Estratificación y monitorización de niveles de adecuación de ingresos urgentes en un hospital de tercer nivel / Classification and monitoring of the appropriateness of emergency admissions in a tertiary hospital

Objetivo: Valorar la adecuación del ingreso urgente de adultos en servicios quirúrgicos y no quirúrgicos, estratificar los servicios clínicos por niveles de inadecuación de ingresos urgentes y comprobar la utilidad de la aplicación de técnicas de evaluación rápida en este tipo de mediciones. Material y métodos: Estudio descriptivo retrospectivo en un hospital de tercer nivel, que evalúa las historias clínicas de los ingresos urgentes mediante el protocolo de evaluación de la adecuación (AEP). Se incluyeron los 12 servicios con más volumen de ingresos. Para estratificarlos se construyeron 4 niveles crecientes de inadecuación («A» al «D») fijando valores estándar y umbral de inadecuación en cada uno de ellos y comprobándolos en cada servicio mediante la aceptación de muestras por lotes (LQAS). Se evaluaron aleatoriamente 156 casos (13 por servicio). Se estimó el esfuerzo evaluativo (tiempo invertido). Resultados: El porcentaje de ingresos inadecuados fue del 22,4 ± 6,3%. Nueve servicios (75%) obtuvieron niveles de adecuación buenos o aceptables y uno (8%) inaceptable. El tiempo invertido en la evaluación fue estimado en 17 h. Conclusiones: El AEP resulta útil para evaluar la adecuación de los ingresos y la gestión del proceso «urgencias», aunque su variabilidad impide las comparaciones externas. Su monitorización no implica gran consumo de recursos combinando LQAS con la estimación global de la inadecuación (unificando las muestras) y la estratificación secuencial por niveles. Extender estas técnicas para otros indicadores de calidad que utilicen como fuente de datos la historia clínica o la observación directa puede aumentar la eficiencia de sus planes de monitorización (AU)

Objective: To measure the appropriateness of hospital admissions, to classify its Clinical Services(CS) according to the level of inappropriateness, and to determine the usefulness of applying rapid assessment techniques (lot quality assurance sampling) in these types of measurements. Material and methods: A descriptive, retrospective study was conducted in a tertiary hospital to assess the clinical records of emergency admissions to the 12 CS with a higher volume of admissions, using the Appropriateness Evaluation Protocol (AEP). A four-level («A» to «D») increasingly inadequate admissions scale was constructed setting both standard and threshold values in every stratum. Every CS was classified in one of them using lot quality assurance sampling (LQAS). A total of 156 cases (13 cases from every CS) were assessed. The assessment effort (devoted time) was also estimated. Results: There were 22.4±6.3% of inadequate admissions. In the CS classification, 9 (75%) got a good or acceptable appropriateness level, and only 1 (8%) got an inacceptable level. The time devoted was estimated at 17 hours. Conclusions: AEP is useful to assess the admission appropriateness and may be included in the «Emergencies» process management, although its variability prevents the use for external comparisons. If both LQAS and the appropriateness classification level and the global estimation (by unifying lot samples) are combined, the monitoring is affordable without a great effort. To extend these tools to other quality indicators requiring direct observation or clinical records, manual assessment could improve the monitoring efficiency (AU)

[Classification and monitoring of the appropriateness of emergency admissions in a tertiary hospital]. / Estratificación y monitorización de niveles de adecuación de ingresos urgentes en un hospital de tercer nivel.

OBJECTIVE: To measure the appropriateness of hospital admissions, to classify its Clinical Services (CS) according to the level of inappropriateness, and to determine the usefulness of applying rapid assessment techniques (lot quality assurance sampling) in these types of measurements. MATERIAL AND METHODS: A descriptive, retrospective study was conducted in a tertiary hospital to assess the clinical records of emergency admissions to the 12 CS with a higher volume of admissions, using the Appropriateness Evaluation Protocol (AEP). A four-level («A¼ to «D¼) increasingly inadequate admissions scale was constructed setting both standard and threshold values in every stratum. Every CS was classified in one of them using lot quality assurance sampling (LQAS). A total of 156 cases (13 cases from every CS) were assessed. The assessment effort (devoted time) was also estimated. RESULTS: There were 22.4±6.3% of inadequate admissions. In the CS classification, 9 (75%) got a good or acceptable appropriateness level, and only 1 (8%) got an inacceptable level. The time devoted was estimated at 17 hours. CONCLUSIONS: AEP is useful to assess the admission appropriateness and may be included in the «Emergencies¼ process management, although its variability prevents the use for external comparisons. If both LQAS and the appropriateness classification level and the global estimation (by unifying lot samples) are combined, the monitoring is affordable without a great effort. To extend these tools to other quality indicators requiring direct observation or clinical records, manual assessment could improve the monitoring efficiency.

Is bioethical training useful in preparing doctors to take decisions in the emergency room?

We study the decisions taken in five real cases by 178 doctors working in hospital emergency services and compare their decisions with those proposed a reference group composed of professionals with a master's degree in bioethics. The findings of our study point to an increased ability to take difficult decisions in critical situations involving the use of life-support measures in the emergency room. The group of professionals chosen as "gold standard", despite lacking the training and clinical preparation of emergency doctors, made decisions that were technically very close to the most suitable. In this respect, an adequate ethical training facilitated the taking of decisions that required the involvement of personally held values, underlining the need for such training in the case of professionals who will work in hospital emergency services.

[Ethics conflicts in the application of mechanical ventilation: analysis of the attitude of critical care and emergency professionals and students]. / Conflictos éticos en la instauración de la ventilación mecánica: análisis de la actitud de profesionales de cuidados críticos, emergencia y estudiantes.

OBJECTIVE: To analyze the influence of prognosis, life quality or previous instructions in the decision making of applying an invasive (intubation/mechanical ventilation), conservative or palliative procedure. MATERIAL AND METHODS: "Casuistry" methodology: opinion on the appropriate decision regarding five clinical histories representative of ethic conflicts with 542 health professionals (220 intensive care specialist, 150 emergency department professionals, 76 nurses, and 96 students). As control group, 26 students enrolled in a International Master on Bioethics. RESULTS: A great inter-group variability was observed (p = 0.005) with a higher agreement with control group between students and lower with intensivists. The agreement observed was highest in cases with "total support" as the appropriate option (kappa 0.85, 0.69, and 0.66) than in cases with "palliative measures" as appropriate option (kappa 0.22 and 0.46). CONCLUSIONS: 1) A high variability was observed regarding decisions on instituting respiratory support. 2) Decisions regarding the restriction of therapeutic efforts are not accepted in the main, even in scenarios merging into futility, as permanent vegetative status. 3) Among severely deteriorated and handicapped patients, perceived life quality is more appreciated by the patient than that estimated objectively. 4) There is no a consensus opinion for the respect of previous guidelines of vital support refusal. 5) Age and deep psychic deficiency are not considered as cause of discrimination. These features may be considered typical of the mediterranean ethics, in which paternalism and charity are more appreciated values than autonomy.

Conflictos éticos en la instauración de la ventilación mecánica: análisis de la actitud de profesionales de Cuidados Críticos, Emergencia y estudiantes / Ethic conflicts regarding the institution of mechanical ventilation: analysis of the attitudes of critical care emergency professionals and students

Objetivo. Analizar la influencia del pronóstico, calidad de vida o instrucciones previas en la decisión de aplicar procedimiento invasivo (intubación/ventilación mecánica), conservador o paliativo. Metodología casuística: opinión sobre la decisión adecuada ante 5 historias representativas de conflictos éticos de 542 profesionales (220 intensivistas, 150 emergenciólogos, 76 enfermeras y 96 alumnos). Como grupo control, 26 alumnos de un Máster Internacional de Bioética. Resultados. Se observa gran variabilidad intergrupos (p = 0,005), con mayor coincidencia con el grupo control entre los alumnos y menor en los intensivistas. La concordancia es más elevada en los casos en que la opción adecuada es soporte total (Kappa 0,85, 0,69 y 0,66) que cuando lo apropiado es medidas paliativas (Kappa 0,22 y 0,46). Conclusiones. 1) Se observa una gran variabilidad en las decisiones sobre instauración de soporte respiratorio.2) Las decisiones de limitación del esfuerzo terapéutico no son mayoritariamente aceptadas, incluso en escenarios que entran en el terreno de la futilidad, como el estado vegetativo permanente. 3) En enfermos muy evolucionados y con grandes limitaciones se valora más la calidad de vida percibida por el paciente que la estimada objetivamente. 4) No existe una opinión mayoritaria por el respeto de directrices previas de rechazo al soporte vital.5) No son tenidas en cuenta la edad y la deficiencia psíquica profunda como causa de discriminación. Estos rasgos quizá puedan considerarse característicos de la ética mediterránea, en la que el paternalismo y la beneficencia constituyen valores más apreciados que la autonomía (AU)