CSV-ARG, Estudio multi-céntrico de validación de una escala de detección temprana de deterioro en pacientes internados / CSV-ARG, multicenter study of validation of an early detection scale of deterioration in hospitalized patients

Introducción: La detección precoz de un paciente con riesgo de deterioro, y la intervención temprana por un equipo de salud competente en el manejo de la vía aérea ha demostrado reducir la mortalidad intrahospitalaria. El NEWS (National Early Warning Score, Reino Unido) clasifica a los pacientes según su probabilidad de deterioro dentro de las siguientes doce horas; en baja (0-1), moderada (2-4) y alta posibilidad de deterioro (5-13), a partir de cuatro signos vitales: frecuencias cardíaca y respiratoria, temperatura y presión arterial sistólica sumados a la saturación de oxígeno y el estado de conciencia. Fue generada a partir de una gran base de datos de signos vitales obtenidos de manera electrónica en pacientes internados en Inglaterra. En las instituciones de nuestro país, los signos vitales son tomados manualmente y hay una percepción generalizada de que estos o "están mal tomados" o no se los ubica dentro del centro de la toma de decisiones. Objetivos: El objetivo de este estudio fue, a partir de signos vitales tal como se toman en nuestro medio, realizar una validación de la capacidad de discriminación de la escala NEWS de eventos severos durante la internación. Diseño, materiales y métodos: Ocho instituciones de la ciudad de Buenos Aires y del área metropolitana participaron recolectando de manera consecutiva los seis parámetros vitales que componen la escala NEWS en los pacientes internados, tal como se toman en las salas de internación, además de datos demográficos, presencia de comorbilidades, eventos de gravedad durante la internación como sepsis, trombo embolismo de pulmón, shock hipovolémico, distrés respiratorio, insuficiencia respiratoria, trastorno de la conciencia y muerte sin evento previo. Los datos se ingresaron a una base de datos virtual calculándose el puntaje de la escala NEWS. Se analiza en este primer trabajo las características de la población con medidas de tendencia central y de dispersión estándares según la distribución de los valores. Mediante regresión logística se analizó la capacidad del primer NEWS al ingreso de predecir un evento independientemente de la edad, el sexo y la presencia de comorbilidades. Resultados: Entre el 1 de enero de 2015 hasta el 31 de julio ingresaron en el estudio 1705 pacientes de nueve Instituciones del área metropolitana, 869 eran mujeres (51%), rango de edad 18 a 100. Un 10% de los pacientes presentó algún evento grave, y la mortalidad global fue de 3,5%. El 90% de los pacientes fue clasificado al ingreso como NEWS de bajo grado de deterioro (0-4), el 5% riesgo moderado (5-6) y el 5% de riesgo alto (mayor a 7). El valor de NEWS, al ingreso de la internación y tal como se toman los signos vitales en nuestro medio, predice el riesgo de presentar un evento severo durante la internación, independientemente de la edad, sexo y la presencia de comorbilidades. Discusión: En este estudio pudimos demostrar que los signos vitales, tomados de manera manual calculando la escala NEWS, es un excelente predictor de la ocurrencia de eventos durante la internación. En próximos análisis evaluaremos la capacidad de discriminación y la capacidad de predecir eventos entre 12 y 24 horas posteriores a la toma. (AU)

Background: Early warning scores at hospital settings have shown to reduce hospital mortality. The NEWS (National Early Warning Score, UK), classifies patients as per their risk to deteriorate in three categories, low risk (0-2), moderate risk (3-4) and high risk (5-13). The scale uses four vital signs, heart rate, respiratory rate, temperature and systolic arterial pressure, plus oxygen saturation and conscious state. It was developed and validated using a large database of electronic captured vital signs in England. In Argentina, most of the vital signs are taken manually. (AU)

Comparing the impacts of hiking, skiing and horse riding on trail and vegetation in different types of forest.

Nature-based tourism in protected areas has increased and diversified dramatically during the last decades. Different recreational activities have a range of impacts on natural environments. This paper reports results from a comparison of the impacts of hiking, cross-country skiing and horse riding on trail characteristics and vegetation in northern Finland. Widths and depths of existing trails, and vegetation on trails and in the neighbouring forests were monitored in two research sites during 2001 and 2002. Trail characteristics and vegetation were clearly related to the recreational activity, research site and forest type. Horse trails were as deep as hiking trails, even though the annual number of users was 150-fold higher on the hiking trails. Simultaneously, cross-country skiing had the least effect on trails due to the protective snow cover during winter. Hiking trail plots had little or no vegetation cover, horse riding trail plots had lower vegetation cover than forest plots, while skiing had no impact on total vegetation cover. On the other hand, on horse riding trails there were more forbs and grasses, many of which did not grow naturally in the forest. These species that were limited to riding trails may change the structure of adjacent plant communities in the long run. Therefore, the type of activities undertaken and the sensitivity of habitats to these activities should be a major consideration in the planning and management of nature-based tourism. Establishment of artificial structures, such as stairs, duckboards and trail cover, or complete closure of the site, may be the only way to protect the most sensitive or deteriorated sites.

Nurses' communication skills: an evaluation of the impact of solution-focused communication training.

AIMS: This paper describes the evaluation of a short training course in solution-focused brief therapy (SFBT) skills. This evaluation examined the relevance of SFBT skills to nursing and the extent to which a short training course affected nurses' communication skills. BACKGROUND: Nurses' communication skills have been criticized for many years, as has the training in communication skills that nurses receive. The absence of a coherent theoretical or practical framework for communication skills training led us to consider the utility of SFBT as a framework for a short training course for qualified nurses, the majority of them are registered nurses working with adults. DESIGN AND METHODS: Quantitative and qualitative data were collected: the former using pre- and post-training scales, the latter using a focus group conducted 6 months after the training. Data were analysed using the Wilcoxon signed-rank test and content analysis. RESULTS AND FINDINGS: Quantitative data indicated positive changes in nurses' practice following the training on four dimensions, and changes in nurses' willingness to communicate with people who are troubled reached levels of significance. Qualitative data uncovered changes to practice, centred on the rejection of problem-orientated discourses and reduced feelings of inadequacy and emotional stress in the nurses. CONCLUSIONS: There are indications that SFBT techniques may be relevant to nursing and a useful, cost-effective approach to the training of communication skills. Solution focused brief therapy provides a framework and easily understood tool-kit that are harmonious with nursing values.

Severe acute lung injury caused by Mycoplasma pneumoniae: potential role for steroid pulses in treatment.

Published evidence of pathogenetic mechanisms of acute respiratory distress syndrome (ARDS) in mycoplasmal lung infections suggests that the pulmonary injury is related to a cell-mediated immune response. Therefore, steroids may play a role in the treatment of severe cases. We describe a patient who had Mycoplasma pneumoniae pneumonia that progressed to severe ARDS requiring mechanical ventilation and who had improvement with prednisolone pulses.

[Application of a preoperative evaluation model in patients undergoing elective abdominal surgery]. / Aplicación de un modelo de evaluación preoperatoria en pacientes operados de cirugia abdominal electiva.

We used a preoperative evaluation model based on the clinical history in order to determine the clinical characteristics of the patients. We also estimated the prevalence of asymptomatic disease in ASA1 patients and described the frequency of diagnosis that motivated suspension of the surgery during the preoperative time. Another purpose was to establish the perioperative complications according to the risk index and to detect the medical reasons for suspension of surgery during hospitalization. A total of 777 patients having an indication of surgery were evaluated in this program. Only 507 completed the preoperative evaluation. Of these, 57.79%, had at least one known disease or were diagnosed by their clinical history. Preoperative tests were indicated according to age in ASA1 patients. Complementary studies were indicated in relationship to the history and physical examination in ASA2 and ASA3 patients. After the evaluation, 27 surgeries were suspended: 21 were considered high risk, 2 suffered unknown active infections, and 4 ASA1 patients had severe asymptomatic anemia. A total of 328 patients were admitted for surgery. In 5 of these patients the anesthesiologist stopped the procedure in the operating room. The causes were acute decompensations of known pathologies. There were no complications or deaths related to unknown diseases and no patients died from cardiopulmonary or metabolic complications. In ASA1 patients, there were no complications related to this evaluation. This study allowed us to determine the clinical status of the patients and in consequence high-risk surgeries were canceled. In admitted patients a few surgeries were canceled for clinical reasons. This program probably decreased patient morbimortality, unnecessary hospitalization and costs.

Aplicación de un modelo de evaluación preoperatoria en pacientes operados de cirugia abdominal electiva. / [Application of a preoperative evaluation model in patients undergoing elective abdominal surgery]

We used a preoperative evaluation model based on the clinical history in order to determine the clinical characteristics of the patients. We also estimated the prevalence of asymptomatic disease in ASA1 patients and described the frequency of diagnosis that motivated suspension of the surgery during the preoperative time. Another purpose was to establish the perioperative complications according to the risk index and to detect the medical reasons for suspension of surgery during hospitalization. A total of 777 patients having an indication of surgery were evaluated in this program. Only 507 completed the preoperative evaluation. Of these, 57.79

, had at least one known disease or were diagnosed by their clinical history. Preoperative tests were indicated according to age in ASA1 patients. Complementary studies were indicated in relationship to the history and physical examination in ASA2 and ASA3 patients. After the evaluation, 27 surgeries were suspended: 21 were considered high risk, 2 suffered unknown active infections, and 4 ASA1 patients had severe asymptomatic anemia. A total of 328 patients were admitted for surgery. In 5 of these patients the anesthesiologist stopped the procedure in the operating room. The causes were acute decompensations of known pathologies. There were no complications or deaths related to unknown diseases and no patients died from cardiopulmonary or metabolic complications. In ASA1 patients, there were no complications related to this evaluation. This study allowed us to determine the clinical status of the patients and in consequence high-risk surgeries were canceled. In admitted patients a few surgeries were canceled for clinical reasons. This program probably decreased patient morbimortality, unnecessary hospitalization and costs.

[Digoxin: continuous or discontinuous treatment?]. / Digoxina: tratamiento continuo o discontinuo?

In our country, patients with congestive heart failure who are treated chronically with digoxin are usually advised by their physicians to stop taking the medication two days a week. This is probably aimed at decreasing digitalis toxicity. Based on digoxin pharmacokinetics we assumed that the drug plasmatic level should diminish by 40 to 50%, below the therapeutic concentration of 0.8 to 2 milligrams, after two days of suspension. The objectives of this study were: a) to analyze the reduction of the plasmatic concentration of digoxin after a two day interruption of treatment, b) to compare the plasmatic levels of the drug between patients who received continuous and discontinuous treatment. A prospective, randomized and simple blind trial was designed. A total of 36 patients with congestive heart failure and systolic dysfunction with atrial fibrillation or sinus rythm were included. Group 1 (19 patients) received continuous treatment and Group 2 (17 patients) took the drug from Monday to Friday. In the continuous treatment group there was no significant difference between the Monday (1.06 +/- 0.55 milligrams) and the Friday (1.1 +/- 0.57 milligrams) digoxin concentrations. In the discontinuous treatment group the Monday digoxin concentration (0.611 +/- 0.396 milligrams) was lower than the Friday one (1.04 +/- 0.58 milligrams). The difference was statistically significant with a p = 0.000002. In conclusion, the two days a week suspension schedule reduces the plasmatic concentration of digoxin to subtherapeutic levels while the continuous regime maintains stable concentrations within the therapeutic range. Adjusting the dose to the creatinine clearance, average concentrations of 1 milligram are obtained. These results suggest that digitalis intoxication could be prevented by adjusting the dose according to renal function rather than interrupting the treatment as it is usually done in our country.

A qualitative study utilizing a focus group to explore the role and concept of the nurse practitioner.

This paper describes the first part of a two-stage study exploring the concept of the nurse practitioner role. By utilization of a focus group methodology, data were collated from a cohort of eight RCN trained nurse practitioners. The transcript from their discussion was subjected to a qualitative-based content analysis. Eight categories emerged from the data and this paper explores four of them. These are: role recognition, feature of the nurse practitioner role, nurse/patient relationship and doctor/patient relationship. As a whole the focus group discussion highlighted the diversity in application of the nurse practitioner title. This in part, reflects the rapidly evolving role and the ongoing debate regarding the terms advanced and specialist practitioner.

[Preoperative clinical evaluation]. / Evaluación clínica preoperatoria.

The purpose of preoperative evaluation is to reduce the morbidity and mortality of surgical interventions. The operative risk is related to: the nosocomial environment, the anesthetic procedure, the surgical team, the magnitude of the intervention and the patient's psychological, physical and pathological conditions. An adequate history and physical examination are essential to evaluate the patient's clinical situation. In our country, an electrocardiogram (EKG) with an estimation of the "surgical risk" and a number of laboratory tests are usually done. This article discusses the evidence and recommendations on the usefulness and indications of the EKG, the laboratory test, the coagulation tests and the chest X-ray. The decision to order preoperative tests should be based on positive clinical findings, the need to obtain basal values before major interventions and the existence of risk factors for certain diseases. The ambulatory preoperative clinical evaluation is the best method for the detection of diseases that could modify the surgical risk. It is also the opportunity to consult specialists if needed and to indicate necessary prophylactic measures.

Can a mental health nurse be a nurse practitioner?

This paper is part of a larger study examining the role of the nurse practitioner and its potential utility in mental health nursing. Two methods were employed for data collection: a focus group interview with eight RCN qualified nurse practitioners, the result of which informed the development of a postal questionnaire which was distributed to the remaining RCN qualified nurse practitioners (n = 130). Forty seven respondents did not feel adequately equipped to assess a mental health problem, despite nearly a third identifying mental health issues as a primary problem with which their patients presented. Just over 40 per cent of respondents stated that mental health needs were not met within their community and 78.7 per cent of respondents supported the development of a mental health nurse practitioner. In light of these findings the concept of a mental health nurse practitioner is discussed, alongside the need to clarify other advanced nursing roles.