[Nursing role in prevention of Ventilator Associated Pneumonia: Spanish project "Neumonìa Zero"]. / Ruolo dell'infermiere nella prevenzione della Polmonite Associata a Ventilazione Meccanica Invasiva: il progetto spagnolo "Neumonìa Zero".

The incidence of Ventilator Associated Pneumonia (VAP) varies between 8 and 28% on patients with invasive mechanical ventilation, and it is associated with high mortality rates. The international literature indicates that the VAP has some risk factors that cannot be changed and some other that are closely related to nursing care procedures. The aim of this study is to analyze compliance level to the protocol of nursing prevention of the VAP in the ICU of "General Hospital" in Castellon de la Plana (Spain) within the project "Neumonía Zero". The data were collected during the months of May and June 2012 through direct observation which lasted 33 days. 5 check lists based on international recommendations were used for the objective evaluation on the adoption of preventive treatments. 58 patients in invasive mechanical ventilation and 43 ICU nurses were enrolled. Compliance procedure showed no significant differences among each other with an average adhesion of 78% of the observations. The observations trend shows a tendency of improvement in accordance with the checklists of cuff pressure and of the inclination of the bed head. An incidence rate of VAP 13,37/1000 was observed. In conclusion, direct observation showed good compliance to the protocols used in the ward. The obtained data allows to re-direct educational choices and assume a systematic application of this methodology with an important contribution to nursing.

Severe 2009 A/H1N1v influenza in pregnant women in Spain.

OBJECTIVES: To describe the severity of the 2009 influenza A/H1N1v illness among pregnant women admitted to Spanish intensive care units. DESIGN AND PATIENTS: Prospective, observational, multicenter study conducted in 148 Spanish intensive care units. We reviewed demographic and clinical data from the Spanish Society of Intensive Care Medicine database reported from April 23, 2009, to February 15, 2010. We included women of reproductive age (15-44 yrs) with confirmed A/H1N1v infection admitted to intensive care units. MAIN RESULTS: Two hundred thirty-four women of reproductive age were admitted to intensive care units, 50 (21.4%) of them pregnant. Seven deaths were recorded in pregnant and 22 in nonpregnant women. Among intensive care unit admissions, there were no statistically significant differences between pregnant women and nonpregnant in Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment scores, chest x-rays, inotrope requirement, or need for mechanical ventilation or steroid therapy. Mortality risk was significantly associated with Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and obesity. Viral pneumonia was more frequent in pregnant women than in nonpregnant women, with an odds ratio (adjusted for asthma, time from onset influenza symptoms to hospital admission and obesity) of 4.9 (95% confidence interval: 1.4-17.2). The development of primary viral pneumonia in women of reproductive age appeared to be related to the time of commencement of antiviral treatment, the lowest rates being reported with initiation of antiviral therapy within 48 hrs of symptom onset (63.6% vs. 82.6%, p = .03). However, antiviral therapy was started within this time span in only 14% of pregnant women. CONCLUSIONS: More than 20% of women of reproductive age admitted to intensive care unit for pH1N1 infection were pregnant. Pregnancy was significantly associated with primary viral pneumonia. Pregnant women should receive prompt treatment with oseltamivir within 48 hrs of the onset of influenza symptoms.

VLAD. Un sistema gráfico de expresión continua de efectividad asistencial aplicado en medicina intensiva / The variable life adjusted display (VLAD). A graphical technique of continuous expression of healthcare effectiveness applied to intensive care medicine

Introducción: Se describen distintos métodos para estimar y expresar la efectividad en la asistencia a pacientes críticos. De entre ellos, se hace especial hincapié en el método VLAD (Variable Life Adjusted Display), que permite una descripción secuencial y continua, con expresión gráfica, fácilmente comprensible y utilizable. El objetivo del trabajo no es hacer una descripción de un nuevo método, sino la difusión de uno poco conocido y su aplicación a pacientes críticos. Material y método: Se describe la metodología de cálculo del método VLAD como resultado de la resta acumulada entre supervivientes reales y predichos supervivientes, por cualquiera de los métodos al uso utilizados para predecir mortalidad en pacientes críticos. Los autores utilizan el Simplified Acute Physiology Score 2. Resultados: El método se aplica a 7.448 pacientes, ingresados consecutivamente en una unidad de cuidados intensivos polivalente desde 1999 a 2004, incluido. Se ofrecen distintos gráficos según que la expresión VLAD se realice sobre la totalidad de la muestra, o sobre submuestras homogéneas (tipo de ingreso, o determinadas causas de ingreso). Discusión: Se ofrece una visión crítica de los medios de expresión de efectividad, desde una perspectiva de gestión clínica, y de sus potenciales aplicaciones: instrumento de gestión, revisión de la asistencia prestada, docencia e investigación

Introduction: Different methods for estimating and expressing effectiveness of the care of critically ill patients are described. Among them, especial interest is placed on VLAD methodology, which allows continuous and sequential expression of the variable under study through a graphic display that is easy to use and understand. The aim of this article was not to describe a new methodology, but rather to present a little-known method not previously used in critically-ill patients in Spain. Material and method: We describe the procedure for calculating VLAD as the result of the cumulative subtraction of real mortality from predicted mortality, irrespective of the methodology used for prediction. In the present article, SAPS 2 was used. Results: The method was applied in 7,448 patients consecutively admitted to a medical­surgical ICU from 1999 to 2004 (inclusive). Graphs depicting the use of VLAD in the whole sample and in homogeneous subgroups (type of admission or certain admission diagnoses) were obtained. Discussion: We provide a critical view of techniques for expressing effectiveness, from the perspective of clinical management, as well as of the possible uses of these techniques in healthcare management, quality evaluation, teaching, and research

[ Contact isolation and prevention of spreading of serious infections in an intensive care unit. Description of a protocol]. / Aislamiento de contacto y prevención de diseminación de infecciones graves en una unidad de cuidados intensivos. Descripción de un protocolo.

Hospital infection (HI) represents a serious care problem in critical patients. The presence of this complication is associated to an increase in the baseline seriousness of the patient, that is translated into greater care effort, multiplication of workload and greater mortality. This situation is clearly complicated when the causal agent of the infection is a multiresistant bacteria, since it also requires specific measures aimed at avoiding crossed transmission of the infection to other patients in addition to route treatment. The objective of the Nursing Note is to communicate our routine action in the face of this problem. From January 2003 to December 2004, 2420 patients were admitted to our Department. Of these 190 had some ICU hospital acquired infection (8.48%). Isolation steps were begun in 112 patients (4.62%) and also preventive measures as they were immunodepressed patients (inverse isolation) or patients at risk of presenting colonization or infection by multiresistant germs (preventive isolation) or due to suffering a demonstrated infection by said microorganisms. The mean seriousness, measured by the Simplified Acute Physiology Score (SAPS II), of the sample was 30+/-16 points. Those infected had a mean seriousness of 44+/-15 points and those isolated 49+/-19 points. Nursing workloads, measured by Nine Equivalents of Nursing Manpower Use Score (NEMST) were 150+/-274 points for all the sample, while the infected patients had 737+/-460 and the isolated ones 811+/-452 points. Global mortality in said period was 12.6%, while those infected had a mortality of 32% and the isolated ones 43%. The average costs per stay were 5069 euro. Patients who suffered any infection during their stay in the ICU increased their stay cost up to 26,630 euro and those isolated up to 29,050 euro. Faced with this situation, it was decided to stress the Contact Isolation procedures to achieve correct fulfillment of the preventive measures and achieve reduction in the hospital infection rates and crossed transmission between patients by multiresistant pathogens.

Aislamiento de contacto y prevención de diseminación de infecciones graves en una unidad de cuidados intensivos. Descripción de un protocolo / Isolation of contact and prevention of spreading of serious infections in an intensive care unit. Description of a protocol

La infección nosocomial (IN) representa un grave problema asistencial en los pacientes críticos. La presencia de esta complicación se asocia a un incremento de la gravedad basal del paciente, que se traduce en un mayor esfuerzo asistencial, la multiplicación de las cargas de trabajo y una mayor mortalidad. Esta situación se complica de forma manifiesta cuando el agente causal de la infección es una bacteria multirresistente, ya que además del tratamiento habitual requiere unas medidas específicas encaminadas a evitar la transmisión cruzada de la infección a otros pacientes. El objetivo de esta «Nota de Enfermería» es dar a conocer nuestra rutina de actuación ante este problema. Desde enero de 2003 a diciembre de 2004 ingresaron en nuestro servicio 2.420 pacientes, de los cuales 190 presentaron alguna IN adquirida en la unidad de cuidados intensivos (UCI) (8,48%). Se instauraron medidas de aislamiento en 112 pacientes (4,62%), bien como medida preventiva por ser pacientes inmunodeprimidos (aislamiento inverso) o por ser pacientes de riesgo de presentar una colonización o infección por gérmenes multirresistentes (aislamiento preventivo), o por presentar una infección demostrada por dichos microorganismos. La gravedad media de la muestra, medida por SAPS II (Simplified Acute Physiology Score), fue de 30 ± 16 puntos. Los infectados presentaron una gravedad media de 44 ± 15 puntos y los aislados de 49 ± 19. Las cargas de trabajo de enfermería, medidas por NEMST (Nine Equivalents of Nursing Manpower Use Score) fueron de 150 ± 274 puntos para el global de la muestra, mientras que los pacientes infectados tuvieron 737 ± 460 y los aislados 811 ± 452. La mortalidad global en dicho período fue del 12,6%, mientras que los infectados presentaron una mortalidad del 32% y los aislados del 43%. Los costes promedio por estancia fueron de 5.069 A. Los pacientes que presentaron alguna infección durante su estancia en UCI incrementaron su coste por estancia hasta 26.630 A y los aislados hasta 29.050. Ante esta situación, se decidió enfatizar en los procedimientos de aislamiento de contacto para conseguir el correcto cumplimiento de las medidas preventivas y lograr una reducción en las tasas de infección nosocomial y de transmisión cruzada entre pacientes por patógenos multirresistentes

Hospital infection (HI) represents a serious care problem in critical patients. The presence of this complication is associated to an increase in the baseline seriousness of the patient, that is translated into greater care effort, multiplication of workload and greater mortality. This situation is clearly complicated when the causal agent of the infection is a multiresistant bacteria, since it also requires specific measures aimed at avoiding crossed transmission of the infection to other patients in addition to route treatment. The objective of the Nursing Note is to communicate our routine action in the face of this problem. From January 2003 to December 2004, 2420 patients were admitted to our Department. Of these 190 had some ICU hospital acquired infection (8.48%). Isolation steps were begun in 112 patients (4.62%) and also preventive measures as they were immunodepressed patients (inverse isolation) or patients at risk of presenting colonization or infection by multiresistant germs (preventive isolation) or due to suffering a demonstrated infection by said microorganisms. The mean seriousness, measured by the Simplified Acute Physiology Score (SAPS II), of the sample was 30±16 points. Those infected had a mean seriousness of 44±15 points and those isolated 49±19 points. Nursing workloads, measured by Nine Equivalents of Nursing Manpower Use Score (NEMST) were 150±274 points for all the sample, while the infected patients had 737±460 and the isolated ones 811±452 points. Global mortality in said period was 12.6%, while those infected had a mortality of 32% and the isolated ones 43%. The average costs per stay were 5069 e. Patients who suffered any infection during their stay in the ICU increased their stay cost up to 26,630 e and those isolated up to 29,050 e. Faced with this situation, it was decided to stress the Contact Isolation procedures to achieve correct fulfillment of the preventive measures and achieve reduction in the hospital infection rates and crossed transmission between patients by nultiresistant pathogens

[Care work load in critical patients. Comparative study NEMS versus NAS]. / Cargas de trabajo asistencial en pacientes críticos. Estudio comparativo NEMS frente a NAS.

INTRODUCTION: The systems of calculating care load have not yet reached the levels of generalized use which the systems of prognostic estimation of survival have. The reason for this is their potential defects of design (medical and not nursing conceptualization) and the sometimes confusing completion (TISS 76). The simplest ("nine equivalents of nurse manpower use score" [NEMS], care levels) add the difficulty of not being useful for the calculation of staff, because the design is not oriented towards nursing. The development of NAS (nursing activity score) by FRICE tries to solve all these problems. Our objective has been to verify to what degree the NEMS and NAS are correlated as systems of expression and calculation of care load. PATIENTS AND METHOD: During the last quarter of 2004, NEMS and NAS have been used simultaneously by the nursing staff. During this period, 150 pairs of daily calculation values of NEMS-NAS and 150 pairs of calculation values by shift of NEMS-NAS have been collected. Comparison of means and linear correlation of values obtained and the analysis of the histograms of values of each series, their value ranges and analysis of their bias coefficients have been done. The analysis was done with the SPSS/PC 11. RESULTS: During the period indicated, it has been verified that NEMS has a much narrower value range than NAS, both in regards to daily values (18-45 versus 29.70-84.50) and in regards to values by shift (18-45 versus 22.40-84.50). The bias analysis shows a deviation to the left of both series of values. Linear correlation between NEMS-NAS by shift shows a R2 of 0.1634 and becomes even poorer in the NEMS-NAS correlation per day with R2 of 0.2012. It should also be stressed that NEMS expresses its results in points while NAS does so in percentage of time occupied in the attention and care of the patient. CONCLUSIONS: In this preliminary study, the better adaptation of NAS versus NEMS to real work loads of patients hospitalized in the ICU and the non-possible correlation between the values of both systems is affirmed.

Cargas de trabajo asistencial en pacientes críticos. Estudio comparativo NEMS frente a NAS / Care work load in critical patients. Comparative study NEMS versus NAS

Introducción. Los sistemas de cómputo de carga asistencial no han alcanzado aún los niveles de utilización generalizada que poseen los sistemas de estimación pronóstica de supervivencia. La causa de ello son sus potenciales defectos de diseño (conceptualización médica y no de enfermería) y la, a veces, farragosa cumplimentación (TISS 76). Los más simples (NEMS [nine equivalents of nursing manpower use score], niveles de asistencia) añaden la dificultad de no ser útil es para el cálculo de plantillas, debido a un diseño no orientado a enfermería. El desarrollo de NAS (nursing activity score) por FRICE® intenta solventar todos estos problemas. Nuestro objetivo ha sido comprobar en qué medida se correlacionan NEMS y NAS como sistemas de expresión y computo de carga asistencial. Pacientes y método. Durante el último trimestre de 2004 se han utilizado simultáneamente NEMS y NAS, por parte del personal de enfermería. Durante este período se han recogido 150 pares de valores de cómputo diario de NEMS-NAS y 150 pares de valores de cómputo por turno de NEMS-NAS. Se ha realizado la comparación de medias y la correlación lineal de valores obtenidos, así como el análisis de los histogramas de valores de cada serie, sus rangos de valor y el análisis de sus coeficientes de sesgo. El análisis se ha realizado mediante SPSS/PC 11. Resultados. Durante el período señalado se ha constatado que NEMS tiene un rango de valor mucho más estrecho que NAS, tanto en lo que se refiere a valores diarios (18-45 frente a 29,70-84,50) como a valores por turno (18-45 frente a 22,40-84,50). El análisis de sesgo muestra una desviación a la izquierda de ambas series de valores. La correlación lineal entre NEMS-NAS por turno, muestra una R2 de 0,1634, y se empobrece aún más en la correlación NEMS-NAS por día con R2 de 0,0212. Debe destacarse, además, que NEMS expresa sus resultados en puntos, mientras que NAS lo hace en porcentaje de tiempo ocupado en la atención y cuidado del paciente. Conclusiones. En este estudio preliminar se constata la mejor adecuación de NAS frente a NEMS a las reales cargas de trabajo de los pacientes ingresados en UCI y la no posible correlación entre los valores de ambos sistemas

Introduction. The systems of calculating care load have not yet reached the levels of generalized use which the systems of prognostic estimation of survival have. The reason for this is their potential defects of design (medical and not nursing conceptulalization) and the sometimes confusing completion (TISS 76). The simplest («nine equivalents of nurse manpower use score» [NEMS], care levels) add the difficulty of not being useful for the calculation of staff, because the design is not oriented towards nursing. The development of NAS (nursing activity score) by FRICE® tries to solve all these problems. Our objective has been to verify to what degree the NEMS and NAS are correlated as systems of expression and calculation of care load. Patients and method. During the last quarter of 2004, NEMS and NAS have been used simultaneously by the nursing staff. During this period, 150 pairs of daily calculation values of NEMS-NAS and 150 pairs of calculation values by shift of NEMS-NAS have been collected. Comparison of means and linear correlation of values obtained and the analysis of the histograms of values of each series, their value ranges and analysis of their bias coefficients have been done. The analysis was done with the SPSS/PC 11. Results. During the period indicated, it has been verified that NEMS has a much narrower value range than NAS, both in regards to daily values (18-45 versus 29.70-84.50) and in regards to values by shift (18-45 versus 22.40-84.50). The bias analysis shows a deviation to the left of both series of values. Linear correlation between NEMS-NAS by shift shows a R2 of 0.1634 and becomes even poorer in the NEMS-NAS correlation per day with R2 of 0.2012. It should also be stressed that NEMS expresses its results in points while NAS does so in percentage of time occupied in the attention and care of the patient. Conclusions. In this preliminary study, the better adaptation of NAS versus NEMS to real work loads of patients hospitalized in the ICU and the non-possible correlation between the values of both systems is affirmed