Protocolo de manejo de pacientes con enfermedad pulmonar obstructiva crónica tras agudización en urgencias / Protocol for the management of patients with chronic obstructive pulmonary disease after exacerbation in the emergency department

En la enfermedad pulmonar obstructiva crónica el síndrome de agudización (SAE) es un episodio de inestabilidad clínica por agravamiento de la limitación espiratoria al flujo aéreo o del proceso inflamatorio subyacente. La gravedad del SAE depende de la estratificación del riesgo basal y la intensidad del episodio agudo. La Atención Primaria es el epicentro del circuito asistencial del SAE, pero puede extenderse al Servicio de Urgencias Extrahospitalarias y al propio hospital dependiendo de la situación clínica, del nivel de gravedad, de la disponibilidad de pruebas complementarias y de los recursos terapéuticos necesarios para cada paciente. El registro de los datos clínicos, antecedentes, factores desencadenantes, tratamiento y evolución de los episodios previos de SAE en la historia clínica electrónica son un aspecto esencial para ajustar el tratamiento actual y prevenir la aparición de futuros episodios (AU)

In chronic obstructive pulmonary disease, an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an episode of clinical instability due to the worsening of expiratory airflow limitation or of the underlying inflammatory process. The severity of AECOPD depends on baseline risk stratification and the intensity of the acute episode. Primary Care is the epicenter of the AECOPD care circuit, but it can be extended to the out-of-hospital emergency department and the hospital itself depending on the clinical situation, the level of severity, the availability of complementary tests, and the therapeutic resources required for each patient. Recording clinical data, history, triggering factors, treatment, and evolution of previous episodes of AECOPD in the electronic medical record is an essential aspect to adjust current treatment and prevent the occurrence of future episodes (AU)

[Protocol for the management of patients with chronic obstructive pulmonary disease after exacerbation in the emergency department]. / Protocolo de manejo de pacientes con enfermedad pulmonar obstructiva crónica tras agudización en urgencias.

In chronic obstructive pulmonary disease, an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an episode of clinical instability due to the worsening of expiratory airflow limitation or of the underlying inflammatory process. The severity of AECOPD depends on baseline risk stratification and the intensity of the acute episode. Primary Care is the epicenter of the AECOPD care circuit, but it can be extended to the out-of-hospital emergency department and the hospital itself depending on the clinical situation, the level of severity, the availability of complementary tests, and the therapeutic resources required for each patient. Recording clinical data, history, triggering factors, treatment, and evolution of previous episodes of AECOPD in the electronic medical record is an essential aspect to adjust current treatment and prevent the occurrence of future episodes.

[Available resources for the management of chronic obstructive pulmonary disease exacerbations in Spain]. / Recursos disponibles para el manejo de la agudización de la enfermedad pulmonar obstructiva crónica en España.

OBJECTIVE: Chronic obstructive pulmonary disease exacerbations (COPDE) lead to a high use of healthcare resources. This study assesses the healthcare and organisational resources of Spanish health care centres for the management of COPDE at different care levels (Primary Care (PC), Respiratory Diseases, Internal Medicine, and Emergency Departments), and compare with current recommendations. MATERIAL AND METHODS: An observational study was carried out through telephone interviews to General Practitioners, Chest Diseases, Internal Medicine, and Emergency Department doctors. RESULTS: A total of 284 doctors were interviewed. According to their responses, at PC centres there is a high availability of pulse oximetry (98.9%) and electrocardiograph (100%), and a low availability of Chest X-Ray (19.1%), or urgent laboratory tests (17.0%) in sites. In hospital wards, non-invasive mechanical ventilation (NIV) availability was 76.1%, with only a 69.7% of nursing staff properly trained in its use. Respiratory intermediate care units (RICUs) were available in 18.3% of public hospitals versus 41.7% of private hospitals. Specific training for COPDE management was received by 47.9% of Emergency Department doctors in the previous year. Only 31.9% of PC centres had specific protocols for referring patients to specialists. More than 35% of PC centres and hospitals do not have their electronic medical records integrated with other healthcare levels. CONCLUSIONS: In general terms, there are sufficient resources available in Spanish healthcare centres. However, several areas of improvement were identified, such as an insufficient level of electronic medical record integration between healthcare levels, limited implementation of RICUs in public hospitals, and deficiencies related to specific training in NIV management.

[Use of complementary tests in emergencies and their relation with patient safety incidents]. / Uso de pruebas complementarias en urgencias y su relación con incidentes de seguridad.

OBJECTIVE: To analyse the use of complementary tests and their relationship with safety incidents in hospital emergency departments. METHODOLOGY: An analysis was performed on 935 patients seen in the 9 hospital emergency departments. The source of data used for the detection of incidents were: emergency department clinical record and reports, together with face-to-face observation in the department, plus a telephone survey of the patient or family member at one week after the care. Statistical tests used: The Student t test for quantitative variables, Chi squared test for qualitative variables, and the ANOVA test. RESULTS: A peripheral venous catheter was used in 397 patients (42.4% (95% CI; 39.3-45.5%)), with a variability with significant differences between hospitals (P<.01), with a range of use from 37% to 81.8%. It was also observed that in 23.4% (95% CI; 19.2-27.6%) of the cases, the catheter was not used after the first blood draw. Radiological tests were requested for 351 patients, 37.7% (95% CI; 34.6-40.8%), also with significant differences between hospitals (P<.01), ranging from 24.6 to 65, 1%. Incidents were detected in 95 (10.2%) patients (95% CI; 8.3-12.1%) in the all the study centres. A higher proportion of safety incidents have been observed in patients where peripheral venous catheter has been used (12.8%) than in those in whom they had not been used (8.5%) (P=.03), as well as in patients on whom an x-ray was requested (12.8%) compared to those who did not (8.64%) (P=.04). A longer stay was also observed in cases with an incident (mean 248.9minutes) than in those where there were none (mean 164.1minutes) (P<.001). No statistically significant differences were found in the other parameters studied. CONCLUSION: A relationship was observed between the use of a peripheral venous catheter (many of them without use) and radiological tests and the occurrence of safety incidents in the Emergency Departments.

Características y cambios epidemiológicos de los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias hospitalarios / Characteristics and epidemiological changes for patients with community-acquired pneumonia in hospital emergency departments

Fundamento. El objetivo de este artículo es determinarla prevalencia y conocer los cambios epidemiológicos más relevantes en la última década en la neumonía adquirida en la comunidad (NAC) en los servicios de urgencias (SU), así como el perfil y manejo de los pacientes. Métodos. Estudio descriptivo con análisis transversal, multicéntrico en 49 SU españoles durante 12 meses. Se incluyeron todos los pacientes con el diagnóstico de NAC, de infección respiratoria y de infección. Se registraron todos los pacientes atendidos en los SU. Resultados. La prevalencia de la NAC ha aumentado entre los pacientes en el SU en la última década del 0,85%al 1,35% (p<0,001). El 51% de las NAC se registraron en pacientes con 70 o más años. El 69,8 % tenían alguna enfermedad de base y el 17,8% alguno de los factores de riesgo para desarrollar infección. El 11,7% cumplían criterios de sepsis, 4,6% de sepsis grave y el 3% shock séptico. El 37% de los pacientes recibieron el alta desde el SU. Conclusiones. El impacto y prevalencia de la NAC en los SU ha aumentado en la última década. Es la causa más frecuente de sepsis, sepsis grave y shock séptico, de ingreso en la unidad de cuidados intensivos y de fallecimiento por enfermedad infecciosa (AU)

Background. The aim of this paper is to determine both the prevalence of community-acquired pneumonia(CAP) in the A & E Department and the most relevant epidemiological changes in the last decade, as well as the profile and management of these patients. Methods. Descriptive cross-sectional analysis at 49 Spanish A & E Departments during 12 months. All patients with infections, respiratory infection or CAP diagnosis were included. All patients attended to in A & E during the study were recorded as well. Results. CAP has increased its prevalence among patients in the A & E Departments in the past decade (0.85% to 1.35%, p <0.001). Fifty-one per cent were over70 years old. Sixty-nine point eight per cent had some underlying disease and 17.8% had risk factors. Eleven point seven per cent met sepsis criteria, 4.6% severe sepsis and 3% septic shock. Thirty-seven per cent of patients were directly discharged from the A & E Departments. Conclusions. The impact and prevalence of CAP in A &E Departments has increased in the last decade. It is the most common cause of sepsis, severe sepsis and septic shock, admission to intensive care units and death due to infectious disease (AU)

Guía española de la enfermedad pulmonar obstructiva crónica (GesEPOC). Diagnóstico y tratamiento hospitalario de la agudización / Spanish COPD guidelines (GesEPOC): hospital diagnosis and treatment of COPD Exacerbation

Las agudizaciones de la enfermedad pulmonar obstructiva crónica (EPOC), especialmente cuando precisan asistencia hospitalaria, son episodios que generan una notable morbimortalidad, gran carga asistencial y elevados costes, por lo que resulta prioritario reducir sus consecuencias, de acuerdo a las mejores evidencias científicas disponibles. El documento actual presenta las recomendaciones que establece la Guía Española de la EPOC (GesEPOC), para guiar el proceso diagnóstico y terapéutico del paciente con agudización que precisa asistencia hospitalaria. Como principales novedades, se proponen nuevas definiciones que tratan de diferenciar la aparición de una nueva agudización de otros conceptos vinculados como son la recaída o el fracaso terapéutico y se establece un proceso diagnóstico en 3 pasos dirigidos a: 1) establecer el diagnóstico de la agudización; 2) valorar su gravedad; y 3) identificar la etiología. Desde el punto de vista terapéutico, la guía propone una actuación en urgencias hospitalarias estructurada en 4 fases: 1) admisión y clasificación; 2) asistencia; 3) evolución, espera y observación; y 4) resolución, orientación y transferencia. También se incluyen recomendaciones para el paciente hospitalizado, criterios de ingreso, de alta y pautas de seguimiento y control orientadas hacia los fenotipos clínicos. Finalmente, el documento incluye diversos estándares de calidad asistencial e indicadores específicos que pueden servir de ayuda para monitorizar la calidad de la atención y mejorar los resultados (AU)

Exacerbations of chronic obstructive pulmonary disease (COPD) generate significant morbidity and mortality, increasing the health care burden and raising costs, particularly when hospital admission is required. Applying high-quality evidence-based methods to attenuate the impact of exacerbations is therefore a high priority. The Spanish COPD Guidelines (GesEPOC) provide recommendations on the diagnosis and treatment of patients with exacerbated COPD requiring hospital care. New definitions are proposed in the interest of differentiating a new COPD exacerbation from therapeutic failure, relapse, and related concepts. The guidelines propose a 3-step diagnostic process: 1) establish the diagnosis of COPD exacerbation; 2) assess its severity, and 3) establish the etiology. For emergency department management of the exacerbation, the guidelines set out 4 phases: 1) admission and classification; 2) treatment;3) observation to monitor clinical course; and 4) resolution of the crisis, with orientation of future care and transfer or discharge. GesEPOC also makes recommendations for care of the admitted patient, including admission and discharge criteria as well as follow-up protocols according to clinical phenotype. Finally, quality-of-care standards are discussed along with specific quality indicators that can be helpful for monitoring the care process and improving outcomes (AU)

[Characteristics and epidemiological changes for patients with community-acquired pneumonia in hospital emergency departments]. / Características y cambios epidemiológicos de los pacientes con neumonía adquirida en la comunidad en los servicios de urgencias hospitalarios.

BACKGROUND: The aim of this paper is to determine both the prevalence of community-acquired pneumonia (CAP) in the A & E Department and the most relevant epidemiological changes in the last decade, as well as the profile and management of these patients. METHODS: Descriptive cross-sectional analysis at 49 Spanish A & E Departments during 12 months. All patients with infections, respiratory infection or CAP diagnosis were included. All patients attended to in A & E during the study were recorded as well. RESULTS: CAP has increased its prevalence among patients in the A & E Departments in the past decade (0.85% to 1.35%, p <0.001). Fifty-one per cent were over 70 years old. Sixty-nine point eight per cent had some underlying disease and 17.8% had risk factors. Eleven point seven per cent met sepsis criteria, 4.6% severe sepsis and 3% septic shock. Thirty-seven per cent of patients were directly discharged from the A & E Departments. CONCLUSIONS: The impact and prevalence of CAP in A & E Departments has increased in the last decade. It is the most common cause of sepsis, severe sepsis and septic shock, admission to intensive care units and death due to infectious disease.

Evaluación de la anamnesis farmacoterapéutica realizada en el servicio de urgencias al ingreso hospitalario / Medication history taking on admission to a hospital emergency department

Objetivo: Determinar la calidad y la precisión de la historia farmacoterapéutica realizada al ingreso en el servicio de urgencias y los factores asociados a la presencia de discrepancias. Método: Estudio transversal descriptivo. Se incluyeron los pacientes mayores de 64 años que ingresaron en el hospital desde el servicio de urgencias durante el último trimestre de 2009. Para determinar la presencia de discrepancias se cotejó la historia farmacoterapéutica realizada por un farmacéutico clínico con la obtenida por el urgenciólogo al ingreso hospitalario. Los factores asociados a de discrepancias se identificaron mediante un análisis de regresión logística univariante con el paquete estadístico SPSS versión 15.0. Resultados: Se incluyeron en el estudio 324 pacientes (53,4% mujeres) con una edad media de 78,3 años. Se identificaron 2.928 discrepancias que afectaron al 95,1%(IC95%: 92,7-97,4%) de los pacientes. Los grupos terapéuticos con mayor número de las discrepancias detectadas fueron los antiulcerosos (10,8%), los antitrombóticos (9,5%) y psicolépticos (7,2%). Se detectaron 257 discrepancias (8,8%) en medicamentos de alto riesgo en el 33,3% (IC95%: 28,2-38,5%) de los pacientes. La polimedicación fue la única variable independiente asociada a una mayor prevalencia de discrepancias [OR: 8,02 (IC95%: 2,79-23,02)].Conclusiones: Nuestros resultados muestran que existe un amplio margen de mejora,en la historia farmacoterapéutica realizada en urgencias, y debe extremarse la precaución en la población anciana y polimedicada (AU)

Objectives: To determine the quality and accuracy of medication histories taken during admission to the emergency department (ED) and to analyze the factors that may be related to the presence of discrepancies. Methods: Descriptive cross-sectional study. Patients over the age of 64 years were enrolled on admission to the hospital from the during the last quarter of 2009. To detect the presence of discrepancies we compared the medication histories taken by a clinical pharmacist to the ones taken by an emergency physician on admission. Regression analysis was used to identify factors associated with the presence of discrepancies. Results: A total of 324 patients (53.4% women) with a mean age of 78.3 years were enrolled. We detected 2928 discrepancies affecting 95.1% (95% confidence interval [CI], 92.7%-97.4%) of the patients. The medication groups with the largest numbers of discrepancies were antiulcer drugs (10.8%), antithrombotic drugs (9.5%), and psycholeptics(7.2%). We detected discrepancies in the recording of 257 high-risk drugs (8.8%) in 33.3% (95% CI, 28.2%-38.5%) of the patients. The only independent variable associated with a higher prevalence of discrepancies was the use of multiple medications (odds ratio, 8.02 (95% CI, 2.79-23.02).Conclusion: Our findings demonstrate that there is ample room for improvement, on medication history taken at ED, and increased cuation should be taken for patients of advanced age and those taking multiple medications (AU)

[Pregnancy and HIV infection: the need for routine serological evaluation]. / Embarazo e infección por VIH: necesidad de la evaluación serológica rutinaria.

OBJECTIVES: To determine the frequency of pregnancies among HIV-infected women in a sanitary area. To evaluate the proportion of women not receiving anti-retroviral treatment to decrease vertical transmission and the reasons why this treatment was not administered. PATIENTS AND METHODS: Point prevalence study performed on all women followed for 1997 at the HIV Infection Unit in a 360-bed hospital. The following variables were obtained: social class, civil status and place of residence, risk factors for HIV infection, obstetric antecedents (pregnancies, number of term pregnancies, living newborns) as well as prescription or not of anti-retroviral therapy during pregnancy. RESULTS: Out of 85 women included in the study, 51 (60%) reported to have had a pregnancy and 17 of these (33%) had interrupted the pregnancy at some time. No significant differences were found between pregnancy or abortion and the analyzed socio-demographic variables or risk factors for HIV infection. Only 12% of women with a full length pregnancy received anti-retroviral therapy. Of women with term pregnancy who were not treated, most (63%) did not know they were infected before delivery and an additional 10% refused therapy. Forty-four percent of women with children continued with pregnancy despite knowing they were infected. Vertical transmission occurred in a 13% of cases in which no therapy was instituted and in no case in which zidovudine was administered during pregnancy. CONCLUSIONS: The frequency of pregnancies among HIV-infected women is high in our area and a substantial number of women do not know they are infected. These data support the serological study to HIV in all pregnant women and the necessity of a higher level of information in order that the seropositive women be aware of the responsibility she takes when she decides to go on with her pregnancy.