[Critically ill patient isolation: risk or protection?] / Aislamiento del paciente crítico: ¿riesgo o protección?

INTRODUCTION: Isolation precautions are an effective measure to prevent the spread of multi-resistant microorganisms (MMR). However, its implementation is complex and can increase some risks to the patient. The aim of this study is to determine whether the implementation of isolation precautions increase the risk of patient safety incidents (PSI) in critically ill patients. MATERIAL AND METHODS: A retrospective observational study was conducted involving patients admitted to the ICU of a University Hospital, and that required isolation for more than 48h. Period of study: two years (from 2013/03/01 to 2015/03/31). Data source was the electronic medical record. The tools for evaluation were the Modular Review Form questionnaires (MRF1 and MRF2). An analysis was made of PSI and adverse events (AEs) during periods with and without isolation precautions, including the PSI type, severity, and preventability. RESULTS: The study included a total of 76 patients, 74 of whom had at least one PSI. A total of 798 PSI were detected (511 during isolation period), 599 were a No harm incident (NHI) and 199 were adverse AEs. The most frequent PSIs were associated with medication (316) and patient health care (279). Most of them were moderately or highly preventable. The incidence of PSI during periods with and without isolation was 27.3 (SD 33.8) and 29 (39.6) per 100 patient-days, respectively. CONCLUSIONS: PSIs in ICU are frequent, and the most of them are preventable. The adoption of isolation precautions does not constitute a risk factor for PSI. Improving patient safety culture is essential for an adequate prevention strategy.

[Identification of adverse events in hospitalised influenza patients]. / Identificación de eventos adversos en pacientes hospitalizados por gripe.

OBJECTIVE: To test the inter-observer agreement in identifying adverse events (AE) in patients hospitalized by flu and undergoing precautionary isolation measures. METHODS: Historical cohort study, 50 patients undergoing isolation measures due to flu, and 50 patients without any isolation measures. RESULTS: The AE incidence ranges from 10 to 26% depending on the observer (26% [95%CI: 17.4%-34.60%], 10% [95%CI: 4.12%-15.88%], and 23% [95%CI: 14.75%-31.25%]). It was always lower in the cohort undergoing the isolation measures. This difference is statistically significant when the accurate definition of a case is applied. The agreement as regards the screening was good (higher than 76%; Kappa index between 0.29 and 0.81). The agreement as regards the accurate identification of AE related to care was lower (from 50 to 93.3%, Kappa index from 0.20 to 0.70). CONCLUSIONS: Before performing an epidemiological study on AE, interobserver concordance must be analyzed to improve the accuracy of the results and the validity of the study. Studies have different levels of reliability. Kappa index shows high levels for the screening guide, but not for the identification of AE. Without a good methodology the results achieved, and thus the decisions made from them, cannot be guaranteed. Researchers have to be sure of the method used, which should be as close as possible to the optimal achievable.

Evaluación del estudio de contactos de tuberculosis en el Departamento de Salud 17 de Alicante / Assessment of tuberculosis contact tracing in the 17th health area in Alicante

Objetivo: Evaluar el estudio de contactos (EC) de tuberculosis realizado en nuestro servicio y analizar la demora en el diagnóstico y en la notificación de los casos de tuberculosis y el retraso en el inicio del EC. Material y métodos: Se realizó un estudio observacional retrospectivo de los casos índices de tuberculosis y sus contactos declarados, además de la adecuación del manejo de los contactos estudiados, y se calculó la demora en el diagnóstico y la notificación de los casos de tuberculosis y la demora en el inicio del estudio de contactos. Resultados: La tasa global de tuberculosis encontrada fue de 10,91 por 100.000 habitantes durante el total de años de estudio. Se identificaron 128 casos de tuberculosis y 635 contactos. Para todos los casos de tuberculosis, la mediana de la demora diagnóstica total fue de 45 días, de la demora en la declaración de tres días y de la demora en el inicio del estudio de contactos de 9,5 días. Entre los contactos evaluados se diagnosticaron ocho nuevos casos de tuberculosis. En el 94,5% de los contactos estudiados el manejo fue adecuado. Conclusión: El manejo de los contactos de tuberculosis fue en su mayor parte adecuado. La demora diagnóstica para los casos de tuberculosis fue elevada, mientras que el retraso en la notificación de los casos de tuberculosis y en el inicio del estudio de contactos, estuvieron en límites normales (AU)

Objective: To assess the tuberculosis (TB) contact investigations conducted in our Department and to analyze the delay in diagnosis and reporting of TB cases and the delay in starting the contacts investigations. Methods: We carried out a retrospective observational study of the reported tuberculosis index cases and their contacts. We analyzed the adequacy of management of contacts investigations and calculated the delay in diagnosis and reporting of TB cases in addition to the delay in the onset of contacts study. Results: The overall rate of tuberculosis found was 10.91 per 100,000 inhabitants during the total years of study. We identified 635 contacts of 128 tuberculosis cases. The median from total diagnostic delay was 45 days, from delay in the notification three days and from delay in the start of contact investigations 9,5 days for all TB cases. Among the assessed contacts were diagnosed eight new TB cases during contact investigations. In the 94.5% of studied contacts the management was adequate. Conclusion: The management of TB contacts was mostly adequate. The delay in diagnosis for tuberculosis cases was elevated. The delay in the notification of tuberculosis cases and the delay in the start of contacts investigations were found within normal limits (AU)

Plan de seguridad clínica del Complejo Hospitalario Universitario de Albacete (CHUA). Diagnóstico inicial: estudio de eventos adversos / Clinical safety plan in a university hospital complex. Initial diagnosis: Study of adverse events

Objetivos. Determinar la incidencia de eventos adversos (EA) y de pacientes con EA en el Complejo Hospitalario Universitario de Albacete (CHUA). Identificar y definir los EA ligados a la asistencia; analizar los EA evitables y conocer su impacto; planificar las acciones de mejora. Método. Diseño. Estudio retrospectivo de cohortes. Ámbito de estudio. Pacientes dados de alta del 5 al 19 de noviembre de 2007. Definición de caso Todo accidente o incidente recogido en la historia clínica que ha causado daño al paciente o lo ha podido causar. Instrumentalización. Guía de cribado de efectos adversos, adaptada del estudio de Harvard. Versión española del formulario modular para revisión retrospectiva de casos, MRF2. Análisis estadístico. Análisis univariante, bivariante y modelo de regresión logística. Resultados. La incidencia de pacientes con EA relacionados con la asistencia hospitalaria fue de 6,8%. La incidencia fue diferente significativamente según: edad, presencia de factores de riesgo intrínseco y extrínseco (excluyendo el catéter venoso periférico). El 8,2% de los EA se relacionaron con cuidados, el 14,3% con medicación, el 26,5% con infecciones nosocomiales, el 35,7% con problemas técnicos en procedimientos, el 11,2% con diagnóstico y el 4,1% restante con otros tipos de EA. El 12,2% se consideraron leves, 78,6% moderados y 8,2% graves. El 50% de EA aumentaron la estancia, y en un 34,7% condicionó el ingreso. El 63,3% de los EA se consideraron evitables. Conclusiones. El estudio de EA en el CHUA constituye un aspecto de mejora dentro del programa de calidad del hospital. Las incidencias de pacientes con EA y con la asistencia sanitaria se encuentran entre las alcanzadas en el conjunto de estudios cuyo objetivo es la mejora de la calidad(AU)

Objectives. To establish the incidence of adverse events (AEs) and incidence of patients with AEs in the University Hospital Complex of Albacete (CHUA); to identify and define the AEs which are linked to health care; to analyse avoidable AE and determine their impact; to plan improvement actions. Method. Design. Retrospective cohort study. Sample. Patients registered from 5 November to 19 November, 2007. Case definition. Any accident or incident reported in the medical record which injured or may have injured the patient. Material. Adverse Events Screening Guide, adapted from the Harvard study. Spanish version of the Modular Review Form (MRF2) for retrospective case record review. Statistical Analysis. Univariate and bivariate analysis and logistic regression model. Results. The incidence of patients with AEs linked to hospital care was 6.8%. The incidence was significantly different depending on: age, presence of intrinsic or extrinsic risk factors (excluding peripheral venous catheter); 8.2% of AE was linked to care; 14.3% to medication; 26.5% to nosocomial infections; 35.7% to technical problems in procedures; 11.2% to diagnosis, and the remaining 4.1% to other types of AEs. In these incidences, 12.2% were considered mild, 78.6% moderate and 8.2% serious. Half (50%) of AEs caused an increase in hospital stay, and in 34.7% cases determined hospitalisation. A total of 63.3% of AEs were considered avoidable. Conclusions. The study of AEs in the CHUA represents an improvement within the hospital quality program. Incidences of patients with AEs and those related to health care fall within the range of those found in the studies where the objective was quality improvement(AU)

[Clinical safety plan in a university hospital complex. Initial diagnosis: study of adverse events]. / Plan de seguridad clínica del Complejo Hospitalario Universitario de Albacete (CHUA). Diagnóstico inicial: estudio de eventos adversos.

OBJECTIVES: To establish the incidence of adverse events (AEs) and incidence of patients with AEs in the University Hospital Complex of Albacete (CHUA); to identify and define the AEs which are linked to health care; to analyse avoidable AE and determine their impact; to plan improvement actions. METHOD: . DESIGN: Retrospective cohort study. SAMPLE: Patients registered from 5 November to 19 November, 2007. CASE DEFINITION: Any accident or incident reported in the medical record which injured or may have injured the patient. MATERIAL: Adverse Events Screening Guide, adapted from the Harvard study. Spanish version of the Modular Review Form (MRF2) for retrospective case record review. STATISTICAL ANALYSIS: Univariate and bivariate analysis and logistic regression model. RESULTS: The incidence of patients with AEs linked to hospital care was 6.8%. The incidence was significantly different depending on: age, presence of intrinsic or extrinsic risk factors (excluding peripheral venous catheter); 8.2% of AE was linked to care; 14.3% to medication; 26.5% to nosocomial infections; 35.7% to technical problems in procedures; 11.2% to diagnosis, and the remaining 4.1% to other types of AEs. In these incidences, 12.2% were considered mild, 78.6% moderate and 8.2% serious. Half (50%) of AEs caused an increase in hospital stay, and in 34.7% cases determined hospitalisation. A total of 63.3% of AEs were considered avoidable. CONCLUSIONS: The study of AEs in the CHUA represents an improvement within the hospital quality program. Incidences of patients with AEs and those related to health care fall within the range of those found in the studies where the objective was quality improvement.

Factores que contribuyen a la infección relacionada con la asistencia sanitaria: cómo evitarlos / Factors that contribute to health care associated infections: how to prevent them

Objetivo. Identificar las características de los pacientes y de la asistencia asociadas con la infección relacionada con la atención sanitaria (IRAS) y determinar si existen diferencias entre las evitables (IRASE) y las que no lo son. Método. Estudio de cohortes retrospectivo basado en tres estudios españoles de eventos adversos ligados a la hospitalización. Se revisaron las historias clínicas valorando si la asistencia era la causante de IRAS e IRASE. Resultados. El 2,3% de los pacientes del estudio presentó una o más IRAS. El 60,2% fueron IRASE. Los que presentaron IRAS eran mayores que el resto, y presentaron mayor número de factores de riesgo intrínseco y extrínseco. Se observaron diferencias entre los pacientes que presentaron IRAS o IRASE en la presencia de algún factor de riesgo intrínseco. Los factores que mejor explicaron IRAS fueron distintos para cada una de las localizaciones más frecuentes. En el caso de las IRAS: catéter urinario (OR=2,4), catéter venoso central (OR=1,8) y sonda nasogástrica (OR=1,9); servicio de ingreso quirúrgico (OR=1,6) y estancia hospitalaria >1 semana (OR=7,5). Las estrategias identificadas para evitar IRAS fueron: técnica aséptica adecuada (25,5%), correcto seguimiento de los protocolos de sondaje vesical (20%) y de los cuidados y la valoración de vulnerabilidad de los pacientes (16,5%). Conclusiones. Entre los pacientes que presentaron IRAS y los que no presentaron se encontraron características diferenciadas. La evitabilidad es un juicio de valor independiente del de causalidad y se relaciona con si se han aplicado de forma correcta o no los protocolos. Identificar estos puntos en la asistencia permite establecer estrategias de mejora de la asistencia(AU)

Objective. To determine the patient and medical care characteristics of Health Care-Associated Infections (HCAI) and to determine whether or not there are any differences between those that may be avoidable. Method. A retrospective cohort study, based on three Spanish cohort studies of Adverse Events associated with hospitalization. The medical records were reviewed to assess whether or not the health care was the causing factor of the HCAI. We carried out the analyses using the same methodology as the National Study on the Adverse Effects associated with hospitalization (ENEAS). After reviewing the patient medical records to identify the HCAI associated factors, the reviewers gave a valued judgment on how likely the health care was the cause of the infection (HCAI) and whether there was evidence that they could have been avoided. Results. A total of 2.3% the patients in the study had one or more HCAI, with 60.2% of them being avoidable. The patients who had an HCAI were older and had a greater number of intrinsic and extrinsic risk factors. There was a significant difference in the presence of some intrinsic risk factor between patients who had an HCAI and those with an avoidable HCAI, but there were no differences as regards medical care extrinsic risk factors. The factors that best explained the HCAI were different for each one of the most common infection locations. Generally, the factors which best explained the HCAI were: urinary catheter (OR=2.4), nasogastric tube (OR=1.9) or central venous catheter (OR=1.8). Similarly, hospital admissions through a surgery department or a hospital stay longer than a week were identified as main factors, (OR=1.6), (OR=7.5), respectively. The best strategies to avoid an HCAI were: proper management of any aseptic technique and use of catheter (25.5%), a proper follow-up of the bladder catheterisation protocols (20%) and a proper health care follow-up of vulnerable patients (16.5%). Conclusion. Patients with an HCAI showed significant different characteristics from those who did not have an HCAI. The preventability is an independent valued judgment from the causality, and is associated to whether the proper protocol has been implemented or not. To identify these weaknesses enables us to establish strategies to improve the quality of medical care(AU)

[Factors that contribute to health care associated infections: how to prevent them]. / Factores que contribuyen a la infección relacionada con la asistencia sanitaria: cómo evitarlos.

OBJECTIVE: To determine the patient and medical care characteristics of Health Care-Associated Infections (HCAI) and to determine whether or not there are any differences between those that may be avoidable. METHOD: A retrospective cohort study, based on three Spanish cohort studies of Adverse Events associated with hospitalization. The medical records were reviewed to assess whether or not the health care was the causing factor of the HCAI. We carried out the analyses using the same methodology as the National Study on the Adverse Effects associated with hospitalization (ENEAS). After reviewing the patient medical records to identify the HCAI associated factors, the reviewers gave a valued judgment on how likely the health care was the cause of the infection (HCAI) and whether there was evidence that they could have been avoided. RESULTS: A total of 2.3% the patients in the study had one or more HCAI, with 60.2% of them being avoidable. The patients who had an HCAI were older and had a greater number of intrinsic and extrinsic risk factors. There was a significant difference in the presence of some intrinsic risk factor between patients who had an HCAI and those with an avoidable HCAI, but there were no differences as regards medical care extrinsic risk factors. The factors that best explained the HCAI were different for each one of the most common infection locations. Generally, the factors which best explained the HCAI were: urinary catheter (OR=2.4), nasogastric tube (OR=1.9) or central venous catheter (OR=1.8). Similarly, hospital admissions through a surgery department or a hospital stay longer than a week were identified as main factors, (OR=1.6), (OR=7.5), respectively. The best strategies to avoid an HCAI were: proper management of any aseptic technique and use of catheter (25.5%), a proper follow-up of the bladder catheterisation protocols (20%) and a proper health care follow-up of vulnerable patients (16.5%). CONCLUSION: Patients with an HCAI showed significant different characteristics from those who did not have an HCAI. The preventability is an independent valued judgment from the causality, and is associated to whether the proper protocol has been implemented or not. To identify these weaknesses enables us to establish strategies to improve the quality of medical care.

Impact and preventability of adverse events in Spanish public hospitals: results of the Spanish National Study of Adverse Events (ENEAS).

OBJECTIVE: To determine the impact and preventability of adverse events (AEs) associated with health care in Spanish hospitals. DESIGN: Retrospective cohort study. SETTING: Twenty-four Spanish hospitals. PARTICIPANTS: Patients of any age with a clinical record indicating an inpatient stay of >24 h and a discharge between 4 and 10 June 2005 (n = 5908). INTERVENTION: None. MAIN OUTCOME MEASURES: Percentage of AEs considered preventable. RESULTS: We were able to identify 525 patients suffering AEs associated directly with medical care, who accumulated 655 AEs with 43% of these AEs considered preventable. Overall, 45% (295 AEs) were considered minor, 39% (255 AEs) moderate and 16% (105 AEs) severe. There were no significant differences in AE severity by hospital size, but AEs associated with surgical services were more likely to be severe than those associated with medical services. Some 31.4% of AEs resulted in a longer stay and 23.4% led to hospital admission. AEs associated with medical care caused 6.1 additional days per patient. Of the patients, 66.3% required additional procedures and 69.9% required additional treatments. Incidence of death in patients with AEs was 4.4% (CI 95%: 2.8-6.5). Age over 65 was associated with a higher incidence of preventable AEs. The highest percentages of preventable AEs were related to diagnosis (84.2%), to nosocomial infections (56.6%) and to care (56%). CONCLUSIONS: In Spanish hospitals, AEs associated with health care cause distress, disability, death, lengthen hospital stay and cause increased consumption of health-care resources. A relatively high percentage of AEs in Spain may be preventable with improvements in medical care.

Realidad de la prescripción y grado de cumplimiento de los suplementos de calcio + vitamina D en el tratamiento de la osteoporosis en la Atención Primaria de Andalucía. Estudio SOL-D8 / Reality of the prescription and degree of compliance regarding calcium + vitamin D supplements in the treatment of osteoporosis in Primary Care of Andalusia. SOL-D8 Study

INTRODUCCIÓN. La osteoporosis es una enfermedad crónica que afecta en España a más de dos millones de mujeres. En su abordaje terapéutico, además de un tratamiento antirresortivo, se debe garantizar un adecuado aporte de calcio y vitamina D, y cuando la paciente no alcanza un mínimo diario de estos elementos se debe proceder a su administración de forma exógena mediante la recomendación de suplementos. En nuestro entorno no se conoce cuál es la realidad de la prescripción y grado de cumplimiento desde la práctica clínica en Atención Primaria de los suplementos de calcio y vitamina D para el tratamiento concomitante de la osteoporosis, por lo que nos hemos planteado realizar un estudio de índole pragmática que permita aclarar estos interrogantes. MATERIAL Y MÉTODOS. Estudio transversal utilizando un cuestionario ad hoc a partir del objetivo del estudio, que fue administrado durante los meses de marzo y abril de 2006, por 49 médicos de Atención Primaria de los 32 distritos sanitarios de Andalucía, elegidos mediante muestreo no probabilístico a criterio, siendo el criterio de selección la condición de experto en osteoporosis. Cada uno de estos investigadores se responsabilizó de contactar con al menos 10 médicos que debían ejercer su actividad profesional en el ámbito de la asistencia primaria, de cara a poder administrarles el cuestionario. RESULTADOS. Respondieron el cuestionario un total de 749 médicos de Atención Primaria correspondientes a todos los distritos sanitarios de Andalucía. Se ha recogido información de 3.745 pacientes ya que cada médico debía revisar 5 historias de pacientes en tratamiento para la osteoporosis. El 31% de los encuestados reconocía que no asocia calcio y vitamina D junto al tratamiento antirresortivo, o lo hacía en menos del 50% de las veces. El 52% de los encuestados reconoció que la tolerancia a los suplementos de calcio y vitamina D era regular, mala o muy mala, y hasta un 62% de los médicos encuestados afirmaron que la mitad de sus pacientes abandonaba los suplementos a los tres meses por intolerancia o efectos secundarios. La mitad de los médicos reconocía no estar preocupado por el aporte de vitamina D en estos pacientes, dado que consideraban que en España, por su clima soleado, el déficit de vitamina D era una situación infrecuente. CONCLUSIONES. La mayoría de los médicos de Atención Primaria de Andalucía opinan que el cumplimiento de los suplementos de calcio y vitamina D para el tratamiento concomitante de la osteoporosis es bastante deficiente, por lo que el abordaje terapéutico integral de la osteoporosis es inadecuado, debiéndose insistir en la importancia de garantizar una adecuada ingesta de calcio y vitamina D. Existe un alto porcentaje de abandono de los suplementos por efectos secundarios e intolerancia. Hay una falsa asociación entre clima soleado y niveles adecuados de vitamina D

INTRODUCTION. Osteoporosis is a chronic disease that affects more than two million women in Spain. In addition to an antiresorptive agent in its therapeutic approach, adequate intake of calcium and vitamin D should be assured. When the patient cannot achieve these minimum daily requirements, these should be administered exogenously through supplements. The real situation in regard to the prescription and degree of compliance with these elements from the clinical practice of Primary Care is unknown, thus we have considered conducting a pragmatic study to address the unanswered questions. METHODS. Cross-sectional study which includes an ad hoc questionnaire, based on the study objective that was administered by 49 Primary Care physicians from the 32 health districts of Andalusia, during March-April 2006, who were chosen by non-probability sampling criteria, the condition of being an expert in osteoporosis being the selection criteria. Each one of the investigators had to contact at least 10 Primary Care physicians in the Primary Care area providing them with the questionnaire. RESULTS. A total of 749 Primary Care physicians from all of the health districts answered the questionnaire. Information was collected from 3,745 patients since each physician had to review 5 clinical records of patients being treated for osteoporosis. A total of 31% of the physicians admitted that they were not concomitantly associating an antiresorptive agent with calcium-vitamin D supplements for at least 50% of the time. Fifty-two percent of those questioned admitted that tolerance to calcium supplements is either regular, poor or very poor, and up to 62% of the physicians addressed claimed that 50% of their patients discontinued supplement treatment within a three month period due to intolerance or adverse effects. Fifty percent of the physicians admitted they were not concerned about vitamin D intake in these patients, since they believed that due to the sunny climate in Spain, insufficient vitamin D was not a frequent issue. CONCLUSIONS. The majority of Primary Care physicians in Andalusia believe that compliance with calcium and vitamin D supplements for concomitant treatment of osteoporosis is quite poor. Therefore, integral therapeutic management of osteoporosis is inadequate. An effort must be made to increase physicians' awareness regarding adequate intake of calcium and vitamin D. There is a high rate of withdrawal of supplements due to side effects or intolerance as well as a false concept of association between sun exposure and adequate vitamin D levels