Carrera profesional del personal médico. Un sistema incentivador útil cuando se mantienen sus principios de aplicación / Medical personnel’s careers. A useful incentive system as long as we adhere to its application principles

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Simple advice for injured hazardous drinkers: an implementation study.

AIM: To evaluate the implementation of a screening and intervention procedure for hazardous drinkers in the routine praxis of an emergency service, without increasing the ED (emergency department) staff. METHODS: Four stages of the implementation process were undertaken: exploration and adoption, programme installation, and initial implementation. Two hospitals participated, with a coordinator, four trainers and all the emergency nursing staff. Eligible patients were males over age 15 presenting at the weekend with a traffic injury. Screening was performed with five questions (the three items of alcohol use disorders identification test (AUDIT-C) plus two questions about drinking within 6 h before the crash). Hazardous drinkers and drivers who had driven while intoxicated were offered simple advice. The programme implementation was evaluated by reviewing the patients' forms and by interviews and surveys of the nursing staff. RESULTS: The study lasted for 27 weeks. Knowledge and compliance with the programme were good. However, only 25% of the eligible patients were identified. Simple advice was accomplished by 94.7% of those in need of it. Although the majority of nurses felt at ease performing the intervention, 75% considered the programme as a work overload and only 21% reckoned that it was feasible for the emergency service. CONCLUSION: The emergency setting poses important barriers to the implementation of brief interventions.

[Lack of inhospital beds: impact on emergency department performance]. / Repercusión de la falta de camas de hospitalización en la actividad de un servicio de urgencias hospitalario.

BACKGROUND AND OBJECTIVE: To determine the effect that the lack of inhospital beds exerts on emergency department performance. MATERIAL AND METHOD: Two different time periods with comparable daily census, but significantly different bed availability. Variables assessed were general emergency department performance markers, emergency department effectiveness markers and objective and subjective quality markers. RESULTS: All variables got worse within lower bed availability period, and reached a change magnitude between 0% and 300% when compared with control period. However, a statistical difference was only achieved in emergency department occupation rate (+14%; p < 0.001), rate of patients waiting to be admitted (+100%; p < 0.001), patients waiting to be seen (+60%; p < 0.01), waiting time to be seen (+83%; p < 0.001), time to employed for first medical assessment and treatment (+44%; p < 0.01), and patients left without being seen (+90%; p < 0.05). CONCLUSIONS: The lack of inhospital beds for patients admitted from the emergency department leads to a remarkable worsening in its function and performance.

Repercusión de la falta de camas de hospitalización en la actividad de un servicio de urgencias hospitalario / Lack of inhospital beds: impact on emergency department performance

Fundamento y objetivo: Investigar el impacto que tiene la falta de camas de hospitalización en la actividad de urgencias. Material y método: Se estudiaron 2 períodos comparables en número de visitas pero significativamente distintos en disponibilidad de camas de hospitalización. Se cuantificaron los índices generales de urgencias, índices de efectividad e índices de calidad objetiva y subjetiva. Resultados: Durante el período de baja disponibilidad de camas de hospitalización se registró un deterioro en todos los índices, con porcentajes de cambio respecto al período control que oscilaron entre el 0 y el 300%. Dicho deterioro alcanzó la significación estadística para el índice de ocupación de urgencias (+14%; p < 0,001), pacientes pendientes de ingreso en urgencias (+100%; p < 0,001), pacientes esperando iniciar visita (+60%; p < 0,01), tiempo de espera para iniciar vista (+83%; p = 0,001), tiempo de actuación médico-enfermería (+44%; p < 0,01) e índice de no visitados (+90%; p < 0,05). Conclusiones: La falta de camas de hospitalización se traduce en un marcado deterioro en diversos aspectos que miden la actividad en urgencias

Background and objective: To determine the effect that the lack of inhospital beds exerts on emergency department performance. Material and method: Two different time periods with comparable daily census, but significantly different bed availability. Variables assessed were general emergency department performance markers, emergency department effectiveness markers and objective and subjective quality markers. Results: All variables got worse within lower bed availability period, and reached a change magnitude between 0% and 300% when compared with control period. However, a statistical difference was only achieved in emergency department occupation rate (+14%; p < 0.001), rate of patients waiting to be admitted (+100%; p < 0.001), patients waiting to be seen (+60%; p < 0.01), waiting time to be seen (+83%; p < 0.001), time to employed for first medical assessment and treatment (+44%; p < 0.01), and patients left without being seen (+90%; p < 0.05). Conclusions: The lack of inhospital beds for patients admitted from the emergency department leads to a remarkable worsening in its function and performance

[Direct discharge from triage in emergency departments: assessment, risks and patient satisfaction]. / Derivación sin visita desde los servicios de urgencias hospitalarios: cuantificación, riesgos y grado de satisfacción.

BACKGROUND AND OBJECTIVE: After triage assessment, some hospitals refer emergency department (ED) patients with minor chief complaints to off-site clinics. The potential for 2 different referral models introduced in 2 urban hospitals was assessed, as well as the suitability of this measure. PATIENTS AND METHOD: After triage assessment, patients with minor complaints were identified. ED from Hospital Clínic of Barcelona (HCB) proposed that these patients should be referred to a hospital affiliated off-site clinic, whereas ED from Hospital Mútua de Terrassa (HMT) tried to refer such patients to their primary care setting. Within a year, we assessed on both ED the following items: number of arrivals, percentage of proposed referrals (PR), percentage of accepted referrals (AR), percentage of carried-out referrals (CR: patients who, once discharged, really attended the other setting), and percentage of returned referrals (RR) to the ED, as well as return reasons, and the percentage of returned patients finally admitted. The degree of patient satisfaction was evaluated by means of a telephone survey. RESULTS: From both ED, 44,764 arrivals and 7,297 (16.3%) PR were registered. The percentage of AR and CR was 94.3% and 75.3%, respectively. The percentage of PR from HMT was higher (18.7% vs 13.1%; p < 0.001), yet HCB obtained a greater percentage of AR (98.9% vs 92%, p < 0.001) and CR (93.7% vs 65%; p < 0.001). The percentage of RR from both ED was 1.5% (2.8% vs 0.4%; p < 0.001). Among returned patients, 12 of them (0.17% respect to AR) were finally admitted. Only 41% of patients who were found to be eligible for direct discharge would have agreed with being referred to another clinical setting, but after the experience, up to 93% of them said they would go through it again. HMT gave referral information to patients faster than HCB (p < 0.05), but HCB got a better model evaluation (p < 0.01), a greater medical complaint solution (p < 0.05), and generated a smaller number of subsequent consultations (p < 0.05). CONCLUSIONS: After a rapid triage assessment, a percentage of patients arriving on EDs may be directly and safely discharged and referred to other clinical settings. This is achieved by both proposed models without additional risks for patients. However, patients feel more satisfied with an hospital-affiliated off-site clinic instead of their primary care setting.

Derivación sin visita desde los servicios de urgencias hospitalarios: cuantificación, riesgos y grado de satisfacción / Direct discharge from triage in emergency departments: assessment, risks and patient satisfaction

Fundamento y objetivo: Desde hace unos años, algunos centros hospitalarios redirigen a los pacientes que acuden a urgencias con enfermedades menores hacia niveles asistenciales más adecuados sin que se les visite. A continuación se presenta la experiencia de 2 hospitales que aplican modelos diferenciales y se analiza la idoneidad de esta medida. Pacientes y método: A los pacientes con síntomas menores que consultan en la Unidad de Urgencias de Medicina (UUM) del Servicio de Urgencias Hospitalario (SUH), del Hospital Clínic de Barcelona (HCB), se les propone que se les visite en un centro externo de urgencias extrahospitalarias que depende del propio hospital, mientras que el Hospital Mútua de Terrassa (HMT) los remite a los centros de asistencia primaria correspondientes. Durante un año, se ha medido la actividad de ambos hospitales, se ha cuantificado el porcentaje de derivaciones propuestas (DP) por los médicos de la UUM, de derivaciones aceptadas (DA) por los pacientes, de derivaciones consumadas (DC, pacientes que acuden realmente al centro externo), de derivaciones retornadas (DR) al SUH, la causa de las DR y el porcentaje de ingresos. Además se ha realizado una encuesta de satisfacción. Resultados: Durante el período de estudio se visitaron 44.764 pacientes y a un 16,3% se les propuso acudir al centro externo sin visita previa. El porcentaje de DA y DC fue del 94,3 y del 75,3%, respectivamente. El de DP fue superior en el HMT (el 18,7 frente al 13,1%; p < 0,001), mientras que el HCB tuvo mayores porcentajes de DA (el 98,9 frente al 92,0%; p < 0,001) y DC (el 93,7 frente al 65,0%; p < 0,001). Se registró un 1,5% de DR, que fueron superiores en el HCB (el 2,8 frente al 0,4%; p < 0,001). El índice global de ingresos fue del 0,17%. Sólo al 41% de los pacientes le pareció bien de entrada acudir a otro recurso asistencial, pero tras la experiencia el 93% afirmó que volvería a aceptarla. El HMT fue más rápido en facilitar la información (p < 0,05), mientras que el HCB tuvo una mejor valoración global del sistema (p < 0,01) y del grado de resolución del problema (p < 0,05) y generó un menor número de consultas médicas posteriores (p < 0,05). Conclusiones: Es posible derivar sin visita previa a un porcentaje sustancial de pacientes que consultan por situaciones menores desde una UUM del SUH a un centro externo, sin que ello signifique un riesgo para ellos. Estos pacientes muestran mayor satisfacción con un modelo en el que el centro externo depende del propio hospital que con uno en que el centro externo sea el propio centro de asistencia primaria

Background and objective: After triage assessment, some hospitals refer emergency department (ED) patients with minor chief complaints to off-site clinics. The potential for 2 different referral models introduced in 2 urban hospitals was assessed, as well as the suitability of this measure. Patients and method: After triage assessment, patients with minor complaints were identified. ED from Hospital Clínic of Barcelona (HCB) proposed that these patients should be referred to a hospital affiliated off-site clinic, whereas ED from Hospital Mútua de Terrassa (HMT) tried to refer such patients to their primary care setting. Within a year, we assessed on both ED the following items: number of arrivals, percentage of proposed referrals (PR), percentage of accepted referrals (AR), percentage of carried-out referrals (CR: patients who, once discharged, really attended the other setting), and percentage of returned referrals (RR) to the ED, as well as return reasons, and the percentage of returned patients finally admitted. The degree of patient satisfaction was evaluated by means of a telephone survey. Results: From both ED, 44,764 arrivals and 7,297 (16.3%) PR were registered. The percentage of AR and CR was 94.3% and 75.3%, respectively. The percentage of PR from HMT was higher (18.7% vs 13.1%; p < 0.001), yet HCB obtained a greater percentage of AR (98.9% vs 92%, p < 0.001) and CR (93.7% vs 65%; p < 0.001). The percentage of RR from both ED was 1.5% (2.8% vs 0.4%; p < 0.001). Among returned patients, 12 of them (0.17% respect to AR) were finally admitted. Only 41% of patients who were found to be eligible for direct discharge would have agreed with being referred to another clinical setting, but after the experience, up to 93% of them said they would go through it again. HMT gave referral information to patients faster than HCB (p < 0.05), but HCB got a better model evaluation (p < 0.01), a greater medical complaint solution (p < 0.05), and generated a smaller number of subsequent consultations (p < 0.05). Conclusions: After a rapid triage assessment, a percentage of patients arriving on EDs may be directly and safely discharged and referred to other clinical settings. This is achieved by both proposed models without additional risks for patients. However, patients feel more satisfied with an hospital-affiliated off-site clinic instead of their primary care setting

[Emergency department activity during the 2003 summer heat wave]. / Impacto de la ola de calor del verano de 2003 en la actividad de un servicio de urgencias hospitalario.

BACKGROUND AND OBJECTIVE: Several thousands deaths were attributed to a heatwave during the summer of 2003 in Europe. The aim of this study was to analyze its consequences in an emergency department. PATIENTS AND METHOD: We performed a descriptive observational study of the patients admitted to our emergency unit between 15 July and 31 August, 2003. We also carried out a comparative study of these patients with those admitted during the same period of 2002. RESULTS: A total of 5197 patients were admitted in our unit during the summer of 2003, in comparison with 4672 in the same interval in 2002. An increase in rates of total fever (17% versus 12%; p < 0.001), non-infectious fever (29% versus 26%; p < 0.001), decompensation of a chronic cardiovascular or respiratory disease (14% versus 11%; p < 0.001), admission (28% versus 22%; p < 0.001), and mortality (2% versus 1%; p < 0.001) were registered during the summer of 2003, in comparison with the previous year. A multivariate study showed a higher risk of death in patients older than 70 years (p < 0.01), in fragile dependent people (p < 0.05), and upon the presence of abnormal blood levels of creatinine (p < 0.05) on arrival at the emergency department. We also found an association between daily maxim temperature and number of daily emergency visits (R2 = 0.15; p < 0.001), total percentage of patients with fever (R2 = 0.26; p < 0.001), percentage of patients with non-infectious fever (R2 = 0.07; p = 0.01), percentage of decreases (R2 = 0.04; p < 0.05), and percentage of hospital admissions (R2 = 0.15; p < 0.001). CONCLUSIONS: The summer 2003 heatwave resulted in an elevation of the total number of emergency visits and hospital admissions, and higher mortality and morbidity rates, especially in old people. In the future, preventive measures must be taken to limit the health consequences of any heatwaves to come.

Impacto de la ola de calor del verano de 2003 en la actividad de un servicio de urgencias hospitalario / Emergency department activity during the 2003 summer heat wave

Fundamento y objetivo: Durante la ola de calor del verano de 2003 se registraron varios miles de fallecimientos en Europa. Se analizan las consecuencias de esta ola de calor en una sección de urgencias de medicina de un servicio de urgencias hospitalario. Pacientes y método: Estudio descriptivo de las características de los pacientes visitados en una sección de urgencias de medicina entre el 15 de julio y el 31 de agosto de 2003, y se compara con las de los que fueron atendidos durante el mismo intervalo en 2002. Resultados: El número total de pacientes atendidos en el verano de 2003 fue de 5.197, frente a los 4.672 del año anterior. Durante 2003 aumentó, con respecto al año 2002, el porcentaje total de pacientes con fiebre (el 17 frente al 12%; p < 0,001), fiebre de causa no infecciosa (el 29 frente al 26%; p < 0,001), descompensación de enfermedad crónica (el 14 frente al 11%; p < 0,001), ingresados (el 28 frente al 22%; p < 0,001) y fallecidos (el 2 frente al 1%; p < 0,001). Los factores predictivos independientes de mortalidad para los pacientes con fiebre visitados durante la ola de calor de 2003 fueron la edad superior a 70 años (p < 0,01), la dependencia para las actividades de la vida diaria (p < 0,05) y la alteración de las concentraciones de creatinina a su llegada a urgencias (p < 0,05). Además, encontramos una asociación lineal con significación estadística entre la temperatura máxima diaria y el número de visitas diarias a urgencias (R2 = 0,15; p < 0,001), así como con el porcentaje total de pacientes que se visitaron por fiebre (R2 = 0,26; p < 0,001), fiebre de causa no infecciosa (R2 = 0,07; p = 0,01), fallecidos (R2 = 0,04; p < 0,05) e ingresados (R2 = 0,15; p < 0,001). Conclusiones: Durante la ola de calor del verano de 2003 se produjo un aumento del número de visitas a urgencias y de ingresos hospitalarios, así como una mayor tasa de morbimortalidad, especialmente en las personas de edad avanzada. Las autoridades sanitarias deberían llevar a cabo medidas preventivas para limitar las consecuencias sobre la salud pública que pudieran derivarse de futuras olas de calor

Background and objective: Several thousands deaths were attributed to a heatwave during the summer of 2003 in Europe. The aim of this study was to analyze its consequences in an emergency department. Patients and method: We performed a descriptive observational study of the patients admitted to our emergency unit between 15 July and 31 August, 2003. We also carried out a comparative study of these patients with those admitted during the same period of 2002. Results: A total of 5197 patients were admitted in our unit during the summer of 2003, in comparison with 4672 in the same interval in 2002. An increase in rates of total fever (17% versus 12%; p < 0.001), non-infectious fever (29% versus 26%; p < 0.001), decompensation of a chronic cardiovascular or respiratory disease (14% versus 11%; p < 0.001), admission (28% versus 22%; p < 0.001), and mortality (2% versus 1%; p < 0.001) were registered during the summer of 2003, in comparison with the previous year. A multivariate study showed a higher risk of death in patients older than 70 years (p < 0.01), in fragile dependent people (p < 0.05), and upon the presence of abnormal blood levels of creatinine (p < 0.05) on arrival at the emergency department. We also found an association between daily maxim temperature and number of daily emergency visits (R2 = 0.15; p < 0.001), total percentage of patients with fever (R2 = 0.26; p < 0.001), percentage of patients with non-infectious fever (R2 = 0.07; p = 0.01), percentage of deceases (R2 = 0.04; p < 0.05), and percentage of hospital admissions (R2 = 0.15; p < 0.001). Conclusions: The summer 2003 heatwave resulted in an elevation of the total number of emergency visits and hospital admissions, and higher mortality and morbility rates, especially in old people. In the future, preventive measures must be taken to limit the health consequences of any heatwaves to come

Extracorporeal albumin dialysis: a procedure for prolonged relief of intractable pruritus in patients with primary biliary cirrhosis.

BACKGROUND AND AIMS: Pruritus is a distressing symptom in patients with primary biliary cirrhosis, and when uncontrollable it is an indication for liver transplantation. Since pruritus can result from unknown substances that accumulate systemically as a consequence of impaired biliary secretion, we have assessed whether a new extracorporeal albumin dialysis (ECAD) procedure, the molecular-adsorbing recirculating system-MARS, has any effect on pruritus of cholestasis. METHODS: Four patients with primary biliary cirrhosis and resistant pruritus were treated with two 7-h ECAD sessions 1 day apart. Pruritus was recorded from 15 days before the first session, before and after each session, and during the follow-up using a visual analogue scale (VAS). Standard liver tests as well as serum bile acid levels were also measured. RESULTS: There was a clear association between ECAD treatment and relief of itching, which promptly disappeared in two patients, or decreased markedly in the other two. One patient was free of pruritus for 18 months except for short periods with mild pruritus. The second patient experienced amelioration of itching, which almost disappeared completely and recurred mildly 4 months later. In the other two patients pruritus was alleviated markedly after ECAD but gradually recurred. These two patients were treated again 9 and 7 months later with favorable effects on pruritus. The scratching skin lesions improved or disappeared in parallel with the alleviation of itching. The albumin dialysis procedure did not result in liver test changes, except for circulating bile acids, which decreased in all the patients. No significant adverse effects were observed. CONCLUSIONS: The ECAD procedure seems to be an effective alternative for the treatment of patients with pruritus of cholestasis who do not respond to other therapeutic methods.