Guía de práctica clínica de la SECT sobre el manejo de pacientes con neumotórax espontáneo / SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax

Esta guía de práctica clínica (GPC) surge como iniciativa del comité científico de la Sociedad Española de Cirugía Torácica. Para elaborar dicha GPC se han formulado las preguntas PICO (paciente, intervención, comparación y outcome o variable resultado) sobre distintos aspectos del neumotórax espontáneo. Para la evaluación de la calidad de la evidencia y elaboración de las recomendaciones se han seguido las directrices del grupo de trabajo Grading of Recommendations, Assessent, Development and Evaluation (GRADE) (AU)

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group (AU)

SECT Clinical practice guideline on the management of patients with spontaneous pneumothorax. / Guía de práctica clínica de la SECT sobre el manejo de pacientes con neumotórax espontáneo.

This clinical practice guideline (CPG) emerges as an initiative of the scientific committee of the Spanish Society of Thoracic Surgery. We formulated PICO (patient, intervention, comparison, and outcome) questions on various aspects of spontaneous pneumothorax. For the evaluation of the quality of evidence and preparation of recommendations we followed the guidelines of the Grading of recommendations, Assessment, Development and Evaluation (GRADE) working group.

Emergency physician sex and emergency department resource use.

OBJECTIVE: We investigated whether there are differences in emergency department (ED) patient management associated with emergency physician (EP) sex, specifically in terms of ordering investigations and hospital admissions. METHODS: We included all EPs working as consultants for at least 24 consecutive months at a Spanish ED during an 8-year period. Every annual period was considered independently. The classificatory variable was EP sex. For every annual period we compiled age and years of experience of each EP, the number of patients who attended, and patient distribution in triage categories. To analyze ED resource use by each EP and period, we recorded percentages of blood tests, radiography, ultrasonography, computerized tomography (CT) scan, and hospital admission orders. RESULTS: Fifty EPs (27 women and 23 men) were included, 291 annual periods were analyzed (132 for women and 159 for men) and 256 524 patient attendances were recorded (114 086 by women and 142 438 by men). Blood tests were ordered in 57.2% of cases, radiography in 58.0%, ultrasounds in 5.0%, CT scans in 7.0%, and hospitalizations in 28.4%. Compared with men, women ordered 6.8% (95% confidence interval 6.1-7.5%) more blood tests, 4.6% (4.3-5.3%) more radiographies, 15.2% (11.6-18.9%) more ultrasonographies, 11.1% (8.1-14.1%) more CT scans, and 12.1% (10.8-13.4%) more hospitalizations. These differences maintained statistical significance in the stratified analysis by EP experience, and were observed for most of the years analyzed. CONCLUSION: Female EPs order more investigations and admit more patients, although from our results the reason for this is unclear, and the impact on healthcare effectiveness and patient outcome is unknown.

Evolución de la actividad asistencial de una plantilla estable de médicos adjuntos de urgencias a lo largo del tiempo / Differences in practice among physicians staffing an emergency department in relation to years of experience

Objetivos: Conocer la evolución de diferentes aspectos asistenciales en un grupo de urgenciólogos con grados de experiencia diversa y comprobar si su experiencia modifica alguna actitud asistencial. Método: Estudio retrospectivo observacional con seguimiento longitudinal que analiza la actividad anual de los urgenciólogos de un hospital universitario entre 2005 y 2012 en términos de actividad asistencial (meses trabajados, pacientes atendidos, y distribución según su grado de prioridad en el triaje), manejo de los pacientes (interconsultas a otros especialistas hospitalarios, ingresos, ambulancias solicitadas), exploraciones realizadas (radiología simple, analítica, ecografía, tomografía computarizada) y tiempo asistencial (tiempo de estancia de los pacientes dados de alta), y se relacionó esta actividad anual con la experiencia del urgenciólogo mediante regresión lineal. Los resultados significativos se ajustaron por las características de los urgenciólogos. Resultados: Se analizaron 50 urgenciólogos y 291 periodos anuales. Su experiencia osciló entre 1 y 22 años (media 9,5; DE: 5,8) y su actividad mensual entre 47 y 157 pacientes atendidos (media: 86; DE: 19). La experiencia del urgenciólogo se relacionó de forma inversa e independiente con el promedio total de pacientes mensuales atendidos y la proporción de estos con prioridad de triaje 1-2, y de forma directa e independiente con el tiempo de estancia en urgencias en los pacientes dados de alta y las solicitudes de radiología simple, si bien todas estas relaciones fueron tenues (R2 siempre inferiores a 0,010). Estas relaciones mantuvieron la significación estadística tras el ajuste realizado con modelos de complejidad creciente, que incluyeron las variables del urgenciólogo edad, sexo, especialidad y formación previa como médico interno residente (MIR) en el propio hospital. Conclusiones: Existen cambios discretos pero significativos en la actividad asistencial de los urgenciólogos en función de la experiencia acumulada (AU)

Objectives: To determine differences in certain variables reflecting clinical practice in a group of emergency physicians with varying levels of experience and to explore whether differences are associated with experience. Methods: Retrospective observational study of differences in variables reflecting emergency physicians’ practice between 2005 and 2012. We studied work variables (months worked, patients treated, caseload distribution according to triage levels), patient management variables (consultation with other specialists, admissions, ambulance requests), diagnostic procedures ordered (simple radiographs, laboratory tests, ultrasound or computed tomography imaging), and time patients discharged home spent in the department (arrival to discharge). We explored relationships between these variables and the emergency physician’s experience using linear regression analysis, followed by the construction of multivariable models to adjust for physician characteristics. Results: Data for 50 emergency medicine physicians, in 291 years of work, were analyzed. The specialists’ experience ranged from 1 to 22 years (mean [SD], 9.5 [5.8] years). They attended between 47 and 158 patients monthly (mean, 86 [19] patients). The physicians’ experience was inversely and independently related to the mean number of patients attended monthly and the percentage of patients assigned a triage level of 1 or 2. Experience was directly and independently related to discharged patients’ time spent in the emergency department and number of simple radiographs ordered. All associations were small (R2<0.010), however. Those variables continued to show statistically significant associations after increasingly complex modeling to adjust for the following physician variables: physician, age, sex, specialty, residency training in the same hospital). Conclusions: The practice of emergency physicians with more accumulated experience shows slight but significant differences from the practice of less experienced physicians (AU)

[Differences in practice among physicians staffing an emergency department in relation to years of experience]. / Evolución de la actividad asistencial de una plantilla estable de médicos adjuntos de urgencias a lo largo del tiempo.

OBJECTIVES: To determine differences in certain variables reflecting clinical practice in a group of emergency physicians with varying levels of experience and to explore whether differences are associated with experience. MATERIAL AND METHODS: Retrospective observational study of differences in variables reflecting emergency physicians' practice between 2005 and 2012. We studied work variables (months worked, patients treated, caseload distribution according to triage levels), patient management variables (consultation with other specialists, admissions, ambulance requests), diagnostic procedures ordered (simple radiographs, laboratory tests, ultrasound or computed tomography imaging), and time patients discharged home spent in the department (arrival to discharge). We explored relationships between these variables and the emergency physician's experience using linear regression analysis, followed by the construction of multivariable models to adjust for physician characteristics. RESULTS: Data for 50 emergency medicine physicians, in 291 years of work, were analyzed. The specialists' experience ranged from 1 to 22 years (mean [SD], 9.5 [5.8] years). They attended between 47 and 158 patients monthly (mean, 86 [19] patients). The physicians' experience was inversely and independently related to the mean number of patients attended monthly and the percentage of patients assigned a triage level of 1 or 2. Experience was directly and independently related to discharged patients' time spent in the emergency department and number of simple radiographs ordered. All associations were small (R2<0.010), however. Those variables continued to show statistically significant associations after increasingly complex modeling to adjust for the following physician variables: physician, age, sex, specialty, residency training in the same hospital). CONCLUSION: The practice of emergency physicians with more accumulated experience shows slight but significant differences from the practice of less experienced physicians.

OBJETIVO: Conocer la evolución de diferentes aspectos asistenciales en un grupo de urgenciólogos con grados de experiencia diversa y comprobar si su experiencia modifica alguna actitud asistencial. METODO: Estudio retrospectivo observacional con seguimiento longitudinal que analiza la actividad anual de los urgenciólogos de un hospital universitario entre 2005 y 2012 en términos de actividad asistencial (meses trabajados, pacientes atendidos, y distribución según su grado de prioridad en el triaje), manejo de los pacientes (interconsultas a otros especialistas hospitalarios, ingresos, ambulancias solicitadas), exploraciones realizadas (radiología simple, analítica, ecografía, tomografía computarizada) y tiempo asistencial (tiempo de estancia de los pacientes dados de alta), y se relacionó esta actividad anual con la experiencia del urgenciólogo mediante regresión lineal. Los resultados significativos se ajustaron por las características de los urgenciólogos. RESULTADOS: Se analizaron 50 urgenciólogos y 291 periodos anuales. Su experiencia osciló entre 1 y 22 años (media 9,5; DE: 5,8) y su actividad mensual entre 47 y 157 pacientes atendidos (media: 86; DE: 19). La experiencia del urgenciólogo se relacionó de forma inversa e independiente con el promedio total de pacientes mensuales atendidos y la proporción de estos con prioridad de triaje 1-2, y de forma directa e independiente con el tiempo de estancia en urgencias en los pacientes dados de alta y las solicitudes de radiología simple, si bien todas estas relaciones fueron tenues (R2 siempre inferiores a 0,010). Estas relaciones mantuvieron la significación estadística tras el ajuste realizado con modelos de complejidad creciente, que incluyeron las variables del urgenciólogo edad, sexo, especialidad y formación previa como médico interno residente (MIR) en el propio hospital. CONCLUSIONES: Existen cambios discretos pero significativos en la actividad asistencial de los urgenciólogos en función de la experiencia acumulada.

Analysis of the characteristics of interconsultations performed by emergency physicians to other hospital specialists and their evolution over time.

OBJECTIVE: The objective of this study was to describe the type of interconsultations carried out in the Emergency Department (ED) to hospital specialists and analyze their pattern over time. METHODS: The study was carried out during the period from 2006 to 2012. It was carried out at EDs attending to all types of interconsultations except pediatrics and obstetrics-gynecology. There were no changes in physical structure, number of personnel, or organization during the study period. The main measurements taken were as follows: monthly ED census, number of interconsultations and specialties consulted, main reason for presentation at the ED during the first (2006) and last year (2012), and, for specialties demonstrating substantial quantitative changes, main reasons for the interconsultation from the ED at the beginning (2006) and the end (2012) of the study. Linear regression analysis was carried out for the relationship between time and number of interconsultations. RESULTS: A total of 628 256 care interventions were carried out, with 128 008 interconsultations (20.4%). Orthopedic surgery and traumatology, psychiatry, and general and digestive surgery were the departments most frequently consulted (54.5% of the interconsultations). Consultations significantly reduced over time (R=0.29; P<0.001) but the percentage of interconsultations (related to ED census) remained unchanged (R=0.01; P=0.49). The behavior related to specialties was heterogeneous: consultations to general and digestive surgery, hematology and hemostasis, and urology specialists decreased, whereas to thoracic surgery, angiology and vascular surgery, neurology, nephrology, neurosurgery, psychiatry, orthopedic surgery and traumatology, and critical care medicine specialists increased. Some of the reasons for specialist consultation also significantly changed over time. CONCLUSION: The study of interconsultations allows us to identify areas of lesser autonomy of emergency physicians. Changes in the pattern of these interconsultations over time may reflect both learning processes and changes in the healthcare circuits in the ED.

Multicenter assessment of the revisit risk for a further drug-related problem in the emergency department in cocaine users (MARRIED-cocaine study).

INTRODUCTION AND OBJECTIVES: Emergency departments (EDs) in Spanish hospitals daily attend a large number of patients for adverse reactions or clinical complications resulting from cocaine use. After discharge, some of these patients revisit the ED for the same reason within a year. The objective of the present study was to quantify the rate of such revisits and identify the factors associated with them. METHOD: We performed a retrospective, multicenter study with cohort follow-up and without a control group, conducted in the EDs of six Spanish hospitals during 12 months (January-December 2009). We included all ED patients attended for cocaine-related symptoms who reported recent cocaine use and those with cocaine-positive urine analysis by immunoassay without declared consumption. Twelve independent variables assessed for each hospital ED were collected: sex, age, place of consumption, month, day, and time of consumption, mode of arrival at the ED, discharge diagnosis, psychiatric assessment on the ED episode, concomitant drugs, destination on discharge, and history of previous ED visits related with drug use and alcohol use. The dependent variable was a subsequent visit to the ED associated with drug use, identified using the computerized hospital admissions system. RESULTS: The study included 807 patients, of whom 6.7% revisited the ED within 30 days, 11.9% within 3 months and 18.9% within 1 year. The variables significantly associated with ED revisits were: presence of clinical manifestations directly related to cocaine (p < 0.05), ED attendance on a working day (p < 0.05), history of ED visits related with the consumption of alcohol (p < 0.001) or drugs (p < 0.001), and the need for urgent consultation with a psychiatrist (p < 0.001), although only the last four were independent predictors in multivariate analysis. We derived a score based on these variables to predict risk of revisits (MARRIED-score, ranging from 0 to 400 points), which had a reasonably good predictive value for revisit (area under ROC of 0.75; 95% CI 0.71-0.79).

[Computerization in urgency and emergency care]. / La informatización en urgencias y emergencias.

The health services are undergoing a significant transformation due to information and communications technologies (ICT). Computerized clinical history in hospital emergency department (ED) is improving care in this area of medicine, increasing the security of the information, access to it and favoring the implementation of clinical management. In this aspect, the EDs present certain distinctive characteristics, such as management of care times, secure management of care areas and rapid acquisition of relevant information on the patient. While there is unanimity on the advantages of incorporating the electronic history into the EDs, there is also unanimity on the difficulties involved in implementing these systems. Human factor is one of the most relevant when it comes to handling the management of the changeover to computerization. To minimize the impact there must be support for the professionals and the applications developed must be integrated into the electronic clinical history of the patient and offer useful functional applications for users and patients. The automatization of repetitive tasks, the use of forms and protocols, the implementation of messages that help in decision making and the system of clinical security are essential in computer applications. The structure and planning of information must be adjusted to the structure and needs of the EDs. The computer applications must be adapted to the functional structure of today's EDs, providing information in real time about the care situation and gathering information to generate indicators that will make it possible to evaluate and improve the different areas of work: triage, boxes, observation rooms, critical units. Management of information, which these systems provide us with, will make it possible to determine and compare the casuistry and case mix of the EDs. In short, for a computer application to be capable of dealing with the complexity of an ED, it must incorporate three elements: operations inside and outside the service, apply intuitive and multiuser user interfaces, and be able to carry out an efficient management of data at the macro, meso and micro levels.