Manejo del paciente disfágico por técnicos paramédicos: evaluación y capacitación en un hospital chileno / Management of the patient with dysphagia by paramedics: assessment and training in a Chilean hospital

El objetivo de este artículo es dar a conocer los resultados de un estudio analítico1 acerca del manejo del paciente con disfagia por parte de técnicos paramédicos en el Hospital San Juan de Dios de Santiago, Chile, y del desarrollo de competencias tras la aplicación de un programa de capacitación. En primera instancia, se aplicó una encuesta validada por tres fonoaudiólogas para determinar el nivel de conocimiento e idoneidad de 145 funcionarios de la Unidad de Paciente Crítico, Cirugía y Medicina, la que evidenció que un 61 por ciento de los encuestados poseía un manejo “no deseable” del paciente y un 39 por ciento de ellos un manejo “regular”. Posteriormente se les impartió un programa de capacitación teórico-práctico con una duración de 21 horas pedagógicas dictadas por el equipo interdisciplinario (médico, enfermero, fonoaudiólogo, kinesiólogo, terapeuta ocupacional y nutricionista) durante tres jornadas. Al término de estas, se les aplicó nuevamente la encuesta, con el fin de comparar los datos con la información inicial. Tras la intervención, el 57 por ciento logró un nivel “deseable”, 41 por ciento un nivel “regular” y solo un 2 por ciento un nivel “no deseable”. Como conclusión, la formación técnica de los paramédicos no les brinda las herramientas suficientes para el manejo de los pacientes con disfagia, por lo que es labor de la institución de salud capacitarlos continuamente para evitar riesgos en los usuarios.

The aim of this article is to present the results of an analytical study in the management of patients with dysphagia by paramedics at San Juan de Dios Hospital in Santiago, Chile, and the development of skills after the implementation of a training program. First of all, a survey validated by three speech therapists was applied to determine the level of knowledge and suitability of 145 paramedics of the Critical Patient Unit, Surgery and Medicine. This survey found that 61 percent had a “non-desirable” management in patients, and 39 percent a “middle” level. Secondly, they participated in a 3-days theoretical and practical program, which lasted 21 hours. The classes were taught by an interdisciplinary team that attend the pathology (Doctor, Nurse, Speech Therapist, Physiotherapist, Occupational Therapist and Nutritionist), where at the end they were re-applied the survey to determine the new data by statistical analysis. After the intervention, 57 percent achieved a “desirable” level, 41 percent a “middle” level, while only 2 percent a “non-desirable” level. In conclusion, the technical training of paramedics does not provide them with the necessary tools for the management of patients with dysphagia; therefore, it is the health institution’s work to train them in order to avoid risks in patients.

Conocimientos sobre la enfermedad renal crónica y el proceder de hemodiálisis / Knowledge about chronic kidney disease and hemodialysis procedure

Introducción: el consentimiento informado supone un proceso que va más allá de la firma de un documento de autorización. Objetivo: determinar el nivel de conocimientos sobre la enfermedad renal crónica y el proceder de hemodiálisis de los pacientes del Hospital General Docente Abel Santamaría Cuadrado de Pinar del Río en el período comprendido de marzo a mayo de 2012. Material y método: se realizó un estudio observacional, descriptivo, transversal y aplicado. El universo estuvo constituido por los pacientes que reciben hemodiálisis (N = 102). La muestra estuvo integrada por los pacientes que recibieron hemodiálisis el día escogido para aplicar la encuesta que debió coincidir con la segunda sesión de hemodiálisis de la semana, utilizando un método aleatorio simple (n= 85), a los que se aplicó una encuesta formulario. Para determinar la asociación entre variables se utilizó el estadígrafo ji cuadrado al 95 % de confianza. Resultados: la muestra resultó ser mayoritariamente joven, con bajo nivel educacional, siendo el dominio de la enfermedad bastante bajo, y aún más crítico el conocimiento sobre posibles complicaciones durante la hemodiálisis, cuestiones evitables de existir un documento informador previo a este proceder. Conclusiones: los pacientes con enfermedad renal crónica y con tratamientos depuradores, como la hemodiálisis, necesitan la existencia de un consentimiento informado, que sea adaptable a cada paciente, para prepararlos mejor y así lograr bienestar, confort y su total cooperación.

Introduction: informed knowledge involves a process that goes beyond the signing of an authorization document. Objective: to determine the level of knowledge about the chronic kidney disease and the hemodialysis procedure by the patients of Abel Santamaría Cuadrado General Teaching Hospital of Pinar del Río, in the period between March and May 2012. Material and method: an observational, descriptive, cross-sectional and applied study was performed. The universe was made up of the patients undergoing hemodialysis (n=120). The sample was composed by the patients who underwent hemodialysis on the days chosen for applying the survey, which should coincide with the second session of hemodialysis within the week, using the random simple method (n=85), whom were conducted the questionnaire-survey on. To determine association amongst variables, the statistical chi-square test was used at 95% of confidence. Results: the sample came to be mostly young, with low schooling, being also low their knowledge on the disease, and even more critical their knowledge about potential complications in hemodialysis, matters evitable to occur in an authorization document before this procedure. Conclusions: patients with chronic kidney disease and with purifying treatments, as hemodialysis, need to know about a proper informed concernment, applicable to each patient, in order to better prepare them and in doing so to achieve welfare, comfort and their total recovery.

Síndrome de burnout en médicos y personal paramédico / Burnout syndrome in medical practitioners and paramedic personel

Introduction Burnout syndrome is one of the most studied manifestations of job stress. The burnout concept was used by the first time in the area of psychology by Freudenberger in 1974. This psychologist defined it as a condition of fatigue or frustration that is produced by the commitment to a reason, lifestyle or relationship that does not produce the expected effort. Afterwards, Maslach and Jackson proposed three interrelated dimensions: emotional weariness (EW) which estimates the experience of emotional fatigue for the demands of work; the depersonalization (DP) which measures the answers of impersonal type and negative attitudes towards the patients; and the personal accomplishment (PA) which reflects the personal satisfaction and the competition in the practice of the daily work. These dimensions are joined in the Maslach Burnout Inventory (MBI) that is used to measure the afore mentioned syndrome. Several studies have demonstrated the presence of burnout syndrome among medical and paramedic personnel. The close contact with the patients and the work overload are the main reasons of this syndrome. In a multicentre study carried out among 248 doctors of the United States, 40% presented the syndrome with emotional detriment, which coincides with another study carried out with nurses attending patients with palliative care and marrow transplants. Also, in a study carried out among residents of internal medicine of the University of Washington, there was a prevalence of 76% of professional wear, with an autoperception of a lower quality in the professional care of the patients, after comparing them with non-affected residents. In Mexico, a study that investigated burnout level in a group of 450 medical practitioners, nurses and paramedics of 12 institutions revealed the following information: 10.9% presented emotional weariness, 19.6%, depersonalization, and 74.9, low personal accomplishment. Palmer et al. determined a general prevalence of 44% of the syndrome in anesthesiologists. The work overload and the conflict of values were variables that influenced the presence of this syndrome. At the Instituto Mexicano del Seguro Social, Aranda et al., carried out a study among family physicians, where the prevalence of burnout syndrome was 42.3%. Likewise, Cabrera et al., found that, out of 236 studied nurses, 92 (39%) had information compatible with burnout syndrome, with statistically significant differences for the age and the antiquity in the place after comparing them with nurses without burnout syndrome. The burnout syndrome was considered by the World Health Organization as work risk. Its trascendence is rooted in the impact it has in the labor relation between medical and/or paramedic personnel and the health institutions. For this reason, we considered it important to investigate the presence of this syndrome among the medical and paramedic personnel working at hospital of the Mexican social security. Material and Methods Design: Transversal comparative survey. Population: Of a total population of 240 workers of the health area assigned to a general hospital a sample of 160 was obtained that included doctors, nurses and medical assistants based on an average prevalence of the syndrome in 30%, with an alpha level of 0.05 and a power of 90%. Instrument of evaluation: The survey was based on the following sociodemographic and labor variables: age, marital status, academic level, labor antiquity, antiquity of adscript ion to the hospital, category, service and labor shift. To evaluate the burnout syndrome, the MBI questionnaire was used in its previously validated Spanish version. The afore mentioned instrument is an objective way of measuring and determining the burnout level that a person experiences, in its three subscales: EW, DP and PA. The survey consists of 22 items with a Likert type punctuation scale (0-6), of which 9 valued EW, 5, DP, and 8, PA. With regard to the EW, which values the sensation of being emotionally exhausted by the daily contact with people to whom it is necessary to attend as object of work, a punctuation of 27 or higher indicated a high level; between 19 and 26, moderated; and lower than 19, low. In the subscale DP, which measures the degree in which the response towards the patients is cold, distant and impersonal, punctuations above 10 indicated a high level; from 6 to 9, moderated; lower than 6, low. In the subscale PA, which values the feelings of competition and efficiency for the accomplishment of the work and the relation with the people who are being attended, values above 40 indicated personal high accomplishment; from 34 to 39, intermediate; and under 33, low. In the case of obtaining a low emotional depletion, a low depersonalization and a high personal accomplishment, it was considered that no burnout was present. In the rest of the cases, the presence of burnout syndrome was established. Compilation of the information: From August to December, 2005, the survey was applied to each of the workers, indicating them that they should answer and return it in a term not longer than five days. They were all informed previously about the general objectives of the study and its confidential and anonymous character. The head investigator integrated later on the database. Statistical tests: Descriptive and inferential statistics were carried out. The odds ratio and confidence intervals of 95% were calculated to measure the association between the sociodemographic and labor factors with the professional wear. Results Of 160 workers to whom the survey MBI was applied, only 146 returned it in a complete form. Regarding the frequency and the percentages of the three categories studied with the qualifications of low, average and high for every subscale that composes the burnout syndrome, it was observed that the highest evaluations fit the medical assistants. There was a 19.6% prevalence of burnout syndrome among the groups of doctors with at least one of three disturb subscales. Likewise, it was observed that all medical assistants had an alteration of a minimum of two subscales. The nursing personnel did not present information that constitutes a risk for the development of burnout syndrome. Only four sociodemographic and labor variables were found as risk factors for the presence of burnout syndrome, as well as their relation with each of the subscales composing it. When the variables compared age, labor antiquity and time of adscript ion in the service with each of the subscales of the burnout, we observed that depersonalization appeared in older workers and longer antiquity in the position and the lack of personal accomplishment in workers with longer time in the service. There were no statistically significant differences in the subscale of emotional weariness. Discussion In the last years, burnout syndrome has acquired special relevance, mainly because of the series of repercussions that it has in the labor and personal area. Numerous studies exist on the prevalence of this syndrome in different health professionals, but in present work incorporated medical assistants, since they are those who have the first contact with the patients in our institution.

Introducción El concepto de burnout fue utilizado por primera vez en el ámbito de la psicología por Freudenberger en el año de 1974. Este psicólogo lo definió como un estado de fatiga o frustración que se produce por la dedicación a una causa, forma de vida o relación que no produce el esperado esfuerzo. Más tarde, Maslach y Jackson propusieron tres dimensiones interrelacionadas: el cansancio emocional (CE), la despersonalización (DP) y la realización personal (RP). Estas dimensiones se integran en el cuestionario Maslach Burnout Inventory (MBI) que se utiliza para medir dicho síndrome. Material y métodos Diseño: Encuesta transversal comparativa. Población: Se entregó el cuestionario MBI a 160 trabajadores del área de la salud adscritos al Hospital General de Zona con Medicina Familiar 36 de la Ciudad de Cardel, Veracruz. Instrumento de evaluación: Se construyó una encuesta sobre las siguientes variables sociodemográficas y laborales: edad, estado civil, nivel académico, antigüedad laboral, antigüedad de adscripción al hospital, categoría, servicio y turno laboral. Para evaluar el síndrome de burnout se utilizó el cuestionario MBI en su versión en español. Dicho instrumento consta de 22 ítems con escala de puntuación tipo Likert (0-6), de los cuales 9 valoran CE, 5 la DP y 8 la RP. Recolección de la información: Durante el periodo comprendido de agosto a diciembre del 2006 se entregó el cuestionario a cada uno de los trabajadores de la salud. Pruebas estadísticas: Se realizó estadística descriptiva e inferencial. Se calculó la razón de momios e intervalos de confianza de 95% para medir la asociación entre los factores sociodemográficos y laborales con el desgaste profesional. Resultados De 160 trabajadores a quienes se les entregó el cuestionario MBI, sólo 146 lo regresaron en forma completa. En lo que respecta a la frecuencia y los porcentajes de las tres categorías estudiadas se observó que las evaluaciones más altas corresponden a las asistentes médicas. Hubo una prevalencia del síndrome de burnout entre el grupo de médicos del 19.6% con al menos una de las tres subescalas alteradas. Asimismo se observa que en todas las asistentes médicas hubo alteración de un mínimo de dos subescalas. Sólo se encontraron cuatro variables sociodemográficas y laborales como factores de riesgo para la presencia del síndrome de burnout, así como su relación con cada una de la subescalas que lo componen. Discusión Existen numerosos estudios sobre la prevalencia de este síndrome en diferentes profesionales de la salud, pero en el presente trabajo se incorpora a las asistentes médicas, ya que son quienes tienen un primer contacto con los pacientes en nuestra institución. Las cifras de prevalencia del síndrome de burnout reportadas por otros estudios realizados en México entre el personal médico van desde el 42.3% y 44% hasta 50%; en esta investigación la prevalencia fue menor y la dimensión de cansancio emocional es la más afectada. Entre las variables que se consideraron factores de riesgo en nuestro estudio se encuentra el estado civil. Asimismo, el trabajar en el turno vespertino y ofrecer sus servicio en la consulta externa también estuvieron relacionados con mayor predisposición al síndrome de burnout. Al igual que otros estudios, en esta investigación se encontró un mayor nivel de Burnout en profesionales con mayor edad. En lo que respecta a la DP y RP, éstas se presentaron en trabajadores cuya antigüedad laboral era mayor. En conclusión, la prevalencia del síndrome de burnout entre las asistentes médicas es muy alta y es necesario adoptar medidas para evitar el desarrollo de esta patología.