Validación de las escalas de valoración de riesgo de úlceras por presión EMINA y EVARUCI en pacientes críticos / Validation of EMINA and EVARUCI scales for assessing the risk of developing pressure ulcers in critical patients

Objetivo: Contribuir a la validación de las escalas EMINA y EVARUCI en el paciente crítico para posteriormente comparar su capacidad predictiva en este mismo contexto. Método: Estudio prospectivo desde diciembre del 2012 hasta junio del 2013. Ámbito: Unidad de Cuidados Intensivos polivalente de 14 camas de hospital de referencia de 2 áreas sanitarias. Pacientes: Incluidos mayores de edad y sin úlceras al ingreso. En estudio hasta que desarrollaron úlcera grado i o superior, fueron defunción, alta o su estancia superó los 30 días. Variables de interés principales: presencia de úlcera, puntuación diaria de riesgo de desarrollar úlceras mediante valoración EMINA y EVARUCI. La validez de ambas escalas se calculó mediante sensibilidad, especificidad, valor predictivo positivo y negativo. El nivel de significación se estableció para p ≤ 0,05. Resultados: Se estudió a 189 pacientes. El 67,2% eran hombres con una edad media ± desviación estándar de 59,4 ± 16,8) años, 53 (28%) desarrollaron úlceras, siendo la tasa de incidencia de 41 úlceras por cada 1.000 días de ingreso. El día medio de aparición fue de 7,7 ± 4,4 días y la localización más frecuente, sacro. La sensibilidad y la especificidad para la media de las observaciones fue de 94,34 (87,17-100) y 33,33 (25,01-41,66) para la escala EMINA para riesgo > 10 y 92,45 (84,40-100) y 42,96 (34,24-51,68) para EVARUCI riesgo > 11. Conclusiones: No se hallaron diferencias en la capacidad predictiva de ambas escalas. Para sensibilidades > 90%, las escalas se muestran poco específicas en la detección del riesgo de úlceras en el paciente crítico

Objective: To contribute to the validation of the EMINA and EVAUCI scales for assessing the risk of pressure ulcers in the critical patient and compare their predictive capacity in this same context. Method: Prospective study from December 2012 until June 2013. Setting: Polyvalent intensive care unit of 14 beds in a reference hospital for two sanitary areas. Patients: patients of 18 years of age or older and without pressure ulcers were included. They were followed until development of a pressure ulcer of grade I or greater, medical discharge, death or 30 days. Main variables: presence of ulcers, daily score of the risk of developing pressure ulcers through EMINA and EVARUCI evaluation. The validity of both scales was calculated using sensitivity, specificity, and positive and negative predictive value. The level of significance was P ≤ 0.05. Results: A total of 189 patients were evaluated. 67.2% were male with a mean age of 59.4 (DE: 16,8) years old, 53 (28%) developed pressure ulcers, being the incidence rate of 41 ulcers per 1000 admission days. The mean day of diagnosis was 7.7 days (DE: 4,4) and the most frequent area was the sacrum. The sensitivity and specificity for the mean of observations was 94.34 (IC95% 87.17-100) and 33.33 (IC95% 25.01-41.66) for the EMINA scale for a risk > 10 and 92.45 (IC95% 84.40-100) and 42.96 (IC95% 34.24-51.68) for the EVARUCI scale for a risk of > 11. Conclusions: No differences were found in predictive capacity of both scales. For sensitivities > 90%the scales show to be insufficiently specific in the pressure ulcer risk detection in critical patients

[Validation of EMINA and EVARUCI scales for assessing the risk of developing pressure ulcers in critical patients]. / Validación de las escalas de valoración de riesgo de úlceras por presión EMINA y EVARUCI en pacientes críticos.

OBJECTIVE: To contribute to the validation of the EMINA and EVAUCI scales for assessing the risk of pressure ulcers in the critical patient and compare their predictive capacity in this same context. METHOD: Prospective study from December 2012 until June 2013. SETTING: Polyvalent intensive care unit of 14 beds in a reference hospital for two sanitary areas. PATIENTS: patients of 18 years of age or older and without pressure ulcers were included. They were followed until development of a pressure ulcer of grade I or greater, medical discharge, death or 30 days. MAIN VARIABLES: presence of ulcers, daily score of the risk of developing pressure ulcers through EMINA and EVARUCI evaluation. The validity of both scales was calculated using sensitivity, specificity, and positive and negative predictive value. The level of significance was P≤0.05. RESULTS: A total of 189 patients were evaluated. 67.2% were male with a mean age of 59.4 (DE: 16,8) years old, 53 (28%) developed pressure ulcers, being the incidence rate of 41 ulcers per 1000 admission days. The mean day of diagnosis was 7.7 days (DE: 4,4) and the most frequent area was the sacrum. The sensitivity and specificity for the mean of observations was 94.34 (IC95% 87.17-100) and 33.33 (IC95% 25.01-41.66) for the EMINA scale for a risk>10 and 92.45 (IC95% 84.40-100) and 42.96 (IC95% 34.24-51.68) for the EVARUCI scale for a risk of>11. CONCLUSIONS: No differences were found in predictive capacity of both scales. For sensitivities>90%the scales show to be insufficiently specific in the pressure ulcer risk detection in critical patients.

Audits in real time for safety in critical care: Definition and pilot study / Análisis aleatorios de seguridad en medicina intensiva: definición y estudio piloto

Adverse events significantly impact upon mortality rates and healthcare costs. Purpose To design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. Methods A list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. Results The final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. Conclusions Audits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors

Los eventos adversos impactan significativamente en la mortalidad y costes sanitarios. Objetivos Elaborar un listado de verificación de medidas de seguridad basadas en la literatura científica más relevante, aplicarlo en tiempo real y aleatoriamente (rondas de seguridad) y determinar su utilidad y factibilidad. Diseño Los investigadores desarrollaron un listado de medidas de seguridad basado en la literatura científica. Posteriormente, mediante el método Delphi un grupo de expertos consensuaron las medidas. Las auditorías fueron realizadas en 14 días durante un mes. Cada día se seleccionaron aleatoriamente el 50% de las variables y se midieron en el 50% de los pacientes. La utilidad se determinó midiendo las modificaciones en la actuación clínica usando la variable «proporción de mejora relacionada con las auditorías». La factibilidad fue determinada por la capacidad de realizar los análisis cada día que fueron previstos. Resultados El listado de verificación estuvo formado por 37 medidas distribuidas en 10 bloques. En el 83,78% de las medidas se produjeron modificaciones después de las rondas. La proporción de mejora relacionada con las rondas fue superior al 25% en las siguientes medidas: evaluación del límite de presión alveolar, revisión de las alarmas de la ventilación mecánica, revisión de las alarmas del monitor, prescripción correcta de las órdenes de tratamiento, evaluación diaria de la necesidad de catéteres, monitorización de la nutrición enteral, posición semiincorporada e información clínica del paciente. Factibilidad: las rondas fueron completadas los 14 días que se propusieron. Conclusiones Las rondas de seguridad aleatorizadas son una herramienta útil y factible para modificar actuaciones clínicas minimizando los errores

Audits in real time for safety in critical care: definition and pilot study.

UNLABELLED: Adverse events significantly impact upon mortality rates and healthcare costs. PURPOSE: To design a checklist of safety measures based on relevant scientific literature, apply random checklist measures to critically ill patients in real time (safety audits), and determine its utility and feasibility. METHODS: A list of safety measures based on scientific literature was drawn up by investigators. Subsequently, a group of selected experts evaluated these measures using the Delphi methodology. Audits were carried out on 14 days over a period of one month. Each day, 50% of the measures were randomly selected and measured in 50% of the randomized patients. Utility was assessed by measuring the changes in clinical performance after audits, using the variable improvement proportion related to audits. Feasibility was determined by the successful completion of auditing on each of the days on which audits were attempted. RESULTS: The final verified checklist comprised 37 measures distributed into 10 blocks. The improvement proportion related to audits was reported in 83.78% of the measures. This proportion was over 25% in the following measures: assessment of the alveolar pressure limit, checking of mechanical ventilation alarms, checking of monitor alarms, correct prescription of the daily treatment orders, daily evaluation of the need for catheters, enteral nutrition monitoring, assessment of semi-recumbent position, and checking that patient clinical information is properly organized in the clinical history. Feasibility: rounds were completed on the 14 proposed days. CONCLUSIONS: Audits in real time are a useful and feasible tool for modifying clinical actions and minimizing errors.

[Is the routine chest radiography following thoracentesis necessary?]. / ¿Es necesaria la práctica sistemática de radiografía de tórax postoracocentesis?

OBJECTIVES: To assess the routine indication of chest roentgenogram after thoracentesis in function of iatrogenic pneumothorax causation, following a procedure protocol. PATIENTS AND METHODS: Prospective study of 104 consecutive thoracentesis procedures performed in 76 patients. The procedure was protocolized and after each thoracentesis a chest roentgenogram was obtained within 6 hours after the procedure. The attending physician completed a questionnaire relative to patients data characteristics of the pleural effusion. RESULTS: Two pneumothorax were noted following thoracentesis (2%) which did not require pleural drainage. These pneumothorax occurred in patients with parapneumonic pleural effusions. CONCLUSIONS: The routine practice of chest roentgenogram after thoracentesis does not seem to be warranted and should be individualized. The performance of thoracentesis by physicians in training period, with procedure protocolization, minimizes the risk of pneumothorax.

¿Es necesariala práctica sistemática de radiografía de tórax postoracocentesis? / Is the routine chest radiography following thoracentesis necessary?

Objetivos. Valorar la indicación sistemática de radiografía de tórax postoracocentesis en función de la incidencia de neumotórax yatrógeno tras protocolización de la técnica. Pacientes y métodos. Estudio prospectivo de 104 toracocentesis consecutivas en 76 pacientes. Se protocolizó la técnica y tras cada toracocentesis se practicó radiografía de tórax en las 6 horas siguientes. Cada facultativo completó una recogida de los datos de cada paciente y características del derrame pleural. Resultados. Se constataron 2 neumotórax secundarios a toracocentesis (2 por ciento) que no precisaron drenaje torácico. Éstos aparecieron en pacientes con derrame pleural paraneumónico. Conclusiones. La práctica sistemática de radiografía de tórax postoracocentesis no parece justificada y ha de individualizarse. La realización de toracocentesis por médicos en formación supervisados por facultativos expertos, con protocolización de la técnica, minimiza el riesgo de neumotórax (AU)

Incidencia y coste de las infecciones nosocomiales en una unidad de lesionados medulares / Incidence and cost of nosocomial infection at a Medullar Lesion Unit

El objetivo es conocer la incidencia y el coste de las infecciones nosocomiales diagnosticadas en pacientes con lesión medular ingresados en la Unidad de Lesionados Medulares del hospital Vall d'Hebron. Durante 1995-1996 se han diagnosticado 229 infecciones nosocomiales en 312 pacientes. El coste sanitario del diagnóstico y tratamiento ha sido de 7.305.559 pesetas. En las infecciones del tracto urinario moderadas se ha realizado un análisis coste-efectividad, agrupando los tratamientos según el tipo de antibiótico y según la vía de administración, obteniéndose una mejor relación coste-efectividad en los tratamientos en que se ha utilizado "antibiótico de uso libre" y en los que se ha administrado "por vía oral", ya que el coste sanitario ha sido menor y la efectividad, valorada por el índice de curación, similar (AU)

Culprit lesion and jeopardized myocardium: correlation between coronary angiography and single-photon emission computed tomography.

BACKGROUND: The term "culprit lesion" is used to designate the coronary stenosis responsible for the symptoms of the patient with coronary artery disease. Its detection is essential when partial revascularization is contemplated. The term "jeopardized myocardium" is commonly used to mean the amount of myocardium put in danger by all the stenotic lesions; however, it should be restricted to the amount of myocardium that could become infarcted if only the most severe stenoses were occluded. HYPOTHESIS: The aim of this study was to investigate (1) the agreement between coronary myocardial single-photon emission computed tomography (SPECT) and coronary angiography for the identification of the culprit lesion, and (2) the correlation of the two studies in the quantification of jeopardized myocardium. METHODS: In all, 159 patients with coronary artery disease without previous myocardial infarction were included in the study. A score for myocardial SPECT was correlated with the angiographic scores by Califf and Gensini and with the authors' score which includes adjustment for collateral circulation. RESULTS: The agreement between coronary angiography and SPECT for the diagnosis of the culprit lesion was 84% (87/104). The correlations between the scores of angiography and SPECT to assess jeopardized myocardium when all coronary stenoses were taken into account were significant (p < 0.0001), but their coefficients were suboptimal (r = 0.48 for Califf, r = 0.48 for Gensini, and r = 0.65 for the authors' score). When only the jeopardized myocardium resulting from the culprit lesion was considered, the correlation clearly improved (r = 0.85). CONCLUSION: Thus, in 84% of patients with multivessel disease, an agreement between coronary angiography and myocardial SPECT for the diagnosis of the culprit lesion was observed. The correlation between these techniques for the quantification of jeopardized myocardium from the culprit lesion was satisfactory.

[Usefulness of body surface cultures in newborns with early infection risk. Study of 735 neonates]. / Valoración de los cultivos superficiales del neonato con riesgo de infección precoz. Estudio de 735 pacientes.

OBJECTIVE: Difficulty in the diagnosis of neonatal sepsis has lead to the practice of superficial cultures. The usefulness of this practice has been criticized repeatedly. PATIENTS AND METHODS: Results of 3881 cultures performed on 735 newborns (age < or = 48 hr) with early infection risk were reviewed. The types of samples chosen were urine (UR), gastric aspirate (GA), pharyngeal (PS), external ear (ES), umbilical swab (US), meconium (MC) and blood. BBV for sepsis for the different samples is calculated, as well as which ones better reflect vertical transmission. RESULTS: At the time of the study, 342 newborns (46.5%) were already colonized. Bacteria most frequently isolated were: E. coli (92), PCN staphylococci (85), enterococci (83) and S. agalactiae (70). Twenty-nine newborns had bacteriemia, with S. agalactiae being the leading cause (16). ES correlated best with positive blood cultures (83.3%). UR culture sensitivity was significantly lower than that of all other samples. The Highest PPVs were for GA, PS and US. NPV was high and similar for all samples (98-99%). ES and US best reflected vertical transmission (p < 0.0001). MC provided the highest number of positive mixed cultures, most of them difficult to evaluate. CONCLUSIONS: Body surface sample advantages are: 1) The possibility of discarding a vertically transmitted infection. 2) Quicker positive results than those in blood whenever liquid blood culture media are employed. 3) The possible identification of the etiologic agent when the mother has been given antibiotics intrapartum. 4). Information about dangerous colonization without infection. In order not to lose this useful information, but to save cost and effort, we advise that the number of surface cultures be reduced, keeping only ES and PS?

Methicillin-resistant Staphylococcus aureus: a four-year experience in a spinal cord injury unit in Spain.

Methicillin-Resistant Staphylococcus aureus (MRSA) infection poses a problem for both acute and long-term-care facilities, Spinal Cord Injury units included. This paper describes the 4-year evolution of MRSA outbreaks in a SCI unit in a university hospital where control measures were implemented from the first case detected. The protocol procedure was as follows: contact isolation, washing with antiseptic soap both those infected and those sharing the same room, contacts study and monitoring of MRSA patients up to the time when three consecutive negative cultures (sampled at time lapses of over 48 h) were obtained, antiseptic soap for the health-care personnel to wash their hands, and cultures of the nares done on the personnel in the event of an outbreak. Twenty-one (3.4%) MRSA positive cases were detected out of 550 admissions registered during the study period (November 1990 through October 1994). The evolution occurred in three outbreaks and six isolated MRSA positive patients without secondary cases. 71.5% of the cases were nosocomial. Seven (33%) were colonizated and 14 (67%) infected. The 14 patients infected presented 15 infections: nine with urinary tract infections, three surgical wound infections, two tracheostomy wound infections, and one patient with a decubitus ulcer infection. Two of those with urinary tract infections presented with secondary sepsis. No carriers were detected amongst the personnel. Urinary tract colonizations responded to treatment with cotrimoxazol except in two cases in which combined treatment was required (cotrimoxazol plus rifampicin). The patients with a MRSA positive tracheal aspirate were negative after combined treatment. Wounds and cultures of the nares responded favorably to initial treatment. One of the patients with a urinary tract infection and sepsis died the infection being a contributing cause. The prospective follow-up of the patients with MRSA positive cultures and the precocious implementation of isolation measures allow for the limitation of transmission, even although complete eradication is not possible.

[The postinfarct prognostic value of right ventricular systolic function]. / Valor pronóstico postinfarto de la función sistólica ventricular derecha.

BACKGROUND: Right ventricular extension of inferior myocardial infarction has been shown to be a predictor of poor prognosis during the acute phase. However, it is not known whether right ventricular dysfunction predicts long term complications. The aim of the present study was to assess whether right ventricular ejection fraction is also a predictor of poor prognosis during the first five follow-up years. METHODS: Ninety-eight consecutive patients (age < or = 65 years) with acute noncomplicated myocardial infarction (49 anterior and 49 inferior) were evaluated before hospital discharge. In all of them the ejection fraction of both ventricles was evaluated with radionuclide ventriculography at rest and during submaximal exercise. All patients were clinically followed up for at least 5 years. The prognostic relevance of right and left ventricular function for the prediction of all complications and severe complications was assessed using univariate and multivariate analysis. RESULTS: After 5 years, 66 patients had 94 complications (angina in 44, heart failure in 21, reinfarction in 10, revascularization procedures in 11, death in 6). In the univariate analysis, resting right ventricular ejection fraction was significantly lower in patients with inferior infarction and severe complications at one year (32 +/- 12% vs 38 +/- 6%, p = 0.03). However, in multivariate analysis only resting left ventricular ejection fraction was predictive of complications at 5 years (odds ratio 5.93, 95% confidence interval = 1.32-26.6). Statistical results did not change when the ejection fraction of both ventricles during submaximal exercise was considered. CONCLUSIONS: Although right ventricular ejection fraction, measured before hospital discharge, is predictive of complications at five years in inferior infarctions, multivariate analysis shows that it does not add prognostic information to the measurement of left ventricular ejection fraction in patients with uncomplicated acute myocardial infarction, either anterior or inferior.