Risk factors for hospital mortality in intensive care unit survivors: a retrospective cohort study.

BACKGROUND: Deaths can occur after a patient has survived treatment for a serious illness in an intensive care unit (ICU). Mortality rates after leaving the ICU can be considered indicators of health care quality. This study aims to describe risk factors and mortality of surviving patients discharged from an ICU in a university hospital. METHODS: Retrospective cohort study carried out from January 2017 to December 2018. Data on age, sex, length of hospital stay, diagnosis on admission to the ICU, hospital discharge outcome, presence of infection, and Simplified Acute Physiology Score (SAPS) III prognostic score were collected. Infected patients were considered as those being treated for an infection on discharge from the ICU. Patients were divided into survivors and non-survivors on leaving the hospital. The association between the studied variables was performed using the logistic regression model. RESULTS: A total of 1,025 patients who survived hospitalization in the ICU were analyzed, of which 212 (20.7%) died after leaving the ICU. When separating the groups of survivors and non-survivors according to hospital outcome, the median age was higher among non-survivors. Longer hospital stays and higher SAPS III values were observed among non-survivors. In the logistic regression, the variables age, length of hospital stay, SAPS III, presence of infection, and readmission to the ICU were associated with hospital mortality. CONCLUSIONS: Infection on ICU discharge, ICU readmission, age, length of hospital stay, and SAPS III increased risk of death in ICU survivors.

Recusa de leitos e triagem de pacientes admitidos nas unidades de terapia intensiva do Brasil: estudo transversal do tipo survey nacional / Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey

RESUMO Objetivo: Conhecer dados sobre recusa de leitos nas unidades intensivas no Brasil, assim como avaliar o uso de sistemas de triagem pelos profissionais atuantes. Métodos: Estudo transversal do tipo survey. Com a metodologia Delphi, foi criado um questionário contemplando os objetivos do trabalho. Foram convidados médicos e enfermeiros inscritos na rede de pesquisa da Associação de Medicina Intensiva Brasileira (AMIBnet). Uma plataforma da web (SurveyMonkey®) foi a forma de aplicação do questionário. As variáveis deste trabalho foram mensuradas em categorias e expressas como proporção. Foram usados o teste do qui-quadrado ou o teste exato de Fisher, para verificar associações. O nível de significância foi de 5%. Resultados: No total, 231 profissionais responderam o questionário, representando todas as regiões do país. As unidades intensivas nacionais tinham mais de 90% de taxa de ocupação sempre ou frequentemente para 90,8% dos participantes. Dentre os participantes, 84,4% já deixaram de admitir pacientes em leito intensivo devido à lotação da unidade. Metade das instituições brasileiras (49,7%) não possuía protocolos de triagem de leitos intensivos instituídos. Conclusão: A recusa de leito pela alta taxa de ocupação é frequente nas unidades de terapia intensiva do Brasil. Ainda assim, metade dos serviços do Brasil não adota protocolos para triagem de leitos.

ABSTRACT Objective: To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals. Methods: A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%. Results: In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds. Conclusions: Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.

Associação entre nível de priorização na admissão da Unidade de Terapia Intensiva e desfecho hospitalar / Association between prioritization level at intensive care unit admission and hospital outcome

Objetivo: avaliar a associação entre os níveis de priorização para admissão na Unidade de Terapia Intensiva (UTI) e o prognóstico dos pacientes. Material e Método: estudo longitudinal retrospectivo que incluiu adultos internados na UTI de hospital universitário, ano de 2020. As variáveis, coletadas nos prontuários e banco de dados eletrônicos do hospital contemplam: identificação, data de entrada no hospital e de admissão na UTI, diagnósticos, antecedentes, data de alta, desfecho, cálculo do Simplified Acute Physiology Score 3 (SAPS 3) e nível de priorização da admissão. Resultados: o estudo avaliou 274 pacientes. As patologias respiratórias totalizaram 41,25% das admissões, sendo COVID-19 o diagnóstico mais frequente (65 casos confirmados e 2 suspeitos). Dentre as comorbidades, destacam-se hipertensão arterial sistêmica (64,32%), diabetes mellitus (25,82%) e tabagismo (18,78%). O SAPS 3 médio foi de 59,29 pontos, representando uma probabilidade de óbito de 39,00%. A respeito dos níveis de priorizações, 174 (63,50%) pacientes foram classificados como prioridade 1 (P1); 94 (34,31%) pacientes como prioridade 2 (P2); e 6 (2,19%) pacientes como prioridade 3 (P3). Comparando os grupos P1 e P2, a probabilidade de óbito foi, respectivamente, 51,95% e 13,75%. E o número de óbitos observado foi de 90 (60,81%) no grupo P1 e 19 no grupo P2 (25,30%; p<0,001)). Conclusão: os pacientes classificados como P1 foram mais frequentes na amostra de estudo. A classificação de prioridades identificou os pacientes mais graves e com maior taxa de mortalidade na primeira categoria, apesar de não haver diferença na idade, comorbidade e fragilidade.

Objective: to assess the association between levels of prioritization for admission to intensive care unit (ICU) and patients' prognosis. Material and Method: longitudinal retrospective study that included adult patients admitted to the ICU of a University Hospital during 2020. The data were collected from paper and electronic medical records, including identification, date of admission to the hospital, date of admission to ICU, diagnosis, medical history, date of hospital discharge, outcome, the Simplified Acute Physiology Score 3 (SAPS-3) and prioritization level. Results: the study evaluated 274 patients during 2020. Respiratory diseases represented 41.25% of admissions, COVID-19 being the most frequent diagnosis (totaling 65 confirmed and 2 suspected cases). Among the comorbidities, the following were highlighted: arterial hypertension (64.32%), diabetes mellitus (25.82%), and smoking (18.78%). The mean SAPS 3 score was 59.29 points, representing a probability of death of 39.00%. About prioritization levels, 174 (63.50%) patients were categorized as Priority 1 (P1); 94 (34.31%) patients as Priority 2 (P2) and 6 (2.19%) patients as Priority 3 (P3), which was not considered due to insufficient sample for testing. Comparing groups P1 and P2, the probability of death of each category was, respectively, 51.95% and 13.75%. During the study period, the number of deaths in each category was 90 (60.81%) for P1 and 19 (25.30%; p<0,001) for P2. Conclusion: the prioritization classification identified patients with more severity and with greater mortality rates in category P1 of prioritization to ICU admission, even though there was no difference on age, comorbidity and frailty.

Refusal of beds and triage of patients admitted to intensive care units in Brazil: a cross-sectional national survey. / Recusa de leitos e triagem de pacientes admitidos nas unidades de terapia intensiva do Brasil: estudo transversal do tipo survey nacional.

OBJECTIVE: To obtain data on bed refusal in intensive care units in Brazil and to evaluate the use of triage systems by professionals. METHODS: A cross-sectional survey. Using the Delphi methodology, a questionnaire was created contemplating the objectives of the study. Physicians and nurses enrolled in the research network of the Associação de Medicina Intensiva Brasileira (AMIBnet) were invited to participate. A web platform (SurveyMonkey®) was used to distribute the questionnaire. The variables in this study were measured in categories and expressed as proportions. The chi-square test or Fisher's exact test was used to verify associations. The significance level was set at 5%. RESULTS: In total, 231 professionals answered the questionnaire, representing all regions of the country. The national intensive care units had an occupancy rate of more than 90% always or frequently for 90.8% of the participants. Among the participants, 84.4% had already refused admitting patients to the intensive care unit due to the capacity of the unit. Half of the Brazilian institutions (49.7%) did not have triage protocols for admission to intensive beds. CONCLUSIONS: Bed refusal due to high occupancy rates is common in Brazilian intensive care units. Even so, half of the services in Brazil do not adopt protocols for triage of beds.

OBJETIVO: Conhecer dados sobre recusa de leitos nas unidades intensivas no Brasil, assim como avaliar o uso de sistemas de triagem pelos profissionais atuantes. MÉTODOS: Estudo transversal do tipo survey. Com a metodologia Delphi, foi criado um questionário contemplando os objetivos do trabalho. Foram convidados médicos e enfermeiros inscritos na rede de pesquisa da Associação de Medicina Intensiva Brasileira (AMIBnet). Uma plataforma da web (SurveyMonkey®) foi a forma de aplicação do questionário. As variáveis deste trabalho foram mensuradas em categorias e expressas como proporção. Foram usados o teste do qui-quadrado ou o teste exato de Fisher, para verificar associações. O nível de significância foi de 5%. RESULTADOS: No total, 231 profissionais responderam o questionário, representando todas as regiões do país. As unidades intensivas nacionais tinham mais de 90% de taxa de ocupação sempre ou frequentemente para 90,8% dos participantes. Dentre os participantes, 84,4% já deixaram de admitir pacientes em leito intensivo devido à lotação da unidade. Metade das instituições brasileiras (49,7%) não possuía protocolos de triagem de leitos intensivos instituídos. CONCLUSÃO: A recusa de leito pela alta taxa de ocupação é frequente nas unidades de terapia intensiva do Brasil. Ainda assim, metade dos serviços do Brasil não adota protocolos para triagem de leitos.

Analysis of oral risk factors for ventilator-associated pneumonia in critically ill patients.

OBJECTIVE: This a cross-sectional study to evaluate the association between oral health findings and ventilator-associated pneumonia (VAP) among critically ill patients in intensive care units (ICU). MATERIAL AND METHODS: Data were collected from medical records, and a detailed oral physical examination was performed on 663 critically ill patients on mechanical ventilation. Data were statistically analysed using univariate and logistic regression models relating the development of VAP with the oral findings. RESULTS: At oral physical examination, the most frequent findings were tooth loss (568-85.67%), coated tongue (422-63.65%) and oral bleeding (192-28.96%). Patients with a coated tongue or oral bleeding on the first day of ICU hospitalization developed more VAP than did patients without these conditions (20.14 vs 13.69%, p = 0.02; 23.44 vs 15.50%, p = 0.01, respectively). In the logistic regression, a coated tongue and oral bleeding were considered independent risk factors for VAP development (OR = 1.61 (1.03-2.51) and OR = 1.69 (1.08-2.66), respectively). CONCLUSIONS: The presence of a coated tongue and oral bleeding in ICU admission could be considered markers for the development of VAP. CLINICAL RELEVANCE: The results of this paper reinforce the importance of proper maintenance of oral hygiene before intubation, which may lead to a decrease in the incidence of VAP in the ICU.

Análise do poder de discriminação de índices prognósticos em pacientes queimados / Analysis of discrimination power of prognostic scores in burn patients

Introdução: As queimaduras são um grave problema de saúde pública. Os índices prognósticos estimam probabilidade prognóstica e ajudam a quantificar a gravidade do paciente. Objetivo:Avaliar o poder de discriminação dos índices Abbreviated Burn Severity Index (ABSI), Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) e Therapeutic Intervention Scoring System 28 (TISS 28) da admissão em pacientes de uma Unidade de Terapia Intensiva (UTI) especializada no tratamento de queimados. Casuística e Métodos:Estudo longitudinal prospectivo, realizado em uma Unidade de Terapia Intensiva especializada no atendimento ao paciente queimado, no período de maio de 2011 a maio de 2013. Foram excluídos pacientes com menos de 18 anos e com menos de 24 horas de internação. Foram coletados dados clínicos e demográficos e calculados os escores prognósticos estudados. A acurácia dos índices foi avaliada pela curva Receiver Operating Characteristic (ROC), discriminando o desfecho do paciente (sobrevivente e não sobrevivente). Foi calculada a área sob a curva (AUC). Resultados: Foram incluídos 180 pacientes no período de estudo, sendo 72,8% do sexo masculino (n=131). A mediana de idade foi de 40 anos (ITQ: 30 ­ 52,5). A mortalidade hospitalar foi de 37,2% (n=67). A maior AUC foi a do escore APACHE II, com valor de 0,837 (ponto de corte do escore = 14, sensibilidade de 83,6% e especificidade de 72,3%). Na análise de pontuação dos escores entre sobreviventes e não sobreviventes, observou-se diferença estatisticamente significativa entre os valores de todos os índices estudados. Conclusões: Os escores ABSI, APACHE II, SOFA e TISS 28 na admissão da UTI mostraram bom poder de discriminação para sobrevivência entre pacientes queimados.

Introduction: Burns are a serious public health problem. Prognostic indexes estimate prognostic probability and help to quantify disease severity. Objective: To evaluate the power of discrimination of Abbreviated Burn Severity Index (ABSI), Acute Physiology and Chronic Health Evaluation II (APACHE II), Sequential Organ Failure Assessment (SOFA) and Therapeutic Intervention Scoring System 28 (TISS 28) in an Intensive Care Unit (ICU) from a burn center. Patients and Methods: This is a prospective longitudinal study, carried out from May 2011 to May 2013. Patients under 18 years of age and with hospitalization for less than 24 hours were excluded. Clinical and demographic data were collected, and the prognostic scores were calculated. The accuracy of the scores was evaluated by the Receiver Operating Characteristic (ROC) curve, which discriminated against the outcome of the patient (survivor and non-survivor). The area under the curve (AUC) was calculated. Results: A total of 180 patients were included, and 72.8% of them were male (n = 131). The median age was 40 years (IQR: 30 - 52.5). Hospital mortality was 37.2% (n = 67). The highest AUC was from the APACHE II score, with a value of 0.837 (associated criterion = 14, sensitivity = 83.6% and specificity = 72.3%). In the analysis of the scores between survivors and non-survivors statistically significant differences were found in all studied scores. Conclusions: ABSI, APACHE II, SOFA and TISS 28 at ICU resulted in good power of discrimination for survival among burn patients.

Fatores de risco para mortalidade em idosos admitidos em unidade de terapia intensiva de hospital público / Risk factors for mortality in geriatric patients admitted to the intensive care unit at a public hospital

OBJETIVO: Avaliar fatores de risco para mortalidade em pacientes idosos com internação em uma unidade de terapia intensiva (UTI). MÉTODOS: Foram estudados pacientes idosos admitidos em UTI, em um estudo de coorte histórica. Foi realizada amostragem de conveniência de todos os pacientes com 60 anos ou mais, internados nos 20 leitos de uma UTI de um hospital de alta complexidade. Foi realizada análise de regressão de Cox para estimar os fatores de risco associados à mortalidade. O nível de significância utilizado foi de 5%. RESULTADOS: A proporção de pacientes idosos representou 45% das admissões em UTI no período. A mortalidade hospitalar foi de 38,4%. A variável pós-operatório de cirurgia de urgência e os escores Acute Physiology and Chronic Health Evaluation (APACHE II) e Sequential Organ Failure Assessment (SOFA) da admissão foram identificados como fatores de risco independentes para mortalidade hospitalar. CONCLUSÃO: Os fatores de risco associados à mortalidade foram os escores APACHE II e SOFA da admissão e pós-operatório de cirurgia de urgência.

OBJECTIVE: To evaluate risk factors for mortality in geriatric patients admitted to an intensive care unit (ICU). METHODS: We studied older patients admitted to the ICU in a historical cohort study. Convenience sampling was performed for all patients aged 60 years or older, admitted to the 20 beds of an ICU of a highly complex hospital. Cox regression analysis was performed to estimate risk factors associated with mortality. The significance level used was 5%. RESULTS: The proportion of geriatric patients represented 45% of ICU admissions in the period. In-hospital mortality was 38.4%. The postoperative emergency surgery variable and the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) admission scores were identified as independent risk factors for in-hospital mortality. CONCLUSION: Risk factors associated with mortality were APACHE II and SOFA scores for admission and postoperative emergency surgery.

Analysis of cerebral blood flow and intracranial hypertension in critical patients with non-hepatic hyperammonemia.

Hyperammonemia in adults is generally associated with cerebral edema, decreased cerebral metabolism, and increased cerebral blood flow. The aim of this study was to evaluate the association between non-hepatic hyperammonemia and intracranial hypertension assessed by Doppler flowmetry and measurement of the optic nerve sheath. A prospective cohort study in critically ill patients hospitalized in intensive care units of a University Hospital between March 2015 and February 2016. Clinical data and severity scores were collected and the Glasgow coma scale was recorded. Serial serum ammonia dosages were performed in all study patients. Transcranial Doppler evaluation was carried out for the first 50 consecutive results of each stratum of ammonemia: normal (<35 µmol/L), mild hyperammonemia (≥35 µmol/L and < 50 µmol/L), moderate hyperammonemia (≥50 µmol/L and < 100 µmol/L), and severe hyperammonemia (≥100 µmol/L). The measurement of the optic nerve sheath was performed at the same time as the Doppler examination if the patient scored less than 8 on the Glasgow coma scale. There was no difference in flow velocity in the cerebral arteries between patients with and without hyperammonemia. Patients with hyperammonemia presented longer ICU stay. Optic nerve sheath thickness was higher in the group with severe hyperammonemia and this group presented an association with intracranial hypertension. Higher mortality was observed in the severe hyperammonemia group. There was an association between severe hyperammonemia and signs of intracranial hypertension. No correlation was found between ammonia levels and cerebral blood flow velocity through the Doppler examination.

Acute kidney injury and intra-abdominal hypertension in burn patients in intensive care. / Injúria renal aguda e hipertensão intra-abdominal em paciente queimado em terapia intensiva.

OBJECTIVE: To evaluate the frequency of intra-abdominal hypertension in major burn patients and its association with the occurrence of acute kidney injury. METHODS: This was a prospective cohort study of a population of burn patients hospitalized in a specialized intensive care unit. A convenience sample was taken of adult patients hospitalized in the period from 1 August 2015 to 31 October 2016. Clinical and burn data were collected, and serial intra-abdominal pressure measurements taken. The significance level used was 5%. RESULTS: A total of 46 patients were analyzed. Of these, 38 patients developed intra-abdominal hypertension (82.6%). The median increase in intra-abdominal pressure was 15.0mmHg (interquartile range: 12.0 to 19.0). Thirty-two patients (69.9%) developed acute kidney injury. The median time to development of acute kidney injury was 3 days (interquartile range: 1 - 7). The individual analysis of risk factors for acute kidney injury indicated an association with intra-abdominal hypertension (p = 0.041), use of glycopeptides (p = 0.001), use of vasopressors (p = 0.001) and use of mechanical ventilation (p = 0.006). Acute kidney injury was demonstrated to have an association with increased 30-day mortality (log-rank, p = 0.009). CONCLUSION: Intra-abdominal hypertension occurred in most patients, predominantly in grades I and II. The identified risk factors for the occurrence of acute kidney injury were intra-abdominal hypertension and use of glycopeptides, vasopressors and mechanical ventilation. Acute kidney injury was associated with increased 30-day mortality.

Injúria renal aguda e hipertensão intra-abdominal em paciente queimado em terapia intensiva / Acute kidney injury and intra-abdominal hypertension in burn patients in intensive care

RESUMO Objetivo: Avaliar a frequência de hipertensão intra-abdominal no paciente grande queimado e sua associação com a ocorrência de injúria renal aguda. Métodos: Estudo de coorte prospectivo, com população de pacientes queimados internados nos leitos de unidade de terapia intensiva especializada. Realizada amostragem de conveniência de pacientes adultos internados no período de 1º de agosto de 2015 a 31 de outubro de 2016. Foram coletados dados clínicos e da queimadura, além de medidas seriadas da pressão intra-abdominal. O nível de significância utilizado foi de 5%. Resultados: Foram analisados 46 pacientes. Evoluíram com hipertensão intra-abdominal 38 pacientes (82,6%). A mediana da maior pressão intra-abdominal foi 15,0mmHg (intervalo interquartílico: 12,0 - 19,0). Desenvolveram injúria renal aguda 32 (69,9%) pacientes. A mediana do tempo para desenvolvimento de injúria renal aguda foi de 3 dias (intervalo interquartílico: 1 - 7). A análise individual de fatores de risco para injúria renal aguda apontou associação com hipertensão intra-abdominal (p = 0,041), uso de glicopeptídeos (p = 0,001), uso de vasopressor (p = 0,001) e uso de ventilação mecânica (p = 0,006). Foi evidenciada associação de injúria renal aguda com maior mortalidade em 30 dias (log-rank, p = 0,009). Conclusão: Ocorreu hipertensão intra-abdominal em grande parte dos pacientes estudados, predominantemente nos graus I e II. Os fatores de risco identificados para ocorrência de injúria renal aguda foram hipertensão intra-abdominal, uso de glicopeptídeos, vasopressor e ventilação mecânica. Injúria renal aguda esteve associada à maior mortalidade em 30 dias.

ABSTRACT Objective: To evaluate the frequency of intra-abdominal hypertension in major burn patients and its association with the occurrence of acute kidney injury. Methods: This was a prospective cohort study of a population of burn patients hospitalized in a specialized intensive care unit. A convenience sample was taken of adult patients hospitalized in the period from 1 August 2015 to 31 October 2016. Clinical and burn data were collected, and serial intra-abdominal pressure measurements taken. The significance level used was 5%. Results: A total of 46 patients were analyzed. Of these, 38 patients developed intra-abdominal hypertension (82.6%). The median increase in intra-abdominal pressure was 15.0mmHg (interquartile range: 12.0 to 19.0). Thirty-two patients (69.9%) developed acute kidney injury. The median time to development of acute kidney injury was 3 days (interquartile range: 1 - 7). The individual analysis of risk factors for acute kidney injury indicated an association with intra-abdominal hypertension (p = 0.041), use of glycopeptides (p = 0.001), use of vasopressors (p = 0.001) and use of mechanical ventilation (p = 0.006). Acute kidney injury was demonstrated to have an association with increased 30-day mortality (log-rank, p = 0.009). Conclusion: Intra-abdominal hypertension occurred in most patients, predominantly in grades I and II. The identified risk factors for the occurrence of acute kidney injury were intra-abdominal hypertension and use of glycopeptides, vasopressors and mechanical ventilation. Acute kidney injury was associated with increased 30-day mortality.

Impacto de ação educativa na manutenção do decúbito elevado como medida preventiva de pneumonia associada à ventilação mecânica em unidade de terapia intensiva / Impact of educational action in maintaining high decubitus as preventive measure of ventilator-associated pneumonia in the intensive care unit

INTRODUÇÃO: A pneumonia adquirida na Unidade de Terapia Intensiva (UTI) ocasiona o prolongamento da hospitalização e impacta na mortalidade. Intervenções educativas com profissionais de saúde são estratégias de prevenção relevantes nas infecções relacionadas à assistência à saúde. OBJETIVO: Avaliar o resultado de uma ação educativa na adesão à manutenção do decúbito elevado, acima de 30 graus, como medida para prevenção de pneumonia associada à ventilação mecânica. MÉTODOS: Estudo quase experimental do tipo antes e depois desenvolvido na UTI do Hospital Universitário de Londrina, no período de março e junho de 2010, dividido em três fases (pré-intervenção, intervenção e pós-intervenção). Durante o período de estudo, foram treinados 49 profissionais. Foram realizadas observações diretas da altura do decúbito antes e após o treinamento e coletados dados clínicos dos pacientes admitidos na UTI. A adesão à recomendação de manter o decúbito elevado foi definida como a manutenção de decúbito acima de 30 graus para cada observação. RESULTADOS: A média de angulação do decúbito apresentou aumento significativo do período pré-intervenção (27,85 ± 6,76 graus) para o primeiro mês pós-intervenção (30,70 ± 8,18 graus; p<0,001), no entanto esses valores não persistiram no terceiro mês de observação pós-intervenção (29,46 ± 6,19 graus). CONCLUSÃO: A ação educativa mostrou-se eficaz a curto prazo, na adesão à elevação do decúbito em ambiente hospitalar, porém essa adesão sofreu redução progressiva, demonstrando a necessidade de uma intervenção continuada para manutenção dos resultados.

INTRODUCTION: Intensive Care Unit (ICU) acquired pneumonia prolongs hospitalization and influences mortality rates. Educational interventions with health professionals are relevant preventive strategies for healthcare-associated infections. OBJECTIVE: To evaluate the result of an educational activity on adherence to the maintenance of a high decubitus, above 30 degrees, as a measure for preventing ventilator-associated pneumonia. METHODS: Quasi-experimental study with a pretestposttest design conducted in the ICU of the University Hospital of Londrina from March to June 2010, divided in three periods (preintervention, intervention and post-intervention). During study period, 49 health professionals were trained. Direct observations of the decubitus' height were performed before and after training and clinical data of patients admitted to the ICU were collected. Adherence to the recommendation of high decubitus was defined as maintenance of decubitus above 30 degrees in each observation. RESULTS: There was an increase in the mean of decubitus' angle from pre-intervention period (27.85±6.76 degrees) to post-intervention (30.70±8.18 degrees; p<0.001), although this difference did not persisted in the third month postintervention observation (29.46±6.19 degrees). CONCLUSION: The educational activity was transiently effective in increasing adherence to maintain high decubitus during hospitalization, but the adherence decreased progressively, showing the need for a continuous intervention to maintain results.

Evaluation of the five-year operation period of a rapid response team led by an intensive care physician at a university hospital. / Avaliação de 5 anos de atuação de um time de resposta rápida liderado por médico intensivista em hospital universitário.

OBJECTIVE: To evaluate the implementation of a multidisciplinary rapid response team led by an intensive care physician at a university hospital. METHODS: This retrospective cohort study analyzed assessment forms that were completed during the assessments made by the rapid response team of a university hospital between March 2009 and February 2014. RESULTS: Data were collected from 1,628 assessments performed by the rapid response team for 1,024 patients and included 1,423 code yellow events and 205 code blue events. The number of assessments was higher in the first year of operation of the rapid response team. The multivariate analysis indicated that age (OR 1.02; 95%CI 1.02 - 1.03; p < 0.001), being male (OR 1.48; 95%CI 1.09 - 2.01; p = 0.01), having more than one assessment (OR 3.31; 95%CI, 2.32 - 4.71; p < 0.001), hospitalization for clinical care (OR 1.77; 95%CI 1.29 - 2.42; p < 0.001), the request of admission to the intensive care unit after the code event (OR 4.75; 95%CI 3.43 - 6.59; p < 0.001), and admission to the intensive care unit before the code event (OR 2.13; 95%CI 1.41 - 3.21; p = 0.001) were risk factors for hospital mortality in patients who were seen for code yellow events. CONCLUSION: The hospital mortality rates were higher than those found in previous studies. The number of assessments was higher in the first year of operation of the rapid response team. Moreover, hospital mortality was higher among patients admitted for clinical care.

Avaliação de 5 anos de atuação de um time de resposta rápida liderado por médico intensivista em hospital universitário / Evaluation of the five-year operation period of a rapid response team led by an intensive care physician at a university hospital

RESUMO Objetivo: Avaliar a implementação de time de resposta rápida multidisciplinar liderado por médico intensivista em hospital universitário. Métodos: Estudo de coorte retrospectiva realizado pela análise de fichas de atendimentos preenchidas durante os atendimentos realizados pelo time de resposta rápida do hospital universitário entre março de 2009 e fevereiro de 2014. Resultados: Foram coletados dados de 1.628 atendimentos realizados em 1.024 pacientes pelo time de resposta rápida, sendo 1.423 códigos amarelos e 205 códigos azuis. Houve maior número de atendimentos no primeiro ano, após implementação do time de resposta rápida. A análise multivariada identificou idade (OR 1,02; IC95% 1,02 - 1,03; p < 0,001), sexo masculino (OR 1,48; IC95% 1,09 - 2,01; p = 0,01), mais de um atendimento (OR 3,31; IC95% 2,32 - 4,71; p < 0,001), internação para especialidades clínicas (OR 1,77; IC95% 1,29 - 2,42; p < 0,001), pedido de vaga de unidade de terapia intensiva posterior ao código (OR 4,75; IC95% 3,43 - 6,59; p < 0,001) e admissão em unidade de terapia intensiva prévia ao código (OR 2,13, IC95% 1,41 - 3,21; p = 0,001) como fatores de risco para mortalidade hospitalar de pacientes atendidos em códigos amarelos. Conclusão: Os índices de mortalidade hospitalar foram elevados quando comparados aos da literatura e houve maior número de atendimentos no primeiro ano de atuação do time de resposta rápida. Houve maior mortalidade hospitalar entre pacientes internados para especialidades clínicas.

ABSTRACT Objective: To evaluate the implementation of a multidisciplinary rapid response team led by an intensive care physician at a university hospital. Methods: This retrospective cohort study analyzed assessment forms that were completed during the assessments made by the rapid response team of a university hospital between March 2009 and February 2014. Results: Data were collected from 1,628 assessments performed by the rapid response team for 1,024 patients and included 1,423 code yellow events and 205 code blue events. The number of assessments was higher in the first year of operation of the rapid response team. The multivariate analysis indicated that age (OR 1.02; 95%CI 1.02 - 1.03; p < 0.001), being male (OR 1.48; 95%CI 1.09 - 2.01; p = 0.01), having more than one assessment (OR 3.31; 95%CI, 2.32 - 4.71; p < 0.001), hospitalization for clinical care (OR 1.77; 95%CI 1.29 - 2.42; p < 0.001), the request of admission to the intensive care unit after the code event (OR 4.75; 95%CI 3.43 - 6.59; p < 0.001), and admission to the intensive care unit before the code event (OR 2.13; 95%CI 1.41 - 3.21; p = 0.001) were risk factors for hospital mortality in patients who were seen for code yellow events. Conclusion: The hospital mortality rates were higher than those found in previous studies. The number of assessments was higher in the first year of operation of the rapid response team. Moreover, hospital mortality was higher among patients admitted for clinical care.

Avaliação dos 12 anos da campanha de acesso público a desfibrilação / Evaluation of ten years of the Campaign for public access defibrillation

JUSTIFICATIVA: Campanhas públicas e leis que visam desenvolver métodos de esclarecimento e incentivo na busca de informações sobre o tratamento da parada cardiorrespiratória devem ser objetivo de todos e implicam em excelentes resultados em todas as esferas de leigos, gestores e profissionais de saúde. OBJETIVO: Avaliar o impacto de uma Campanha de Acesso Público a Desfibrilação na população leiga, profissionais de saúde e gestores. MÉTODO: A pesquisa quantitativa foi desenvolvida após a avaliação de 12 anos das atividades efetuadas por uma Comissão de Ressuscitação Cardiopulmonar sobre a Campanha de Acesso Público a Desfibrilação voltada para as manobras de ressuscitação cardiopulmonar. RESULTADOS: Como principais resultados diretos e indiretos nos 12 anos de análise, promoveu-se a realização de cursos de suporte básico de vida para profissionais de saúde e leigos, cursos de suporte avançado de vida em cardiologia para profissionais de saúde, treinamento em massa para a população geral, implantação da temática no currículo da Faculdade de Medicina e a primeira lei de Acesso Público a Desfibrilação da América Latina, assim como o modelo para a lei federal que se encontra em tramitação. CONCLUSÕES: É evidente que mesmo com os resultados positivos ainda há necessidade real de maior número de profissionais e leigos treinados, assim como o amplo estabelecimento dos cinco elos atuais da corrente de sobrevivência em nosso território nacional, podendo outras campanhas, espelhadas nesta, serem implantadas.

BACKGROUND: Public campaigns and laws developing methods of enlightenment and encouragement in finding information on the treatment of cardiac arrest should be the objective of all and imply excellent results in all spheres of lay people, government managers and health professionals. OBJECTIVE: To evaluate the impact of a Public Access Defibrillation Campaign implementation in the lay population, health professionals and government managers. METHODS: The quantitative study was conducted after the 12 year review of the activities undertaken by a Hospital Committee of Cardiopulmonary Resuscitation and a Campaign for Public Access Defibrillation geared toward cardiopulmonary resuscitation. RESULTS: The main direct and indirect results in the 12 years of analysis promoted courses in basic life support for health professionals and lay public, courses of advanced cardiac life support for health professionals, mass training for general population, implementation of the thematic curriculum in the School of Medicine and the first law of Public Access Defibrillation in Latin America as well as the model for the federal law that steel in progress. CONCLUSIONS: It is clear that with the direct and indirect experiences of these 12 years of Public Access Defibrillation Campaign we shown positive results. There is real need for more professionals and trained lay people as well as the extensive establishment of five current links in the chain of survival in our Nationwide.

Nursing Activities Score and workload in the intensive care unit of a university hospital.

OBJECTIVE: The nursing workload consists of the time spent by the nursing staff to perform the activities for which they are responsible, whether directly or indirectly related to patient care. The aim of this study was to evaluate the nursing workload in an adult intensive care unit at a university hospital using the Nursing Activities Score (NAS) instrument. METHODS: A longitudinal, prospective study that involved the patients admitted to the intensive care unit of a university hospital between March and December 2008. The data were collected daily to calculate the NAS, the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the Therapeutic Intervention Scoring System (TISS-28) of patients until they left the adult intensive care unit or after 90 days of hospitalization. The level of significance was set at 5%. RESULTS: In total, 437 patients were evaluated, which resulted in an NAS of 74.4%. The type of admission, length of stay in the intensive care unit and the patients' condition when leaving the intensive care unit and hospital were variables associated with differences in the nursing workload. There was a moderate correlation between the mean NAS and APACHE II severity score (r=0.329), the mean organic dysfunction SOFA score (r=0.506) and the mean TISS-28 score (r=0.600). CONCLUSION: We observed a high nursing workload in this study. These results can assist in planning the size of the staff required. The workload was influenced by clinical characteristics, including an increased workload required for emergency surgical patients and patients who died.

Nursing Activities Score e carga de trabalho em unidade de terapia intensiva de hospital universitário / Nursing Activities Score and workload in the intensive care unit of a university hospital

Objetivo: A carga de trabalho de enfermagem é constituída pelo tempo dispendido pela equipe de enfermagem para realizar as atividades de sua responsabilidade, relacionadas direta ou indiretamente ao atendimento do paciente. O objetivo deste estudo foi avaliar a carga de trabalho de enfermagem em uma unidade de terapia intensiva adulto de hospital universitário com o uso do instrumento Nursing Activities Score (NAS). Métodos: Estudo longitudinal, prospectivo, envolvendo pacientes admitidos na unidade de terapia intensiva de um hospital universitário no período de março a dezembro de 2008. Foram coletados dados para o cálculo do NAS, do Acute Physiology and Chronic Health Evaluation (APACHE II), do Sequential Organ Failure Assessment (SOFA) e do Therapeutic Intervention Scoring System (TISS-28), diariamente até a saída da unidade de terapia intensiva adulto ou 90 dias de internação. O nível de significância adotado foi de 5%. Resultados: Foram avaliados 437 pacientes, resultando em NAS de 74,4%. O tipo de internação, tempo de permanência na unidade de terapia intensiva e condição de saída do paciente da unidade de terapia intensiva e do hospital foram variáveis associadas a diferenças na carga de trabalho da enfermagem. Houve correlação moderada do NAS médio com o escore de gravidade APACHE II (r=0,329), com o escore de disfunção orgânica SOFA médio (r=0,506) e com o TISS-28 médio (r=0,600). Conclusão: Encontramos elevada carga de trabalho de enfermagem no estudo. Esse resultado pode subsidiar planejamento para dimensionamento da equipe. A carga de trabalho sofreu influência de caraterísticas clínicas, sendo observado aumento do trabalho nos pacientes cirúrgicos de urgência e nos não sobreviventes. .

Objective: The nursing workload consists of the time spent by the nursing staff to perform the activities for which they are responsible, whether directly or indirectly related to patient care. The aim of this study was to evaluate the nursing workload in an adult intensive care unit at a university hospital using the Nursing Activities Score (NAS) instrument. Methods: A longitudinal, prospective study that involved the patients admitted to the intensive care unit of a university hospital between March and December 2008. The data were collected daily to calculate the NAS, the Acute Physiology and Chronic Health Evaluation (APACHE II), the Sequential Organ Failure Assessment (SOFA) and the Therapeutic Intervention Scoring System (TISS-28) of patients until they left the adult intensive care unit or after 90 days of hospitalization. The level of significance was set at 5%. Results: In total, 437 patients were evaluated, which resulted in an NAS of 74.4%. The type of admission, length of stay in the intensive care unit and the patients' condition when leaving the intensive care unit and hospital were variables associated with differences in the nursing workload. There was a moderate correlation between the mean NAS and APACHE II severity score (r=0.329), the mean organic dysfunction SOFA score (r=0.506) and the mean TISS-28 score (r=0.600). Conclusion: We observed a high nursing workload in this study. These results can assist in planning the size of the staff required. The workload was influenced by clinical characteristics, including an increased workload required for emergency surgical patients and patients who died. .

Colistina parenteral no tratamento de infeccoes graves: experiencia em centro unico / Parenteral colistin for the treatment of severe infections: a single center experience

Objetivo: Descrever a experiência de um único centro com o uso de colistina para tratar infecções hospitalares causadas por bactérias Gram-negativas resistentes a múltiplos fármacos e identificar fatores associados com lesão renal aguda e mortalidade. Métodos: Estudo longitudinal retrospectivo que avaliou pacientes gravemente enfermos, com infecções causadas por bactérias Gram-negativas resistentes a múltiplos fármacos. Foram considerados elegíveis para este estudo, durante o período compreendido entre janeiro e dezembro de 2008, todos os pacientes adultos com necessidade de tratamento com colistina endovenosa (colistimetato de sódio). As informações coletadas incluem dados demográficos, diagnóstico, duração do tratamento, presença de lesão renal aguda e mortalidade em 30 dias. Resultados: A colistina foi utilizada para tratar uma infecção em 109 de 789 pacientes (13,8%) admitidos à unidade de terapia intensiva. A mortalidade em 30 dias observada nestes pacientes foi de 71,6%. Vinte e nove pacientes (26,6%) tinham lesão renal prévia ao tratamento com colistina, sendo que seis deles conseguiram recuperar a função renal, mesmo durante o tratamento com colistina. Vinte e um pacientes (19,2%) desenvolveram lesão renal aguda durante o tratamento com colistina, sendo que 11 destes pacientes necessitaram ser submetidos à diálise. A variável independentemente associada com a presença de lesão renal aguda foi a pontuação segundo o sistema Sequential Organ Failure Assessment no início do tratamento com colistina (OR=1,46; IC95%=1,20-1,79; p<0,001). Idade (OR=1,03; IC95%=1,00-1,05; p=0,02) e uso de vasopressores (OR=12,48; IC95%=4,49-34,70; p<0,001) foram fatores associados a óbito, segundo um modelo de regressão logística. ...

Objective: To describe a single center experience involving the administration of colistin to treat nosocomial infections caused by multidrug-resistant Gram-negative bacteria and identify factors associated with acute kidney injury and mortality. Methods: This retrospective longitudinal study evaluates critically ill patients with infections caused by multidrug-resistant Gram-negative bacteria. All adult patients who required treatment with intravenous colistin (colistimethate sodium) from January to December 2008 were considered eligible for the study. Data include demographics, diagnosis, duration of treatment, presence of acute kidney injury and 30-day mortality. Results: Colistin was used to treat an infection in 109 (13.8%) of the 789 patients admitted to the intensive care unit. The 30-day mortality observed in these patients was 71.6%. Twenty-nine patients (26.6%) presented kidney injury prior to colistin treatment, and six of these patients were able to recover kidney function even during colistin treatment. Twenty-one patients (19.2%) developed acute kidney injury while taking colistin, and 11 of these patients required dialysis. The variable independently associated with the presence of acute kidney injury was the Sequential Organ Failure Assessment at the beginning of colistin treatment (OR 1.46; 95%CI 1.20-1.79; p<0.001). The factors age (OR 1.03; 95%CI 1.00-1.05; p=0.02) and vasopressor use (OR 12.48; 95%CI 4.49-34.70; p<0.001) were associated with death in the logistic-regression model. Conclusions: Organ dysfunction at the beginning of colistin treatment was associated with acute kidney injury. In a small group of patients, we were able to observe an improvement of kidney function during colistin treatment. Age and vasopressor use were associated with death. .

The performance of a rapid response team in the management of code yellow events at a university hospital.

OBJECTIVE: To describe the epidemiological data of the clinical instability events in patients attended to by the rapid response team and to identify prognostic factors. METHODS: This was a longitudinal study, performed from January to July 2010, with an adult inpatient population in a hospital environment. The data collected regarding the code yellow service included the criteria of the clinical instability, the drug and non-drug therapies administered and the activities and procedures performed. The outcomes evaluated were the need for intensive care unit admission and the hospital mortality rates. A level of p=0.05 was considered to be significant. RESULTS: A total of 150 code yellow events that occurred in 104 patients were evaluated. The most common causes were related to acute respiratory insufficiency with hypoxia or a change in the respiratory rate and a concern of the team about the patient's clinical condition. It was necessary to request a transfer to the intensive care unit in 80 of the 150 cases (53.3%). It was necessary to perform 42 procedures. The most frequent procedures were orotracheal intubation and the insertion of a central venous catheter. The patients who were in critical condition and had to wait for an intensive care unit bed had a higher risk of death compared to the other patients (hazard ratio: 3.12; 95% CI: 1.80-5.40; p<0.001). CONCLUSIONS: There are patients in critical condition that require expert intensive care in the regular ward unit hospital beds. The events that most frequently led to the code yellow activation were related to hemodynamic and respiratory support. The interventions performed indicate the need for a physician on the team. The situation of pent-up demand is associated with a higher mortality rate.

Atuação do time de resposta rápida em hospital universitário no atendimento de código amarelo / The performance of a rapid response team in the management of code yellow events at a university hospital

OBJETIVO: Descrever dados epidemiológicos de eventos de instabilidade clínica em pacientes atendidos pelo time de resposta rápida e identificar fatores prognósticos. MÉTODOS: Estudo longitudinal, realizado de janeiro a junho de 2010, com população adulta internada em ambiente hospitalar. Os dados coletados sobre o atendimento do código amarelo foram critérios de instabilidade clínica, terapia medicamentosa e não medicamentosa, orientações e procedimentos. Os desfechos avaliados foram necessidade de admissão em unidade de terapia intensiva e mortalidade hospitalar. O nível de significância utilizado foi de p=0,05. RESULTADOS: Foram avaliados 150 códigos amarelos que ocorreram com 104 pacientes. Os motivos mais frequentes estiveram relacionados à insuficiência respiratória aguda, apresentando hipóxia ou alteração da frequência respiratória, e preocupação da equipe com o estado clínico do paciente. Houve necessidade de solicitação de transferência para unidade de terapia intensiva em 80/150 (53,3%) ocasiões. Foi necessária a realização de 42 procedimentos, sendo os mais frequentes a intubação orotraqueal e a inserção de cateter venoso central. Os pacientes graves que aguardavam leito de unidade de terapia intensiva apresentaram maior chance de morte, comparados aos demais pacientes (hazard ratio: 3,12; IC95%: 1,80-5,40; p<0,001). CONCLUSÃO: Existem pacientes graves que necessitam de tratamento intensivo especializado nos leitos comuns de enfermarias dos hospitais. Os eventos que mais levaram ao acionamento do código amarelo estiveram relacionados a suporte respiratório e hemodinâmico. As intervenções realizadas caracterizam a necessidade do médico na equipe. A situação de demanda reprimida está associada à maior mortalidade.

OBJECTIVE: To describe the epidemiological data of the clinical instability events in patients attended to by the rapid response team and to identify prognostic factors. METHODS: This was a longitudinal study, performed from January to July 2010, with an adult inpatient population in a hospital environment. The data collected regarding the code yellow service included the criteria of the clinical instability, the drug and non-drug therapies administered and the activities and procedures performed. The outcomes evaluated were the need for intensive care unit admission and the hospital mortality rates. A level of p=0.05 was considered to be significant. RESULTS: A total of 150 code yellow events that occurred in 104 patients were evaluated. The most common causes were related to acute respiratory insufficiency with hypoxia or a change in the respiratory rate and a concern of the team about the patient's clinical condition. It was necessary to request a transfer to the intensive care unit in 80 of the 150 cases (53.3%). It was necessary to perform 42 procedures. The most frequent procedures were orotracheal intubation and the insertion of a central venous catheter. The patients who were in critical condition and had to wait for an intensive care unit bed had a higher risk of death compared to the other patients (hazard ratio: 3.12; 95% CI: 1.80-5.40; p<0.001). CONCLUSIONS: There are patients in critical condition that require expert intensive care in the regular ward unit hospital beds. The events that most frequently led to the code yellow activation were related to hemodynamic and respiratory support. The interventions performed indicate the need for a physician on the team. The situation of pent-up demand is associated with a higher mortality rate.