Effectiveness of a quality improvement strategy with implementation of a specific visual tool to promote ICU early mobilization.

Early progressive mobilization is a safe strategy in the intensive care unit (ICU), however, it is still considered challenging by the inherent barriers and poor adherence to early mobilization protocol. The aim of this study was to evaluate the effectiveness of a quality improvement (QI) multifaceted strategy with implementation of a specific visual tool, the "mobility clock", in reducing non-compliance with the institutional early mobilization (EM) protocol in adult ICUs. A single-center QI with a retrospective before-after comparison study was conducted using data from medical records and hospital electronic databases. Patients from different periods presented similar baseline characteristics. After the QI strategy, a decline in "non-compliance" with the protocol was observed compared to the previous period (10.11% vs. 26.97%, p < 0.004). The proportion of patients walking was significantly higher (49.44% vs. 29.21%, p < 0.006) and the ICU readmission rate was lower in the "after" period (2.25% vs. 11.24%; p = 0.017). The multifaceted strategy specifically designed considering institutional barriers was effective to increase out of bed mobilization, to reduce the "non-compliance" rate with the protocol and to achieve a higher level of mobility in adult ICUs of a tertiary hospital.

Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience.

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. non-invasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Physiotherapy care of patients with coronavirus disease 2019 (COVID-19) - a brazilian experience

Some patients with coronavirus disease (COVID-19) present with severe acute respiratory syndrome, which causes multiple organ dysfunction, besides dysfunction of the respiratory system, that requires invasive procedures. On the basis of the opinions of front-line experts and a review of the relevant literature on several topics, we proposed clinical practice recommendations on the following aspects for physiotherapists facing challenges in treating patients and containing virus spread: 1. personal protective equipment, 2. conventional chest physiotherapy, 3. exercise and early mobilization, 4. oxygen therapy, 5. nebulizer treatment, 6. non-invasive ventilation and high-flow nasal oxygen, 7. endotracheal intubation, 8. protective mechanical ventilation, 9. management of mechanical ventilation in severe and refractory cases of hypoxemia, 10. prone positioning, 11. cuff pressure, 12. tube and nasotracheal suction, 13. humidifier use for ventilated patients, 14. methods of weaning ventilated patients and extubation, and 15. equipment and hand hygiene. These recommendations can serve as clinical practice guidelines for physiotherapists. This article details the development of guidelines on these aspects for physiotherapy of patients with COVID-19.

Functional evolution of critically ill patients undergoing an early rehabilitation protocol.

OBJECTIVE: Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit. METHODS: A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan's parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial). RESULTS: In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays. CONCLUSION: The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an early rehabilitation protocol.

Evolução funcional de pacientes graves submetidos a um protocolo de reabilitação precoce / Functional evolution of critically ill patients undergoing an early rehabilitation protocol

RESUMO Objetivo: Avaliar a evolução funcional dos pacientes submetidos a um protocolo de reabilitação precoce do paciente grave da admissão até a alta da unidade de terapia intensiva. Métodos: Foi conduzido um estudo transversal retrospectivo, incluindo 463 pacientes adultos com diagnóstico clínico e/ou cirúrgico, submetidos a um protocolo de reabilitação precoce. A força muscular global foi avaliada na admissão da unidade de terapia intensiva por meio da escala Medical Research Council. De acordo com a pontuação da Medical Research Council os pacientes foram alocados em um dos quatro planos de intervenção, de acordo com a adequação ou não desses parâmetros, com a escala crescente do plano significando melhor status funcional. Os pacientes não colaborativos foram alocados nos planos de intervenção, conforme seu status funcional. A força muscular global e/ou o status funcional foram reavaliados na alta da unidade de terapia. Por meio do comparativo entre o plano de Intervenção na admissão (Planoinicial) e na alta (Planofinal). Os pacientes foram categorizados em três grupos, de acordo com a melhora ou não do status funcional: respondedores 1 (Planofinal > Planoinicial), respondedores 2 (Planofinal = Planoinicial) e não respondedores (Planofinal < Planoinicial). Resultados: Dos 463 pacientes submetidos ao protocolo, 432 (93,3%) pacientes responderam positivamente à estratégia de intervenção, apresentando manutenção e/ou melhora do status funcional inicial. Os pacientes clínicos classificados como não respondedores apresentaram idade superior (74,3 ± 15,1 anos; p = 0,03) e maior tempo de internação na unidade de terapia intensiva (11,6 ± 14,2 dias; p = 0,047) e no hospital (34,5 ± 34,1 dias; p = 0,002). Conclusão: A manutenção e/ou melhora do status funcional admissional esteve associada com menor tempo de internação na unidade de terapia intensiva e hospitalar. Os resultados sugerem que o tipo de diagnóstico, clínico ou cirúrgico, ...

ABSTRACT Objective: Evaluation of the functional outcomes of patients undergoing an early rehabilitation protocol for critically ill patients from admission to discharge from the intensive care unit. Methods: A retrospective cross-sectional study was conducted that included 463 adult patients with clinical and/or surgical diagnosis undergoing an early rehabilitation protocol. The overall muscle strength was evaluated at admission to the intensive care unit using the Medical Research Council scale. Patients were allocated to one of four intervention plans according to the Medical Research Council score, the suitability of the plan’s parameters, and the increasing scale of the plan expressing improved functional status. Uncooperative patients were allocated to intervention plans based on their functional status. The overall muscle strength and/or functional status were reevaluated upon discharge from the intensive care unit by comparison between the Intervention Plans upon admission (Planinitial) and discharge (Planfinal). Patients were classified into three groups according to the improvement of their functional status or not: responsive 1 (Planfinal > Planinitial), responsive 2 (Planfinal = Planinitial) and unresponsive (Planfinal < Planinitial). Results: In total, 432 (93.3%) of 463 patients undergoing the protocol responded positively to the intervention strategy, showing maintenance and/or improvement of the initial functional status. Clinical patients classified as unresponsive were older (74.3 ± 15.1 years of age; p = 0.03) and had longer lengths of intensive care unit (11.6 ± 14.2 days; p = 0.047) and hospital (34.5 ± 34.1 days; p = 0.002) stays. Conclusion: The maintenance and/or improvement of the admission functional status were associated with shorter lengths of intensive care unit and hospital stays. The results suggest that the type of diagnosis, clinical or surgical, fails to define the positive response to an ...

Treatment-related risk factors for development of skin breakdown in subjects with acute respiratory failure undergoing noninvasive ventilation or CPAP.

BACKGROUND: Noninvasive ventilation (NIV) has been recognized as an effective strategy in preventing endotracheal intubation in subjects with acute respiratory failure (ARF). Some interface-related complications have also been recognized, such as skin breakdown (SB). The aim of this study was to determine the frequency of SB and identify potential treatment-related risk factors for its development in adults with ARF undergoing NIV or CPAP. METHODS: A cross-sectional study was conducted in a general hospital. Subjects were retrospectively enrolled in this study if they were > 18 y old and developed ARF caused by any condition in which NIV or CPAP was indicated for at least one application for a period longer than 2 h. The outcomes were the prevalence of SB and the evaluation of related risk factors. Data were extracted from the electronic medical records. A stepwise forward logistic regression model was used to identify independent risk factors for SB development. RESULTS: A total of 375 subjects (160 males) met the inclusion criteria and were enrolled in the study. Fifty-four subjects (14.4%) developed SB. The mean number of applications of NIV or CPAP carried out for > 2 h was higher in subjects with SB (7.1 ± 13.3 h) than in those without SB (4.4 ± 13.3 h) (P = .03). Subjects with SB also presented a higher total duration of NIV use (44.6 ± 118.5 h) compared with subjects without SB (21.8 ± 45.5 h) (P = .01). Subjects who developed SB presented a higher use of oronasal mask (92.6%) compared with the group that did not (21.5%) (P < .001). CONCLUSIONS: In patients with ARF undergoing NIV or CPAP, oronasal mask use for > 26 h was independently associated with development of SB.

¿Creen haber cambiado los docentes un año después de un curso de docencia clínica? / Do clinical tutors believe to have changed their teaching practices one year after finishing a faculty development course?

Introducción. Los cursos de formación pedagógica pueden mejorar el desempeño de los docentes clínicos. Diseñamos un curso de diez sesiones para mejorar las competencias docentes de profesionales que tienen responsabilidades como tutores clínicos. En el año 2008 se realizaron tres cursos. Las actividades se programaron una vez a la semana, de 08:30 a 10:00 h de la mañana, para facilitar la asistencia. El curso se componía de tres módulos -currículo, metodología y evaluación- y se diseñó para centrarse en los alumnos. Fueron facilitadores de los cursos docentes clínicos con formación en docencia en ciencias de la salud (con diploma o maestría). Objetivo. Evaluar si los asistentes percibían haber realizado cambios en sus prácticas docentes a un año de haber finalizado el curso. Sujetos y métodos. Se administró de modo anónimo, mediante una plataforma informática, un cuestionario con 13 preguntas cerradas y espacio para comentarios. Se envió por correo electrónico una invitación a responder el cuestionario a los 55 tutores clínicos que fueron alumnos de los tres cursos realizados durante el año 2008. El cuestionario se remitió un año después de haber finalizado el curso respectivo. Resultados. El cuestionario fue respondido por 41 tutores clínicos (74,5%). Las respuestas apuntaron a cambios realizados en todos los aspectos consultados: programas (34%), metodología (83%) y evaluación (71%). Conclusiones. La mayoría de los participantes en estos cursos de formación docente perciben haber hecho cambios positivos en sus prácticas docentes. Actualmente se está dictando el noveno curso de estas características (AU)

Introduction. Faculty development courses can improve the performance of teachers. We designed a ten sessions course aimed to improve the teaching skills of professionals who have responsibilities as tutors in clinical settings. Three courses were given in year 2008. The courses were held in teaching hospitals once a week to make easier for tutors to attend. The courses included curriculum, methodology and evaluation modules. They were student centred, took place in the workplace and employed local teachers with a degree in health sciences education that were clinical tutors themselves. Aim. To assess whether clinical tutors perceived themselves as having made changes in their teaching practices one year after having finished the course. Subjects and methods. An anonymous online survey with thirteen closed questions and space for open comments was administered online. One year after finishing the respective course, an invitation to complete the survey was e-mailed to the fifty-five tutors who completed one of the year 2008 courses. Results. Forty-one tutors answered the survey (74.5%). Changes in teaching practices and in major aspects of the teaching process were declared in all the items consulted in the survey: teaching methodology 83%, assessment of students 71%, programs 34%. Conclusions. Clinical tutors perceive themselves as having made positive changes in their teaching practices after a faculty development course. Currently the ninth similar course is being given (AU)

Efeitos da pigmentação e do envelhecimento acelerado na estabilidade de cor de um silicone médico com potencial de uso nas próteses maxilofaciais / Effects of pigmentation and accelerated aging on color stability of a medical silicone with potential for use in maxillofacial prosthetics

Este estudo avaliou a alteração de cor do silicone Ortho Pauher, tendo como padrão ouro o silicone MDX 4 - 4210, frente ao envelhecimento e à pigmentação. Foram obtidos sessenta espécimes para cada material, os quais receberam pigmentação intrínseca ou pigmentação intrínseca e extrínseca. Como pigmento, foi utilizado pó de maquiagem. Os espécimes foram distribuídos aleatoriamente em três grupos e submetidos ao envelhecimento ou por termociclagem, luz ultravioleta ou para compor o grupo controle. Como controle, espécimes foram mantidos em um recipiente hermeticamente fechado na ausência de luz. O envelhecimento simulou um período de uso de 12 meses. Os testes ANOVA e Tukey (p < 0,05) indicaram diferença significante entre o grupo controle e osgrupos envelhecidos por termociclagem e luz ultravioleta, sendo que estes se mostraram iguais. Em relação aos materiais, não houve diferença entre eles. Houve diferença entre as pigmentações. Na interação, o Ortho Pauher sofreu maior variação de cor causada pela luz ultravioleta, enquanto o MDX, pela termociclagem. Comparando-seos materiais com pigmentação intrínseca, nos três grupos de envelhecimento houve diferença entre o controle e a luz ultravioleta, sendo que a maior alteração foi encontrada para o Ortho Pauher. Para os materiais com pigmentação intrínseca e extrínseca, houve diferença nos três grupos de envelhecimento, com maior variação para o MDX.Notam-se comportamentos distintos dos materiais em função da pigmentação e do envelhecimento, devendo-se considerar a associação entre material, tipo de pigmento e tipo de exposição para que se faça a indicação clínica corretamente, podendo-se considerar o Ortho Pauher na confecção de próteses maxilofaciais.

This study evaluated the color change of the silicone Ortho Pauher, with the standard gold silicone MDX 4 - 4210, facing the aging and pigmentation. Sixty specimens were obtained for each material, which received intrinsic or intrinsic and extrinsic pigmentation. Powder makeup was used as pigment. The specimens were randomly dividedinto three groups and subjected to aging or thermal cycling, ultraviolet light or to compose the control group. As control, specimens were kept in an airtight container in the absence of light. Aging simulated a period of 12 months. ANOVA and Tukey tests (p < 0.05) indicated a significant difference between control group and the groups aging by thermal cycling and ultraviolet light, which were equal. In relation to materials, there was no difference between them. There was a difference between pigmentation. In the interaction, Ortho Pauher suffered major color changescaused by ultraviolet light, while the MDX, by thermocycling. Comparing the materials with intrinsic pigmentation, the aging in the three groups was difference between control and ultraviolet light, and the greatest change was found for the Ortho Pauher. For materials with intrinsic pigmentation and extrinsic, there were differences between the three groups of the aging, with greater variation for the MDX. Note the different behavior of materials as a function of pigmentation and aging, one should considered the relationship between material, pigment type and type ofexposure in order to do properly the clinical indication, and may be considered silicone Ortho Pauher in making of the maxillofacial prosthesis.

A report on student abuse during medical training.

The purpose of this study was to determine the incidence, and the consequences, of abusive situations as perceived by students during the course of their medical training. A descriptive study was carried out surveying the entire 2000 fifth-year class of 181 in the Medical School of the University of Chile. The questionnaire was answered by 144 students. Results showed that 91.7% of the students who responded had suffered at least one episode of abuse while enrolled in medical school. The main offenders were teachers and peers. Verbal abuse was the most common (85.4%), followed by psychological (79.9%), sexual(26.4%) and physical (23.6%) abuse. Students reported that abuse had effects on their mental health, social life and the image they had of physicians; 17% considered dropping out of school as a consequence of this experience. Efforts should be addressed to prompt educators to reflect on their role.