Experiencias de la aplicación del programa de seguridad del paciente en la Clínica Internacional-Lima-Perú 2010-2011 / Experiences of applying patient safety program at the Clínica International-Lima-Peru 2010-2011

La Clínica Internacional es una organización privada que opera bajo el modelo de red asistencial y que presenta la visión de ser la institución de referencia en el sector a nivel nacional, los estamentos directivos de la Clínica priorizaron desde Noviembre del 2007, la decisión estratégica de implementar un programa propio de seguridad del paciente. El programa de seguridad del paciente es el conjunto de medidas adoptadas para proactivamente minimizar la ocurrencia de eventos adversos y reactivamente mitigar los resultados para el paciente y para la organización cuando estos se produzcan. Se presentan los resultados obtenidos en la aplicación del programa de seguridad del paciente de la Clínica Internacional en dos aspectos relevantes: la implementación de procedimientos para optimizar la seguridad en la atención quirúrgica y su impacto en la reducción de eventos adversos quirúrgicos y de infecciones intrahospitalarias con énfasis en las asociadas al uso de dispositivos invasivos.

The Clinica Internacional is a private organization managed under the health care network scheme presenting the view of being the countrywide institution of reference. From November 2007, the management of the Clinic gave priority to the strategic decision of implementing their own patient’s security program. The patient’s security program is a group of measures taken to proactively minimize the occurrence of adverse events and reactively mitigate the results, for the patient and for the organization, once these occur. The results obtained in the application of the patient’s security program of the Clinica Internacional are presented in two significative. Aspects: the implementation of procedures to optimize the security in the surgical attention and its impact in the reduction of surgical adverse events and nosocomial infections emphasizing in the ones associated to the use of invasive devices.

Instrumento para evaluar niveles de problemas o dificultades estresantes, los esfuerzos que se realizan para dominarlos y lo que se logra con los esfuerzos / Instrument for to evaluate levels of: problems or stressing difficulties, efforts done for to manage them and that is reached with efforts

En el presente artículo reportamos un instrumento sencillo que hemos creado para evaluar en una persona los niveles de: problemas estresantes que se le presentan (problemas); los esfuerzos que se realiza intentando dominarlos (afrontamientos); y lo que consigue con esos esfuerzos (logros). Y a los resultados obtenidos con el instrumento en un grupo de pacientes ambulatorios los hemos buscado posible relaciones con los obtenidos empleando también instrumentos validados para medir niveles de estrés social y depresión, habiendo encontrado una interesante correlación con los niveles de depresión obtenidos empleando el Inventario de la Depresión de Beck.

In the present article we afford a simple instrument that we have created to evaluate in a person levels of: stressing problems that occur to him or her (problems); the efforts that he or she performs to control the problems (confrontations); and what he or she obtains with those efforts (accomplishments). And the results obtained with the instrument in a group of ambulatory patients have been compared with results obtained using validated instruments to evaluate levels of social stress and depression, having found an interesting correlation with the levels of depression obtained using the Beck Depression Inventory.

Estrés emocional, depresión e hipercolesterolemia / Emotional stress, depression and hypercholesterolemia

Objetivo. El presente trabajo fue llevado a cabo pensando en la posibilidad de que el estrés de tipo psicológico y la depresión, al inducir hipercortisolismo, pudieran ser factores determinantes de la elevación del colesterol sanguíneo. Material y métodos. Se estudiaron 416 sujetos, con edades de 18 a 78 años (media: 35,5 años), 206 (49,5%) de sexo masculino y 210 (50,5%) de sexo femenino, atendidos por control preventivo de salud en una clínica privada de Lima, y en los cuales se determinó sus niveles de colesterol sanguíneo. Para medir el estrés de tipo psicológico se empleó la Escala para Evaluar Reajuste Social (Social Readjustment Rating Scale, SRRS) de Holmes y Rahe; y, para medir la depresión, el Inventario de la Depresión de Beck (Beck Depression Inventory, BDI). Resultados. En 97 de los 416 (23,3%) sujetos se encontró estrés psicológico significativo y en 39 (9,4%), depresión. Los niveles de colesterol sanguíneo no fueron significativamente diferentes en los sujetos con estrés que en los que no lo tenían (118-298 mg/dL, con una mediamas o menos DE de 192,3 mas o menos 41,9 mg/dL, vs. 118-311 mg/dL, con una media mas o menos DE de 194,5 mas o menos 42,5 mg/dL, respectivamente); pero, sí significativamente mayores en los sujetos con depresión moderada-severa vs. los sujetos con depresión leve y con los que no la tenían (135-299 mg/dL, con una media mas o menos DE de 229,6 mas o menos 44,2 mg/dL vs. 144-263 mg/dL, con una media mas o menos DE de 201 mas o menos 50,6 mg/dL, y vs. 118-311 mg/dL, con una media mas o menos DE de 191,7 mas o menos 40,9 mg/dL). Conclusión: Los acontecimientos estresantes no son el problema en sí, sino el problema es la forma cómo los afrontamos: la depresión, como su consecuencia, sí parece ser negativa, ya que se asocia con uno de los principales factores de riesgo cardiovascular, que es la dislipidemia.

Objective. The present study was performed thinking in the possibility that stress of psychological type and depression, by inducing hypercortisolism, could be a determinant factor of elevation of blood cholesterol. Material and methods. The study was done in 416 subjects, from 18 to 78 year-old (mean: 35,5 year-old), 206 (49,5%) were male and 210 (50,5%) female, attended for health preventive control, and in whom their blood cholesterol levels were determined. To measure in them levels of psychological stress the Social Readjustment Rating Scale (SRRS) of Holmes and Rahe was used, and to measure levels of depression, the Beck Depression Inventory (BDI). Results. In 97 (23,3%) of the 416 subjects significant psychological stress was found, and in 39 (9,4%) depression. The levels of blood cholesterol were not significantly different in the subjects with stress than in the subjects without it (118-298 mg/dL, with a mean mor or less SD of 192,3 more or less 41,9 mg/dL, vs. 118-311 mg/dL, with a mean more or less SD of 194,5 ± 42,5 mg/dL, respectively); but, significantly higher in the subjects with moderate- severe depression than mild depression and the subjects without it (135-299 mg/dL, with a mean more or less SD of 229,6 more or less 44,2 mg/dL, vs. 144-263 mg/dL, with a mean more or less SD of 201 more or less 50,6 mg/dL, and vs. 118-311 mg/dL, with a mean more or less SD of 191,7 more or less 40,9 mg/dL, respectively). Conclusion. The stress situations are not, thus, the significant problem, but the way how we affront them. Depression, as their consequence, seems to be negative because of its association with dyslipidemia that is one of the principal factors of cardiovascular risk.

[Gastrointestinal syndromes (3): flatulence (2)]. / Grandes síndromes gastrointestinales (3): flatulencia (2).

The second part of the article on flatulence reviewed aspects of the pathogenesis, diagnosis and treatment of this syndrome.

Grandes síndromes gastrointestinales (3): flatulencia (2) / Gastrointestinal syndromes (3): flatulence (2)

Esta segunda parte del artículo sobre flatulencia toca aspectos sobre la etiopatogenia, diagnóstico y tratamiento del síndrome.

The second part of the article on flatulence reviewed aspects of the pathogenesis, diagnosis and treatment of this syndrome.

[Gastrointestinal syndromes (3): flatulence (1)]. / Grandes síndromes gastrointestinales (3): flatulencia (1).

Now we expose important data on definition and cardinal symptoms of the flatulence syndrome and, besides, on accumulated knowledge in relation to digestive tract gases.

Grandes síndromes gastrointestinales (3): flatulencia (1) / Gastrointestinal syndromes (3): flatulence (1)

Ahora exponemos datos importantes sobre definición y síntomas cardinales del síndrome flatulencia y, además, sobre conocimientos acumulados en relación con gases en el tracto digestivo.

Now we expose important data on definition and cardinal symptoms of the flatulence syndrome and, besides, on accumulated knowledge in relation to digestive tract gases.

[Major gastrointestinal syndromes (2): dyspepsia or syndrome of the upper digestive system related with food (2)]. / Grandes síndromes gastrointestinales (2): dispepsia o síndrome del aparato digestivo alto relacionado con alimentos (2).

We expose, this time, our ideas and findings on the etiopathogenesis, diagnosis and treatment of the dyspeptic syndrome.

[Common gastrointestinal syndromes (2): dyspepsia or upper digestive tract syndrome related to food (I)]. / Grandes síndromes gastrointestinales (2): dispepsia o síndrome del aparato digestivo alto relacionado con alimentos (I).

We expose, this time, our ideas and findings on the definition, the classification and the cardinal symptoms of the dyspeptic syndrome.

Grandes síndromes gastrointestinales (2): Dispepsia o síndrome del aparato digestivo alto relacionado con alimentos (I) / Major Gastrointestinal Syndromes (2: Dyspepsia Syndrome or High Digestive Diseases associated with food (I)

Exponemos, esta vez, nuestras ideas y hallazgos sobre la definición, la clasificación y los síntomas cardinales del síndrome dispepsia.

We expose, this time, our ideas and findings on the definition, the classification and thecardinal symptoms of the dyspeptic syndrome.

[Major gastrointestinal syndromes (1): general remarks]. / Grandes síndromes gastrointestinales (1): generalidades.

We will review concepts of the maladies of the people, focusing the problems as "great" syndromes, that are those that include the greater number of gastrointestinal symptoms. We begin this series of articles, reviewing aspects of the multifactorial genesis of the diseases, the real core of the diagnosis and the classification of the organic and "functional" gastrointestinal disorders.

Grandes síndromes gastrointestinales (1): generalidades / Major gastrointestinal syndromes (1): general remarks

Revisaremos conceptos de las molestias o males de las personas, enfocando los problemas como síndromes grandes, que son los que incluyen el mayor número de síntomas gastrointestinales. Introducimos esta serie de artículos recordando aspectos de la génesis multifactorial de las enfermedades, la escencia real del diagnóstico y la clasificación de los transtornos gastrointestinales en 'orgánicos' y 'funcionales'.

Great Gastrointestinales Syndromes (1): An Overview We will review concepts of the maladies of the people, focusing the problems as “great”syndromes, that are those that include the greater number of gastrointestinal symptoms. We begin this series of articles, reviewing aspects of the multifactorial génesis of thediseases, the real core of the diagnosis and the classification of the organic and “functional "gastrointestinal disorders.

[The high fermentative capacity of colonic bacteria in the origin of flatulence and its sensibility to bismuth subsalicylate]. / Alta capacidad fermentativa de las bacterias colónicas en la génesis de la flatulencia, y su sensibilidad al subsalicilato de bismuto.

Using a previously described technique, "in vitro" determinations were carried out for faecal fermentation (FF): basal faecal fermentation (BFF), i.e, only with faeces, with faeces and lactulose (LFF) and with faeces, lactulose and bismuth subsalicylate (BiLFF) in 34 patients with flatulence. The media+d.s. of the difference between the LFFand BFF levels (LFF-BFF) in patients with flatulence was significant and markedly higher than the respective media +d.s. in 30 normal control patients previously studied (9.1+4.7 vs. 3.9+3.2 ml gas/24 hrs; p<0.000001 respectively). And, although FF was reduced by adding bismuth salicylate in only 24% (70.6%) of the patients with flatulence but not in the remaining 10 (29.4%), in total the media+d.s. of the differences between the levels BiLFF and BFF (BiLFFBFF) was significantly lower that the media+d.s. of the differences between the LFF and BFF levels (LFF-BFF) (6.0+4.2 vs 9.1+4.7 ml gas/24 hrs; p<0.01 respectively). These results confirm that: 1) The fermentative capacity of the colonic bacteriae is most likely to be abnormally intense in peoples with flatulence and 2) Bismuth subsalicylate can be useful in the control of excessive colonic fermentation and flatulence; they raise, furthermore, the interesting possibility that we may have found the way to predict when the use of bismuth subsalicylate could be effective in the treatment of a patient with flatulence.

Alta capacidad fermentativa de las bacterias colónicas en la génesis de la flatulencia, y su sensibilidad al subsalicilato de bismuto / Fermentative capacity high of the colonic bacteriae in the genesis of the flatulence, and their sensitivity to the bismuth subsalicylate

Empleando una técnica descrita previamente, se hicieron determinaciones "in vitro" de fermentación fecal (FF) basal (FFB), sólo con heces, también con heces y lactulosa (FFL), y con heces, lactulosa y subsalicilato de bismuto (FFLBi), en 34 pacientes con flatulencia. La media+d.s. de las diferencias entre los niveles de FFL y FFB (FFL-FFB) en los pacientes con flatulencia fue significativa y marcadamente mayor que la respectiva media+d.s. en 30 sujetos controles normales estudiados anteriormente (respectivamente, 9.1+4.7 vs. 3.9+3.2 ml de gas/24h; p menor que 0.000001). Y, aunque la FF disminuyó con la adición de subsalicilato de bismuto en sólo 24 (70.6 por ciento) de los pacientes con flatulencia pero no en los restantes 10 (29.4 por ciento), en total la media+d.s. de las diferencias entre los niveles de FFLBi y FFB (FFLBi-FFB) fue significativamente más baja que la media+d.s. de las diferencias entre los niveles de FFL y FFB (FFL-FFB) (respectivamente, 6.0+4.2 vs. 9.1+4.7 ml de gas/24h; p menor que 0.01). Estos resultados confirman que: 1) Muy probablemente, la capacidad fermentativa de las bacterias colónicas es anormalmente intensa en personas con flatulencia; y 2) El subsalicilato de bismuto puede ser de utilidad en el control de la fermentación colónica excesiva y la flatulencia; y, además sugieren la interesante posibilidad de que pudiéramos haber encontrado la forma de predecir cuándo el empleo del subsalicilato de bismuto va a ser efectivo en el tratamiento de un paciente con flatulencia.

Using a previously described technique, “in vitro” determinations were carried out for faecal fermentation (FF): basal faecal fermentation (BFF), i.e, only with faeces, with faeces and lactulose (LFF) and with faeces, lactulose and bismuth subsalicylate(BiLFF) in 34 patients with flatulence.The media+d.s. of the difference between the LFFand BFF levels (LFF-BFF) in patients with flatulence was significant and markedly higher than the respective media +d.s. in 30 normal control patients previously studied (9.1+4.7 vs. 3.9+3.2 ml gas/24 hrs;p<0.000001 respectively). And, although FF was reduced by adding bismuth salicylate in only 24 per cent (70.6 per cent) of the patients with flatulence but not in the remaining 10 (29.4 per cent), in total the media+d.s. of the differences between the levels BiLFF and BFF (BiLFFBFF) was significantly lower that the media+d.s. of the differences between the LFF and BFF levels (LFF-BFF) (6.0+4.2 vs 9.1+4.7 ml gas/24hrs; p<0.01 respectively). These results confirm that: 1) The fermentative capacity of the colonic bacteriae is most likely to be abnormally intense in peoples with flatulence and 2) Bismuth subsalicylate can be useful in the control of excessive colonic fermentation and flatulence; they raise, furthermore, the interesting possibility that we may have foundthe way to predict when the use of bismuth subsalicylate could be effective in the treatment of a patient with flatulence.

[Gastroesophageal reflux symptoms: their association with dyspepsia]. / Síntomas de reflujo gastroesofágico: su asociación con dispepsia.

The clinical histories of 364 patients with heartburn and/or regurgitations, that is, with symptoms of gastroesophageal reflux (GER), were reviewed to determine the frequencies with which these symptoms appeared in isolated form or associated with manifestations of dyspepsia. Only 41 (11.3%) of the patients presented symptoms of GER in isolated form; in the remaining 323 (88.7%), the symptoms appeared associated with manifestations of dyspepsia. In view of these results and various reasons exposed in the present article, we question the decision of the Rome Working Group of separating the GER from the dyspeptic syndrome.

Síntomas de reflujo gastroesofágico: su asociación con dispepsia / Symptoms of gastroesophageal reflux: its association with dyspepsia

Se revisaron las historias clínicas de 364 pacientes con vinagreras y/o regurgitaciones, esto es, con síntomas de reflujo gastroesofágico (RGE), para precisar las frecuencias con que estos síntomas aparecieron en forma aislada o asociados con manifestaciones de dispepsia. Sólo 41 (11.3 por ciento) de los pacientes presentaron síntomas de RGE en forma aislada; en los restantes 323 (88.7 por ciento), los síntomas se presentaron asociados a manifestaciones de dispepsia. En vista de estos resultados y varias razones que planteamos en el presente trabajo, cuestionamos el acuerdo del Rome Working Group de separar el RGE del síndrome dispéptico.

The clinical histories of 364 patients with heartburn and/or regurgitations, that is, with symptoms of gastroesophageal reflux (GER), were reviewed to determine the frequencies with which these symptoms appeared in isolated form or associated with manifestatipns of dyspepsia. Only 41 (11.3 percent) of the patients presentedsymptoms of GER in isolated form; in the remaining 323 (88.7 percent), the symptoms appeared associated with manifestations of dyspepsia. In view of these results and various reasons exposed in the present article, we question the decision of the Rome Working Group of separating the GER from the dyspeptic syndrome.

[Basal fecal fermentation and with lactulose in patients with flatulence]. / Fermentación fecal basal y con lactulosa en pacientes con flatulencia.

Determinations of the fecal fermentation in subjects may be very useful to know the fermentative capacity of his colonic bacteria. Determinations of basal fecal fermentation (FFB) and fecal fermentation with lactulose (FFL) were done in 30 normal subjects and 126 patients with flatulence, especially meteorism. The media +/- s.d. of FFB was significantly higher in the normal subjects than in the patients with flatulence (1.82 +/- 1.55 vs. 1.24 +/- 1.40 ml of gas/24 h; P: 0.015). On the contrary, in patients with flatulence the obtained media +/- s.d. of FFL and of the differences between FFL and FFB (FFL-FFB) were significantly and markedly higher than in the normal subjects (respectively: 8.84 +/- 5.55 vs. 5.72 +/- 3.72 ml of gas/24 h, P: 0.004; and 7.60 +/- 5.05 vs. 3.91 +/- 3.22 ml of gas/24 h, P<0.00001). The obtained results seem to indicate that patients with flatulence tend to have a colonic flora with high fermentative capacity.

Fermentación fecal basal y con lactulosa en pacientes con flatulencia / Basal fecal fermentation and with lactulose in patients with flatulence

Las determinaciones de fermentación fecal en una persona pueden ser muy útiles para conocer la capacidad fermentativa de sus bacterias colónicas. Se hicieron determinaciones de fermentación fecal basal (FFB) y con adición de lactulosa (FFL) en 30 sujetos normales y 126 pacientes con flatulencia, especialmente meteorismo. La media más menos d.s. de FFB fue significativamente algo mayor en los sujetos normales que en los pacientes con flatulencia (1.82 más menos 1.55 vs. 1.24 más menos 1.40 ml de gas/24 h; P:0.015). Por el contrario, en los pacientes con flatulencia se obtuvieron medias más menos d.s. de FFL y de las diferencias entre FFL y FFB (FFL-FFB) significativa y marcadamente mayores que en los sujetos normales (respectivamente: 8.84 más menos 5.55 vs. 5.72 más menos 3.72 ml de gas/24h, P:0.004); y 7.60 más menos 5.05 vs. 3.91 más menos 3.22 ml de gas/24 h, P menor 0.00001). Los resultados obtenidos parecerían indicar que pacientes con flatulencia tienden a tener una flora colónica con alta capacidad fermentativa.

[Small intestine bacterial overgrowth in patients with chronic diarrhea and normal control subjects]. / Sobrecrecimeinto bacteriano en el intestino delgado en pacientes con diarreea crónica y sujetos controles normales.

The purpose of this study was to investigate the prevalence and meaning of small intestine bacterial overgrowth (SIBO) in patients with chronic diarrhea and normal control subjects. To that effect, a hydrogen breath test was performed using lactulose on 54 patients with chronic diarrhea and 16 normal control subjects. The presence of SIBO was defined as an increase in the hydrogen concentration, of > 20 parts per million above the basal value in any of the breath tests after the ingestion of lactulose. In addition, the logarithms of the areas under the hydrogen concentration curves were calculated.SIBO was present in two (12.5%) of the 16 normal control subjects. The frequency of SIBO was higher in patients with chronic diarrhea (24.1%) than in the normal control subjects; however, this difference was not statistically significant (p:0.27). Finally, the mean + sd of the logarithms of the areas under the hydrogen concentration curves was significantly higher in patients with chronic diarrhea (6.485 + 0.751) than in normal control subjects (6.135 + 0.500) (p<0.05). The results obtained show that SIBO occurs in a certain percentage of the population, without presenting diarrhea. For SIBO to produce diarrhea, it probably requires some additional characteristics. However, it is worth it to suspect and investigate for SIBO in all chronic diarrhea cases.