Diseño y validación del Índice de Evaluación de Casos Complejos (IECC), un instrumento para identificar pacientes complejos / Design and validation of the Complex Case Evaluation Index, an instrument to identify complex patients

Fundamento: Desarrollar y validar un instrumento específico de identificación de pacientes complejos, elÍndice de Evaluación de Casos Complejos (IECC). Métodos: Estudio instrumental con dos fases: 1) Elaboración del instrumento: se definieron y operacionalizaronlas variables extraídas de la literatura que, posteriormente, fueron sometidas al juicio de expertos. El IECCincluyó catorce variables divididas en dos dimensiones:complejidad del manejo clínico y complejidad del manejo comunitario. 2) Estudio psicométrico: evaluaciónde la fiabilidad por equivalencia entre observadores (rPearson), de la validez de criterio respecto al sistema declasificación Clinical Risk Groups (CRG) y de la validezde constructo a través de grupos conocidos y a travésdel estudio de conglomerados jerárquicos. Los análisisse realizaron con el paquete estadístico SPSS.v.17. Resultados: La fiabilidad entre observadores para lasubescala clínica fue r = 0,97, para la subescala comunitaria r = 0,74 y para la puntuación total r = 0,89. El 88,4%(n = 458) de los 518 casos identificados como complejospor el IECC fueron categorizados por el sistema CRG enlas categorías de más complejidad clínica (niveles 6 a9). Los resultados sustentan la validez de constructode la escala. El análisis de conglomerados mostró dosclusters diferentes, aunque relacionados. Conclusión: El IECC es un índice breve y de fácil aplicación, con una buena adecuación conceptual y evidencias de su fiabilidad y validez dirigido a la detección depacientes con necesidades complejas.(AU)

Background: The aim was to develop and validate theComplex Case Assessment Index (CCAI), a specific instrument to identify complex patients. Methods: Instrumental study in two phases: 1) Development of the scale: the variables extracted from theliterature were firstly defined and operationalized, andthen submitted for expert judgment. The CCAI included14 variables divided into two dimensions: complexity ofclinical management and complexity of community management. 2) Psychometric study: evaluation of the reliability and validity of the scale by equivalence betweenobservers (Pearson’s r), criterion validity with respect tothe Clinical Risk Groups (CRG) classification system, andconstruct validity through known groups and study ofhierarchical clusters were examined. The analyses werecarried out with the SPSS version 17 statistical package. Results: Reliability by equivalence between observers was r = 0.97 for the clinical subscale, r = 0.74 for thecommunity subscale, and r = 0.89 for the total score.The CCAI identified 518 cases as complex; 458 of them(88.4%) were categorized by the CRG system in the categories of greatest clinical complexity (levels 6 to 9).The results support the construct validity of the scale.The cluster analysis showed two different, although related, clusters. Conclusion: The CCAI is a fast and easy-to-use index,with good conceptual adequacy and evidence of reliability and validity for screening patients with complexneeds.(AU)

Asociación entre eventos adversos en el cuidado de enfermería, cultura de seguridad y complejidad de pacientes en un hospital chileno

RESUMEN Objetivo: Determinar asociación entre cultura de seguridad, complejidad de pacientes e incidencia de eventos adversos (EA) asociados al cuidado de enfermería en un hospital chileno de alta complejidad. Material y Método: Estudio transversal, cuantitativo, analítico y diseño ecológico, que en 869 reportes midió los EA ocurridos entre 2014 y 2017. Se midió la cultura de seguridad con el total de enfermeros/as (95) a través del Cuestionario sobre Seguridad de los Pacientes, versión española adaptada de Hospital Survey on Patient Safety Culture, encuesta original de la Agency for Healthcare Research and Quality (AHRQ), de los Estados Unidos; la complejidad del paciente se midió según datos del Grupo Relacionado de Diagnósticos (GRD). El análisis consideró estadística descriptiva y correlaciones de Spearman y regresiones logísticas entre incidencia de EA ajustada a complejidad y cultura de seguridad. Resultados: La media de la percepción de seguridad global fue de 7,69 puntos; las dimensiones 4 (aprendizaje organizacional/mejora continua) y 5 (trabajo en equipo en la unidad/servicio) son consideradas fortalezas; la dimensión 9 (dotación de personal) una oportunidad de mejora; los servicios de mayor complejidad presentan mayor incidencia de EA y mayor cultura de seguridad; existe asociación lineal entre incidencia de EA ajustada a complejidad y clima de seguridad global (coeficiente beta=-5,11; p valor 0,004; IC 1,65-8,5). Conclusiones: Se confirma la asociación entre eventos adversos con cultura de seguridad y complejidad del cuidado. La mayor incidencia de EA se debe al mayor número de reportes y no a su mayor ocurrencia. Las instituciones de salud deben promover estrategias que incrementen el nivel de cultura de seguridad para mejorar los cuidados de enfermería y la calidad en salud.

ABSTRACT Objective: To determine the association between safety culture, the degree of complexity of the patients and the incidence of adverse events associated with nursing care in a Chilean hospital. Method: Cross-seccional study, with a quantitative approach, analytical and ecological design, which in 869 reports measured AE that occurred between 2014 - 2017. Safety culture was measured with the total number of nurses (95) through the Patient Safety Questionnaire, a Spanish version adapted from the Hospital Survey on Patient Safety Culture, an original survey from the Agency for Healthcare Research and Quality (AHRQ), from the United States; the complexity of the patient was measured according to data from the Related Group of Diagnoses (DRG). The analysis considered descriptive statistics and Spearman correlations and logistic regressions between AD incidence adjusted for complexity and safety culture. Results: The mean global security perception was 7.69 points; Dimensions 4 (organizational learning / continuous improvement) and 5 (teamwork in the unit / service) are considered strengths; dimension 9 (staffing) with opportunity for improvement; more complex services have a higher incidence of AE and a higher safety culture; There is a linear association between the incidence of AD adjusted to complexity and the global security climate (beta coefficient = -5.11; p value 0.004; CI 1.65 and 8.5). Conclusions: The association between quality culture, complexity of care and adverse events is confirmed. The higher incidence of AE is due to the greater number of reports and not to its greater occurrence. Health institutions must promote and implement strategies to increase the safety culture level in nursing personnel to improve the delivery of quality care in health.

RESUMO Objetivo: Determinar a associação entre cultura de segurança, complexidade do paciente e incidência de eventos adversos (EA) associados à assistência de enfermagem em um hospital chileno de alta complexidade. Material e Método: Estudo transversal, quantitativo, analítico e de desenho ecológico, que em 869 relatórios mediu EA ocorridos entre 2014-2017. A cultura de segurança foi medida com todos os enfermeiros (95) por meio do Questionnaire, versão em espanhol adaptada do Hospital Survey on Patient Safety Culture, pesquisa original da Agência dos Estados Unidos para Pesquisa e Qualidade em Saúde (AHRQ), a complexidade do paciente foi medida de acordo com dados do Related Group of Diagnoses (DRG). A análise considerou estatísticas descritivas e correlações de Spearman e regressões logísticas entre a incidência de DA ajustada para complexidade e cultura de segurança. Resultados: A percepção de segurança global média foi de 7,69 pontos; As dimensões 4 (aprendizagem organizacional / melhoria contínua) e 5 (trabalho em equipe na unidade / serviço) são consideradas pontos fortes; dimensão 9 (pessoal) com oportunidade de melhoria; serviços mais complexos apresentam maior incidência de EA e maior cultura de segurança; Existe uma associação linear entre a incidência de DA ajustada à complexidade e clima de segurança global (coeficiente beta = -5,11; valor de p 0,004; IC 1.65 e 8.5). Conclusões: Confirma-se a associação entre cultura de qualidade, complexidade do atendimento e eventos adversos. A maior incidência de EA se deve ao maior número de notificações e não à sua maior ocorrência. As instituições de saúde devem promover e implementar estratégias que aumentem o nível de cultura de segurança no pessoal de enfermagem para melhorar a prestação de cuidados e a qualidade em saúde.

[Description of the clinical complexity of patients admitted to long term care hospitals in Catalonia during 2003-2009]. / Descripción del perfil de complejidad de los pacientes admitidos en unidades sociosanitarias de larga estancia entre los años 2003 y 2009.

INTRODUCTION: This work describes the clinical complexity of patients admitted to long term care hospitals between 2003 and 2009. MATERIAL AND METHODS: Cross-sectional analysis of Minimum Basic Dataset for Social and Healthcare Units information system data for 47,855 admissions. Outcomes assessed were functional and cognitive status, Resource Utilization Groups III (RUG-III), resource use categories, coverage and intensity of therapies, diagnosis, comorbidities, and medical procedures. Descriptive analyses were performed by year of admission. RESULTS: Dementia and acute cerebrovascular disease were the most frequent primary diagnoses, and showed a steady decline over time (8.8% and 2.3% decline), while family respite admissions and fractures increased (7.7% and 1.9%, respectively). The average functional and cognitive status of the treated population was similar across all years, although individuals with dependence in each Activity of Daily Living increased. The most frequent resource use categories were rehabilitation, reduced physical function, clinically complex care, and special care. A sharp increase in rehabilitation was observed during the study period (20.3%), while the other categories decreased. Increasingly more patients received rehabilitation therapy during their hospital stay (20.8%). Coverage increased particularly for physiotherapy (25.4%) and occupational therapy (17.4%). CONCLUSION: The clinical complexity faced by long term care hospitals increased during 2003- 2009. The use of resources and provision of therapies show an increasing rehabilitation effort, possibly as a response to changes in the clinical complexity of the treated population, the standards of care, or the established information reporting practices.