Niveles de gestión clínica / Clinical management levels

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A randomized clinical trial for the timing of tracheotomy in critically ill patients: factors precluding inclusion in a single center study.

INTRODUCTION: We investigated the potential benefits of early tracheotomy performed before day eight of mechanical ventilation (MV) compared with late tracheotomy (from day 14 if it still indicated) in reducing mortality, days of MV, days of sedation and ICU length of stay (LOS). METHODS: Randomized controlled trial (RCT) including all-consecutive ICU admitted patients requiring seven or more days of MV. Between days five to seven of MV, before randomization, the attending physician (AP) was consulted about the expected duration of MV and acceptance of tracheotomy according to randomization. Only accepted patients received tracheotomy as result of randomization. An intention to treat analysis was performed including patients accepted for the AP and those rejected without exclusion criteria. RESULTS: A total of 489 patients were included in the RCT. Of 245 patients randomized to the early group, the procedure was performed for 167 patients (68.2%) whereas in the 244 patients randomized to the late group was performed for 135 patients (55.3%) (P <0.004). Mortality at day 90 was similar in both groups (25.7% versus 29.9%), but duration of sedation was shorter in the early tracheotomy group median 11 days (range 2 to 92) days compared to 14 days (range 0 to 79) in the late group (P <0.02). The AP accepted the protocol of randomization in 205 cases (42%), 101 were included in early group and 104 in the late group. In these subgroup of patients (per-protocol analysis) no differences existed in mortality at day 90 between the two groups, but the early group had more ventilator-free days, less duration of sedation and less LOS, than the late group. CONCLUSIONS: This study shows that early tracheotomy reduces the days of sedation in patients undergoing MV, but was underpowered to prove any other benefit. In those patients selected by their attending physicians as potential candidates for a tracheotomy, an early procedure can lessen the days of MV, the days of sedation and LOS. However, the imprecision of physicians to select patients who will require prolonged MV challenges the potential benefits of early tracheotomy. TRIAL REGISTRATION: Controlled-Trials.com ISRCTN22208087 . Registered 27 March 2014.

The use of electronic health records in Spanish hospitals.

The aims of this study were to describe the level of adoption of electronic health records in Spanish hospitals and to identify potential barriers and facilitators to this process. We used an observational cross-sectional design. The survey was conducted between September and December 2011, using an electronic questionnaire distributed through email. We obtained a 30% response rate from the 214 hospitals contacted, all belonging to the Spanish National Health Service. The level of adoption of electronic health records in Spanish hospitals was found to be high: 39.1% of hospitals surveyed had a comprehensive EHR system while a basic system was functioning in 32.8% of the cases. However, in 2011 one third of the hospitals did not have a basic electronic health record system, although some have since implemented electronic functionalities, particularly those related to clinical documentation and patient administration. Respondents cited the acquisition and implementation costs as the main barriers to implementation. Facilitators for EHR implementation were: the possibility to hire technical support, both during and post implementation; security certification warranty; and objective third-party evaluations of EHR products. In conclusion, the number of hospitals that have electronic health records is in general high, being relatively higher in medium-sized hospitals.

Standardizing admission and discharge processes to improve patient flow: a cross sectional study.

BACKGROUND: The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes. METHODS: This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann-Whitney test for non-normal continuous variables. RESULTS: The median patients' global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01). CONCLUSIONS: In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput.

Reclamaciones en un servicio de urgencias: estudio de 13 años en un hospital universitario / Complaints in an emergency department: a 13-year study in a university hospital

Introducción: Los servicios de urgencias hospitalarios (SUH) han sido concebidos para dar una respuesta óptima a las necesidades del ciudadano. Objetivos: En primer lugar, analizar las reclamaciones recibidas por el servicio de urgencias de un hospital universitario de tercer nivel para plantear recomendaciones para reducir su incidencia. En segundo lugar, determinar si existe asociación entre el tiempo de permanencia en urgencias y el número de reclamaciones recibidas. Material y método: Estudio descriptivo retrospectivo de las reclamaciones dirigidas al Servicio de Urgencias del Hospital Universitari de Bellvitge durante 13 años consecutivos, entre el 1 de enero de 1992 y el 31 de diciembre de 2004. Se trata de un hospital con capacidad para 960 camas, que atiende anualmente a 110.381 individuos adultos por consultas urgentes, excluyendo la obstetricia. Resultados: Durante los 13 años estudiados, el SUH recibió un total de 1.610 reclamaciones, de las que el 19,7% (n = 317) fueron verbales y el 80,3% (n = 1.293), escritas. El 51,2% (n = 824) de los reclamantes fueron hombres. Los motivos más frecuentes fueron demora excesiva para ser atendido en urgencias, con el 48,9% (n = 792), e insatisfacción con la asistencia, con el 14,7% (n = 102). La tasa media de reclamaciones fue de 1,2 cada 1.000 visitas urgentes. Encontramos una asociación moderada-intensa (rho de Spearman = 0,6; p < 0,005), entre el tiempo de permanencia en el SUH y el número de reclamaciones. Conclusiones: La mayoría de las reclamaciones en un SUH son sobre cuestiones organizativas y por insatisfacción con la asistencia. La información aportada por el análisis de las reclamaciones facilita la detección de oportunidades de mejora

Introduction: Emergency departments (ED) were founded to provide an optimal response to population demand. Objectives: Firstly, to analyze the complaints received by the ED of a tertiary teaching hospital during a 13-year period with a view of making recommendations to reduce their incidence. Secondly, to determine whether there is an association between length of stay in the ED and the number of complaints. Material and method: A descriptive, retrospective study of all the complaints sent to the ED of Bellvitge Hospital over 13 consecutive years, from January 1st, 1992 to December 31st, 2004 was performed. The hospital has 960 beds and attends a mean of 110,381 adult emergency visits per year, excluding obstetrics. Results: During the study period, the ED received 1610 complaints, of which 19.7% (n = 317) were oral and 80.3% (n = 1,293) were written. A total of 51.2% (n = 824) of the complainants were men. The most frequent reasons for complaints were excessive waiting time, with 48.9% (n = 792) of the complaints, and lack of satisfaction with the healthcare received, with 14.7% (n = 102) of the complaints. The mean complaint rate was 1.2 per 1000 emergency visits. A moderate-intense association (Spearman's rho = 0.6; p < 0.005) was found between length of stay in the ED and the number of complaints. Conclusions: Most complaints received in the ED concerned organizational procedures and the healthcare received. Information provided by analysis of these complaints can be used to detect opportunities for improvement