK, Switzerland, Belgium, Australia and New Zealand, Italy, and Sri Lanka), with one state level (Kansas, USA), one international (Extracorporeal Life Support Organization) and one specific to military hospitals (Department of Defense, USA). The guidelines covered several broad themes: use of ethical frameworks, criteria for ICU admission and discharge, adaptation of criteria as demand changes, equality across health conditions and healthcare systems, decision-making processes, communication of decisions, and guideline development processes. We have synthesised the current guidelines and identified the different approaches taken globally to manage the triage of intensive care resources during the COVID-19 pandemic. There is limited consensus on how to allocate the finite resource of ICU beds and ventilators, and a lack of high-quality evidence and guidelines on resource allocation during the pandemic. We have developed a set of factors to consider when developing guidelines for managing intensive care admissions, and outlined implications for clinical leads and local implementation.


Asunto(s)
/epidemiología , Cuidados Críticos/organización & administración , Hospitalización , Humanos , Respiración Artificial , Triaje/organización & administración
19.
Am J Nurs ; 121(1): 48-54, 2021 01 01.
Artículo en Inglés | MEDLINE | ID: covidwho-990816

RESUMEN

ABSTRACT: In March 2020, in response to the coronavirus disease 2019 (COVID-19) pandemic, the executive leadership of an academic medical center in Atlanta tasked an interprofessional quality improvement (QI) team with identifying ways to improve staff and patient safety while caring for patients with suspected or confirmed COVID-19 infection. Additional goals of the initiative were to improve workflow efficiency by reducing the amount of time spent donning and doffing personal protective equipment (PPE) and to conserve PPE, which could be in short supply in a prolonged pandemic. The QI team developed a "warm zone model" that allowed staff members to wear the same mask, eye protection, and gown while moving between the rooms of patients who had tested positive for COVID-19. The risk of self-contamination while doffing PPE is well documented. Staff members were trained to conserve PPE and to properly change gloves and perform hand hygiene between exiting and entering patients' rooms. The warm zone model allowed multidisciplinary team members to reduce the times they donned and doffed PPE per shift while maintaining or increasing the times they entered and exited patients' rooms. Staff members believed that the model improved workflow and teamwork while maintaining staff members' personal safety. Daily gown use decreased on the acute care unit where the model was employed, helping to preserve PPE supplies. Once the model was proven successful in acute care, it was modified and instituted on several critical care COVID-19 cohort units.


Asunto(s)
/prevención & control , Cuidados Críticos/organización & administración , Transmisión de Enfermedad Infecciosa de Paciente a Profesional/prevención & control , Modelos Organizacionales , Equipo de Protección Personal , Guantes Protectores/estadística & datos numéricos , Guantes Protectores/provisión & distribución , Humanos , Equipo de Protección Personal/estadística & datos numéricos , Equipo de Protección Personal/provisión & distribución , Ropa de Protección/estadística & datos numéricos , Ropa de Protección/provisión & distribución , Estados Unidos
20.
J Invasive Cardiol ; 33(2): E71-E76, 2021 02.
Artículo en Inglés | MEDLINE | ID: covidwho-984012

RESUMEN

In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel.


Asunto(s)
Cateterismo Cardíaco/métodos , Servicio de Cardiología en Hospital , Unidades de Cuidados Coronarios , Cuidados Críticos , Control de Infecciones , Laboratorios de Hospital/organización & administración , Innovación Organizacional , Infarto del Miocardio con Elevación del ST , /epidemiología , Servicio de Cardiología en Hospital/organización & administración , Servicio de Cardiología en Hospital/tendencias , Unidades de Cuidados Coronarios/métodos , Unidades de Cuidados Coronarios/organización & administración , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Cuidados Críticos/tendencias , Humanos , Control de Infecciones/métodos , Control de Infecciones/organización & administración , Ciudad de Nueva York/epidemiología , Grupo de Atención al Paciente/organización & administración , Atención Perioperativa/métodos , Infarto del Miocardio con Elevación del ST/epidemiología , Infarto del Miocardio con Elevación del ST/terapia
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