Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study.

BACKGROUND: All health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were the following: (1) to analyze the association between IHA and the development of subsequent AEs; (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions. METHODS: An observational cross-sectional study was conducted on hospitalized patients in May 2019 in a high-complexity hospital in Madrid, Spain. The Appropriateness Evaluation Protocol was used to measure IHA, and the methodologies of the Harvard Medical Practice Study and the European Point Prevalence Survey of Healthcare-associated Infections were used to detect and characterize AEs. The association between IHA and the subsequent. RESULTS: A total of 558 patients in the hospital ward were studied. IHA increased the risk of subsequent occurrence of AEs (OR [95% CI]: 3.54 [1.87 to 6.69], versus appropriate) and doubled the mean AEs per patient (coefficient [95% CI]: 0.19 [0.08 to 0.30] increase, versus appropriate) after adjusting for confounders. IHA was a predictive variable of subsequent AEs and the number of AEs per patient. AEs developed after IHA were associated with scheduled admissions (78.9% of AEs, versus 27.9% after appropriate admissions; p < 0.001). Compared with AEs developed after appropriate admissions, AEs after IHA added 2.4 additional days of stay in the intensive care unit and incurred an extra cost of €166,324.9 for the studied sample. CONCLUSIONS: Patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns.

Adverse events: an expensive and avoidable hospital problem.

INTRODUCTION: Adverse healthcare-related events (AE) entail reduced patient safety. Estimating their frequency, characteristics, avoidability and impact is a means to identify targets for improvement in the quality of care. METHODS: This was a descriptive observational study conducted within the Patient Safety Incident Study in Hospitals in the Community of Madrid (ESHMAD). The study was conducted in a high-complexity hospital in May 2019 through a two-phase electronic medical record review: (1) AE screening and epidemiological and clinical data collection and (2) AE review and classification and analysis of their impact, avoidability, and associated costs. RESULTS: A total of 636 patients were studied. The prevalence of AE was 12.4%. Death during the stay was associated with the presence of AE (OR [CI95%]: 2.15 [1.07 to 4.52]) versus absence and emergency admission (OR [CI95%]: 17.11[6.63 to 46.26]) versus scheduled. A total of 70.2% of the AEs were avoidable. Avoidable AEs were associated with the presence of pressure ulcers (OR [CI95%]: 2.77 [1.39 to 5.51]), central venous catheter (OR [CI95%]: 2.58 [1.33 to 5.00]) and impaired mobility (OR [CI95%]: 2.24[1.35 to 3.71]), versus absences. They were associated too with the stays in the intensive care unit (OR [CI95%]: 2.75 [1.07 to 7.06]) versus medical service. AEs were responsible for additional costs of €909,716.8 for extra days of stay and €12,461.9 per patient with AE. CONCLUSIONS: The prevalence of AEs was similar to that found in other studies. AEs led to worse patient outcomes and were associated with the patient's death. Although avoidable AEs were less severe, their higher frequency produced a greater impact on the patient and healthcare system.Key messagesAdverse events are one of the main problems in healthcare delivery and patients who suffer from at least one AE are double as likely to die during hospitalization.Avoidable adverse events are the most frequent in health care and they are a good target where achieve improvement areas that allow getting optimal patient safety and quality of care levels.Patients hospitalized in the ICU, with the previous presence of pressure ulcers, central venous catheter, or impaired mobility were associated with the development of avoidable AE, so optimal management of these patients would reduce the impact of AE.

How Does Vaccination against SARS-CoV-2 Affect Hospitalized Patients with COVID-19?

(1) Background: The development of effective COVID-19 vaccines has reduced the impact of COVID-19 on the general population. Our study aims to analyze how vaccination modifies the likelihood of death and length of stay in hospitalized patients with COVID-19; (2) Methods: A retrospective cohort study of 1927 hospitalized patients infected with COVID-19 was conducted. Information was gathered on vaccination status, hospitalization episode, and clinical profile of the patients. The effect of vaccination on mortality was analyzed using a multiple logistic regression model, and length of stay was analyzed using linear regression. The performance and fit of the models were evaluated; (3) Results: In hospitalized patients with COVID-19, the risk of dying during admission in vaccinated patients was half that of non-vaccinated (OR: 0.45; CI 95%: 0.25 to 0.84). In patients who were discharged due to improvement, the reduction in hospital stay in vaccinated patients was 3.17 days (CI 95%: 5.88 to 0.47); (4) Conclusions: Patients who, despite having been vaccinated, acquire the infection by SARS-CoV-2, have a significant reduction of the risk of death during admission and a reduction of hospital stay compared with unvaccinated patients.

Surgical Error Compensation Claims as a Patient Safety Indicator: Causes and Economic Consequences in the Murcia Health System, 2002 to 2018.

OBJECTIVES: Compensation claims are a useful source of information on patient safety research. The purpose of this study was to determine the main causes of surgical compensation claims and their financial impact on the health system. METHODS: A descriptive observational study with analytical components was carried out on compensation claims brought against the surgical area of the Murcia Health System between 2002 and 2018. We analyzed the frequency, causes, consequences, locations and surgical settings of these claims, the time of judicial procedure, and compensation adjusted to the Consumer Price Index. RESULTS: There were 1172 compensation claims. "orthopedic surgery and traumatology" (27.4%), "gynecology and obstetrics" (25.7%), and "general surgery" (17.2%) were the main surgical settings involved. The most frequent causes were surgical error (42.4%) and treatment error (30.9%). The main sequelae were musculoskeletal (20.0%), neurological (17.7%), and obstetric (17.7%). The average time from incident to resolution of claims was 6.3 years. A total of 20.1% of these claims were successful, particularly those involving retained surgical foreign bodies (71.4% successful claims; P < 0.001). The total compensation paid was €56,338,247 (an average of €17,207 per claim). Compensation was higher in cases with respiratory sequelae (median, 131,600; P = 0.033), death (75,916; P < 0.001), and neurological (60,000; P = 0.024). CONCLUSIONS: Compensation claims associated with surgical procedures are made on a variety of grounds. They are drawn-out proceedings, and patients are only successful in 20% of cases.

Surgery Is in Itself a Risk Factor for the Patient.

(1) Background: Adverse events (AE) affect about 1 in 10 hospitalised patients, and almost half are related to surgical care. The aim of this study is to determine the prevalence of AE in operated and non-operated patients in surgical departments in order to determine whether surgical treatment is a risk factor for AE. (2) Methods: A cross-sectional design that included 3123 patients of 34 public hospitals in the Community of Madrid determining the prevalence of AEs in operated and non-operated patients in surgical departments. (3) Results: The prevalence of AE in non-operated patients was 8.7% and in those operated was 15.8%. The frequency of AE was higher in emergency surgery (20.6% vs. 12.4%). The 48.3% of AEs led to an increase in hospital stay, and surgery was involved in 92.4% of cases. The most frequent AEs were related to hospital-acquired infection (42.63%), followed by those related to a procedure (37.72%). In the multivariate analysis, being operated on represented 2.3 times the risk of developing an AE. (4) Conclusions: Surgical sites are particularly vulnerable to AE. Surgical intervention alone is a risk factor for AE, and we must continue to work to improve the safety of both patient care and the working environment of surgical professionals.

[Apropriateness of hospital admissions due to COVID-19 in the 2nd and 5th phase of the pandemic.] / Adecuación de ingresos hospitalarios por COVID-19 en la 2ª y 5ª fase de la pandemia.

OBJECTIVE: The increase in the demand for healthcare caused by COVID-19 implies a lower availability of health resources and influences the appropriateness of their use. Due to the variability of demand during the pandemic, the study aimed to compare the appropriateness of hospital admissions between the 2nd and 5th phases of the pandemic according to the criteria of the Hospital Emergency Service (CiHRyC). These results were compared with those obtained according to the Pneumonity Severity Index (FINE) and the Appropriateness Evaluation Protocol (AEP). As a secondary objective, the clinical and sociodemographic characteristics of the patients studied were described. METHODS: 80 patients hospitalized from the Emergency Department were randomly selected in two study periods (2nd and 5th pandemic phase) obtained from the registry of hospitalizations of the Preventive Medicine service of Hospital Ramon y Cajal. Prevalences of inappropriateness were estimated according to the CiHRyC, FINE and AEP and an analysis was performed using univariate logistic regression between epidemiological variables of both periods collected through the electronical medical records. RESULTS: Inappropriateness of admissions were 35% and 45% in the 2nd and 5th phase of the pandemic according with CiHRyC, 25% and 5/% according with FINE and 0% and 5% according with AEP. Median age was 71.4 and 50.0 years in 2nd and 5th phase (p=0.02). 72.5% and 17.5% of the patients in the 2nd and 5th phases had at least one risk factor for COVID-19 severe illness (p<0.01). CONCLUSIONS: The measurement tools used identified more inappropriately cases in the 5th phase of the pandemic than in the 2nd one. CiHRyC coincided with FINE and AEP in the result of their evaluation.

OBJETIVO: El aumento de la demanda asistencial hospitalaria producida por la COVID-19 supone una menor disponibilidad de recursos sanitarios e influye en la adecuación de su utilización. Debido a la variabilidad de la demanda durante la pandemia, el objetivo del estudio fue comparar la adecuación de los ingresos hospitalarios entre la 2ª y 5ª fase de la pandemia según los criterios del servicio de Urgencias del Hospital (CiHRyC). Se compararon estos resultados con los obtenidos según el Pneumonity Severity Index (FINE) y el Appropriateness Evaluation Protocol (AEP). Como objetivo secundario se describieron las características clínicas y sociodemográficas de los pacientes estudiados. METODOS: Se seleccionaron aleatoriamente 80 pacientes hospitalizados desde Urgencias en dos periodos de estudio (2ª y 5ª fase pandémica) obtenidos del registro de hospitalizaciones del servicio de Medicina Preventiva del Hospital Ramón y Cajal. Se estimaron las prevalencias de inadecuación según los CiHRyC, el FINE y el AEP para admisiones y se realizó un análisis mediante regresión logística univariante entre las variables epidemiológicas de ambos periodos recogidas mediante la Historia Clínica Electrónica (HCE). RESULTADOS: La inadecuación de la hospitalización fue del 35% y 45% en la 2ª y 5ª fase de la pandemia con los CiHRyC, del 25% y 57% con el FINE y del 0% y 5% con el AEP. La mediana de edad fue de 71,4 y 50 años en la 2ª y 5ª fase (p=0,02). El 72,5% y el 17,5% de los pacientes de la 2ª y 5ª fase tuvieron al menos un factor de riesgo de complicaciones de COVID-19 (p<0,01). CONCLUSIONES: Los instrumentos de medida empleados (CiHRyC, el FINE y el AEP) identificaron más casos inadecuadamente ingresados en la 5ª fase de la pandemia que en la 2ª, coincidiendo el CiHRyC con el FINE y el AEP en el resultado de su evaluación.

Adecuación de ingresos hospitalarios por COVID-19 en la 2ª y 5ª fase de la pandemia / Apropriateness of hospital admissions due to COVID-19 in the 2nd and 5th phase of the pandemic

Fundamentos: El aumento de la demanda asistencial hospitalaria producida por la COVID-19 supone una menor disponibilidad de recursos sanitarios e influye en la adecuación de su utilización. Debido a la variabilidad de la demanda durante la pandemia, el objetivo del estudio fue comparar la adecuación de los ingresos hospitalarios entre la 2ª y 5ª fase de la pandemia según los criterios del servicio de Urgencias del Hospital (CiHRyC). Se compararon estos resultados con los obtenidos según el Pneumonity Severity Index (FINE) y el Appropriateness Evaluation Protocol (AEP). Como objetivo secundario se describieron las características clínicas y sociodemográficas de los pacientes estudiados. Métodos: Se seleccionaron aleatoriamente 80 pacientes hospitalizados desde Urgencias en dos periodos de estudio (2ª y 5ª fase pandémica) obtenidos del registro de hospitalizaciones del servicio de Medicina Preventiva del Hospital Ramón y Cajal. Se estimaron las prevalencias de inadecuación según los CiHRyC, el FINE y el AEP para admisiones y se realizó un análisis mediante regresión logística univariante entre las variables epidemiológicas de ambos periodos recogidas mediante la Historia Clínica Electrónica (HCE). Resultados: La inadecuación de la hospitalización fue del 35% y 45% en la 2ª y 5ª fase de la pandemia con los CiHRyC, del 25% y 57% con el FINE y del 0% y 5% con el AEP. La mediana de edad fue de 71,4 y 50 años en la 2ª y 5ª fase (p=0,02). El 72,5% y el 17,5% de los pacientes de la 2ª y 5ª fase tuvieron al menos un factor de riesgo de complicaciones de COVID-19 (p<0,01). Conclusiones: Los instrumentos de medida empleados (CiHRyC, el FINE y el AEP) identificaron más casos inadecuadamente ingresados en la 5ª fase de la pandemia que en la 2ª, coincidiendo el CiHRyC con el FINE y el AEP en el resultado de su evaluación.(AU)

Background: The increase in the demand for healthcare caused by COVID-19 implies a lower availability of health resources and influences the appropriateness of their use. Due to the variability of demand during the pandemic, the study aimed to compare the appropriateness of hospital admissions between the 2nd and 5th phases of the pandemic according to the criteria of the Hospital Emergency Service (CiHRyC). These results were compared with those obtained according to the Pneumonity Severity Index (FINE) and the Appropriateness Evaluation Protocol (AEP). As a secondary objective, the clinical and sociodemographic characteristics of the patients studied were described. Methods: 80 patients hospitalized from the Emergency Department were randomly selected in two study periods (2nd and 5th pandemic phase) obtained from the registry of hospitalizations of the Preventive Medicine service of Hospital Ramon y Cajal. Prevalences of inappropriateness were estimated according to the CiHRyC, FINE and AEP and an analysis was performed using univariate logistic regression between epidemiological variables of both periods collected through the electronical medical records. Results: Inappropriateness of admissions were 35% and 45% in the 2nd and 5th phase of the pandemic according with CiHRyC, 25% and 5/% according with FINE and 0% and 5% according with AEP. Median age was 71.4 and 50.0 years in 2nd and 5th phase (p=0.02). 72.5% and 17.5% of the patients in the 2nd and 5 th phases had at least one risk factor for COVID-19 severe illness (p<0.01). Conclusions: The measurement tools used identified more inappropriately cases in the 5th phase of the pandemic than in the 2 nd one. CiHRyC coincided with FINE and AEP in the result of their evaluation.(AU)

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

BACKGROUND: Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice. METHODS: This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to "Choosing Wisely", "No Hacer" and "Essencial" initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units. RESULTS: A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the "No Hacer" recommendation and 73.3% according to "Choosing Wisely" and "Essencial" criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to "Choosing Wisely" and "Essencial"; 4.1% according to "No Hacer"). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to "No Hacer" and EUR 3895.29 (2276.1 Relative Value Units) according to "Choosing Wisely" or "Essencial" criteria. CONCLUSIONS: There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

Mascarillas como equipo de protección individual durante la pandemia de COVID-19: cómo, cuándo y cuáles deben utilizarse / Masks as personal protective equipment in the COVID-19 pandemic: How, when and which should be used

ANTECEDENTES Y OBJETIVO: Durante la pandemia COVID-19 se ha producido un aumento de la demanda de mascarillas por parte de profesionales sanitarios y de la población general. En este contexto, se hace necesario sintetizar las características y las indicaciones de uso de los distintos tipos de mascarillas existentes. MATERIAL Y MÉTODOS: Se consultaron y recopilaron las diferentes recomendaciones difundidas por instituciones de reconocido prestigio, como la Organización Mundial de la Salud, The European Centre for Disease Prevention, The Centre for Evidence-Based Medicine o el Ministerio de Sanidad del Gobierno de España. RESULTADOS: Las instituciones consultadas aconsejan reservar las mascarillas filtering face piece (FFP) para el personal sanitario, especialmente en la realización de procedimientos generadores de aerosoles (PGA) (protección mínima de FFP2), y plantean posibles sistemas de reutilización durante épocas de escasez. Asimismo, se recomienda el uso de mascarillas quirúrgicas en profesionales que no realicen PGA y en población sintomática, existiendo variación en las indicaciones de uso para población general sana. CONCLUSIÓN: En situaciones de escasez de equipos de protección individual por pandemia de COVID-19 se debe establecer una priorización y racionalización de uso de cada tipo de mascarilla en función del usuario y de la actividad a realizar

BACKGROUND AND OBJECTIVE: In the COVID-19 pandemic, the demand of masks has been increased by health professionals and the general population. In this context, it is necessary to summarize the features and indications of the different types of masks. MATERIAL AND METHODS: To consult and to compile the different recommendations disseminated by prestigious institutions such as the World Health Organization, the European Center for Disease Prevention, the Center for Evidence-Based Medicine, or the Ministry of Health of the Government of Spain has been reviewed. RESULTS: The institutions consulted recommend reserving FFP respirators for healthcare workers, especially when carrying out aerosol-generating procedures (AGPs) (minimum FFP2 protection) and consider some reutilization systems during times of scarcity. The use of surgical masks is recommended to professionals who do not perform AGPs and to the symptomatic population but exist variations in its indications intended for the general healthy population. CONCLUSION: In the context of shortage of personal protective equipment due to the COVID-19 pandemic, a prioritization and rationalization of the use of each type of mask should be established according to the user and the activity performed

[Masks as personal protective equipment in the COVID-19 pandemic: How, when and which should be used]. / Mascarillas como equipo de protección individual durante la pandemia de COVID-19: cómo, cuándo y cuáles deben utilizarse.

BACKGROUND AND OBJECTIVE: In the COVID-19 pandemic, the demand of masks has been increased by health professionals and the general population. In this context, it is necessary to summarize the features and indications of the different types of masks. MATERIAL AND METHODS: To consult and to compile the different recommendations disseminated by prestigious institutions such as the World Health Organization, the European Center for Disease Prevention, the Center for Evidence-Based Medicine, or the Ministry of Health of the Government of Spain has been reviewed. RESULTS: The institutions consulted recommend reserving FFP respirators for healthcare workers, especially when carrying out aerosol-generating procedures (AGPs) (minimum FFP2 protection) and consider some reutilization systems during times of scarcity. The use of surgical masks is recommended to professionals who do not perform AGPs and to the symptomatic population but exist variations in its indications intended for the general healthy population. CONCLUSION: In the context of shortage of personal protective equipment due to the COVID-19 pandemic, a prioritization and rationalization of the use of each type of mask should be established according to the user and the activity performed.

Low-Value Clinical Practices: Knowledge and Beliefs of Spanish Surgeons and Anesthetists.

OBJECTIVES: To know the frequency and causes of low value surgical practices, according to the opinion of surgeons and anesthetists, and to determine their degree of knowledge about the Spanish "Choosing wisely" initiative. METHODS: Cross-sectional observational study, based on a self-administered online questionnaire through an opportunistic sample of 370 surgeons and anesthetists from three Spanish regions, contacted through Scientific Societies. The survey took part between July and December 2017. RESULTS: A patient profile requesting unnecessary practices was identified (female, 51-65 years old and unaffiliated disease). The frequency of requests was weekly or daily for 50.0% of the professionals, of whom 15.1% acknowledged succumbing to these pressures. To dissuade the patient, clinical reasons (47%) were considered the most effective. To increase control and safety in the case was the main reason to indicate them. The greatest responsibility for overuse was attributed to physicians, defensive medicine and mass media. Assessing professionals' knowledge on unnecessary practices, an average of 5 correct answers out of 7 was obtained. Some 64.1% of the respondents were unaware of the Spanish "Choosing wisely" initiative. CONCLUSIONS: Low value surgical practices are perceived as a frequent problem, which requires an approach entailing intervention with patients and the media as well as professionals. Increase awareness on unnecessary surgical practices, and how to avoid them remain essential.

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