Mejora en la seguridad de un proceso clínico utilizando el análisis modal de fallos y efectos: profilaxis de la enfermedad tromboembólica venosa en pacientes críticos / Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critically ill patients

No disponible

Un primer paso hacia una analgosedación más segura: evaluación sistemática de objetivos y grado de analgesia y sedación en el paciente crítico con ventilación mecánica / A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient

Introducción: Para garantizar el bienestar y la seguridad en los pacientes críticos es necesario aplicar estrategias de analgosedación seguras que eviten la infra- y sobresedación. Objetivos: Comparar un protocolo multidisciplinar de evaluación sistemática y manejo de la analgosedación del paciente crítico con ventilación mecánica frente a la praxis habitual. Material y métodos: Estudio de cohorte con series contemporáneas, realizado en UCI polivalente de hospital terciario, febrero-noviembre de 2013-2014. Criterios de inclusión: ventilación mecánica ≥ 24h y sedación en infusión continua. Se monitorizó sedación con Richmond Agitation-Sedation Scale o índice biespectral y analgesia con escala verbal numérica o escala indicadora de conductas dolorosas. Variables de estudio: tiempo de ventilación mecánica, tiempo de destete, tiempo de soporte ventilatorio, tiempo de vía aérea artificial, tiempo de sedación en infusión, dosis diaria y frecuencia de uso de fármacos sedantes y analgésicos, estancia y mortalidad en UCI y hospitalaria, mediciones Richmond Agitation-Sedation Scale, índice biespectral, escala verbal numérica y escala indicadora de conductas dolorosas. Se empleó Kruskal Wallis y chi cuadrado, significación p < 0,05. Resultados: Se incluyeron 153 ingresos, 75 preintervención y 78 postintervención, edad 55,7±13años, 67% hombres. Ambos grupos fueron similares en cuanto a edad, motivo de ingreso y APACHE. Se disminuyó sin significación estadística el tiempo de ventilación mecánica 4 (1,4-9,2); 3,2 (1,4-8,1) días; p=0,7, días de sedación 6 (3-11); 5 (3-11) días; p=0,9, estancia hospitalaria 29 (18-52); 25 (14-41) días; p=0,1, mortalidad UCI 8 vs. 5%; p=0,4 y hospitalaria 10,6 vs. 9,4%: p=0,8. Las dosis diarias de midazolam y remifentanilo disminuyeron 347 (227-479) mg/día; 261 (159-358) mg/día; p=0,02 y 2.175 (1.427-3.285) mcg/día; 1.500 (715-2.740) mcg/día; p=0,02 respectivamente. Se incrementó el uso de remifentanilo (32 vs. 51%; p=0,01), dexmedetomidina (0 vs. 6%; p=0,02), dexquetoprofeno (60 vs.76%; p=0,03) y haloperidol (15 vs. 28%; p=0,04) y el uso de cloruro mórfico descendió (71 vs. 54%; p=0,03). Se incrementó el número de valoraciones y registro de Richmond Agitation-Sedation Scale 6 (3-17); 21 (9-39); p < 0,0001, escala indicadora de conductas dolorosas 6 (3-18); 19 (8-33); p < 0,001 y escala verbal numérica 4 (2-6); 8 (6-17); p < 0,0001. Conclusiones: Al implementar un protocolo multidisciplinar de evaluación sistemática y manejo de la analgosedación se consigue una correcta monitorización y mayor adecuación de las dosis a las necesidades del paciente, mejorando los resultados

Introduction: Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. Objectives: To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. Materials and methods: A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. Results: The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p = 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p = 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p = 0.1, ICU mortality (8 vs. 5%; p = 0.4), and hospital mortality (10.6 vs. 9.4%: p = 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p = 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p = 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p = 0.01), dexmedetomidine (0 vs.6%; p = 0.02), dexketoprofen (60 vs. 76%; p = 0.03), and haloperidol (15 vs.28%; p = 0.04). The use of morphine decreased (71 vs. 54%; p = 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p < 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p < 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p < 0.0001. Conclusions: The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes

Mejora en la seguridad de un proceso clínico utilizando el análisis modal de fallos y efectos: profilaxis de la enfermedad tromboembólica venosa en pacientes críticos / Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients

OBJETIVO: Mejorar la seguridad del paciente crítico en la prevención de enfermedad tromboembólica venosa mediante metodología de la herramienta de seguridad del análisis modal de fallos y efectos. DISEÑO: Estudio de cohortes con serie contemporánea de enero de 2014 a marzo de 2015 en 4 fases: fase 1) previa al análisis modal de fallos y efectos; fase 2) desarrollo del análisis modal e implementación de las mejoras detectadas; fase 3) evaluación de los resultados, y fase 4) impacto tras introducción post-checklist. Ámbito: Pacientes hospitalizados en una UCI polivalente de adultos en un hospital de tercer nivel. PACIENTES: Ciento noventa y seis pacientes hospitalizados en UCI, mayores de 18 años, sin enfermedad tromboembólica al ingreso y sin haber recibido tratamiento anticoagulante previamente. INTERVENCIONES: Tras el análisis modal, se implementó un paquete de intervenciones: formación, instauración de protocolo y checklist, para incrementar las medidas profilácticas de enfermedad tromboembólica. Variables de interés: Indicación y prescripción de medidas profilácticas de trombosis venosa antes y después de la implementación de medidas resultantes del análisis modal de fallos y efectos. RESULTADOS: En la fase 1 se incluyeron 59 pacientes, 97 en la fase 3 y 40 en la fase 4, analizando el porcentaje de pacientes que recibieron tromboprofilaxis. Se desarrolló un análisis modal de fallos y efectos detectando errores potenciales, asociados a la ausencia de formación y de protocolos relacionados con la enfermedad tromboembólica. Se elaboró una campaña de sensibilización y formación del personal, así como la introducción del protocolo para la prevención de tromboembolismo venoso. La prescripción de medidas profilácticas aumentó en el grupo de la fase 3 (91,7 vs. 71,2%, p = 0,001). En el grupo post-checklist, la profilaxis fue prescrita en el 97,5% de los pacientes, aumentado la indicación de la doble profilaxis (4,7, 6,7 y 41%; p < 0,05). No hubo diferencias en la tasa de complicaciones asociadas al incremento de medidas profilácticas. CONCLUSIONES: Tras el análisis modal de fallos y efectos, se objetivaron mejoras en la prevención de enfermedad tromboembólica en el paciente crítico, por lo que consideramos que puede ser una herramienta útil para mejorar la seguridad de nuestros pacientes en diferentes procesos

OBJECTIVE: To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DESIGN: A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. SETTING: Patients admitted to the adult polyvalent ICU of a third-level hospital center. PATIENTS: A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. INTERVENTIONS: A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. Variables of interest: Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. RESULTS: A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. CONCLUSIONS: The failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes

Improvement of the safety of a clinical process using failure mode and effects analysis: Prevention of venous thromboembolic disease in critical patients. / Mejora en la seguridad de un proceso clínico utilizando el análisis modal de fallos y efectos: profilaxis de la enfermedad tromboembólica venosa en pacientes críticos.

OBJECTIVE: To improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool. DESIGN: A contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact. SETTING: Patients admitted to the adult polyvalent ICU of a third-level hospital center. PATIENTS: A total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment. INTERVENTIONS: A series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease. VARIABLES OF INTEREST: Indication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis. RESULTS: A total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures. CONCLUSIONS: The failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.

[A first step towards safer sedation and analgesia: A systematic evaluation of outcomes and level of sedation and analgesia in the mechanically ventilated critically ill patient]. / Un primer paso hacia una analgosedación más segura: evaluación sistemática de objetivos y grado de analgesia y sedación en el paciente crítico con ventilación mecánica.

INTRODUCTION: Safe analgesia and sedation strategies are necessary in order to avoid under or over sedation, as well as improving the comfort and safety of critical care patients. OBJECTIVES: To compare and contrast a multidisciplinary protocol of systematic evaluation and management of analgesia and sedation in a group of critical care patients on mechanical ventilation with the usual procedures. MATERIALS AND METHODS: A cohort study with contemporary series was conducted in a tertiary care medical-surgical ICU February to November during 2013 and 2014. The inclusion criteria were mechanical ventilation ≥ 24h and use of sedation by continuous infusion. Sedation was monitored using the Richmond agitation-sedation scale or bispectral index, and analgesia were measured using the numeric rating scale, or behavioural indicators of pain scale. The study variables included; mechanical ventilation time, weaning time, ventilation support time, artificial airway time, continuous sedative infusion time, daily dose and frequency of analgesic and sedative drug use, hospital stay, and ICU and hospital mortality, Richmond agitation-sedation scale, bispectral index, numeric rating scale, and behavioural indicators of pain scale measurements. Kruskal Wallis and Chi2, and a significance of p<.05 were used. RESULTS: The study included 153 admissions, 75 pre-intervention and 78 post-intervention, with a mean age of 55.7±13 years old, and 67% men. Both groups showed similarities in age, reason for admission, and APACHE. There were non-significant decreases in mechanical ventilation time 4 (1.4-9.2) and 3.2 (1.4-8.1) days, respectively; p= 0.7, continuous sedative infusion time 6 (3-11) and 5 (3-11) days; p= 0.9, length of hospital stay 29 (18-52); 25 (14-41) days; p= 0.1, ICU mortality (8 vs. 5%; p= 0.4), and hospital mortality (10.6 vs. 9.4%: p= 0.8). Daily doses of midazolam and remifentanil decreased 347 (227-479) mg/day; 261 (159-358) mg/day; p= 0.02 and 2175 (1427-3285) mcg/day; 1500 (715-2740) mcg/day; p= 0.02, respectively. There were increases in the use of remifentanil (32% vs. 51%; p= 0.01), dexmedetomidine (0 vs.6%; p= 0.02), dexketoprofen (60 vs. 76%; p= 0.03), and haloperidol (15 vs.28%; p= 0.04). The use of morphine decreased (71 vs. 54%; p= 0.03). There was an increase in the number of measurements and Richmond agitation-sedation scale scores 6 (3-17); 21 (9-39); p< 0.0001, behavioural indicators of pain scale 6 (3-18); 19(8-33); p< 0.001 and numeric rating scale 4 (2-6); 8 (6-17); p< 0.0001. CONCLUSIONS: The implementation of a multidisciplinary protocol of systematic evaluation of analgesia and sedation management achieved an improvement in monitoring and adequacy of dose to patient needs, leading to improved outcomes.