Jc Montejo González

Impact on patient outcome of emergency department length of stay prior to ICU admission.

OBJECTIVEnThe favorable evolution of critically ill patients is often dependent on time-sensitive care intervention. The timing of transfer to the intensive care unit (ICU) therefore may be an important determinant of outcomes in critically ill patients. The aim of this study was to analyze the impact upon patient outcome of the length of stay in the Emergency Care Department.nnnDESIGNnA single-center ambispective cohort study was carried out.nnnSETTINGnA general ICU and Emergency Care Department (ED) of a single University Hospital.nnnPATIENTSnWe included 269 patients consecutively transferred to the ICU from the ED over an 18-month period.nnnINTERVENTIONSnPatients were first grouped into different cohorts based on ED length of stay (LOS), and were then divided into two groups: (a) ED LOS ≤5h and (b) ED LOS >5h.nnnVARIABLESnDemographic, diagnostic, length of stay and mortality data were compared among the groups.nnnRESULTSnMedian ED LOS was 277min (IQR 129-622). Patients who developed ICU complications had a longer ED LOS compared to those who did not (349min vs. 209min, p<0.01). A total of 129 patients (48%) had ED LOS >5h. The odds ratio of dying for patients with ED LOS >5h was 2.5 (95% CI 1.3-4.7). Age and sepsis diagnosis were the risk factors associated to prolongation of ED length of stay.nnnCONCLUSIONSnA prolonged ED stay prior to ICU admission is related to the development of time-dependent complications and increased mortality. These findings suggest possible benefit from earlier ICU transfer and the prompt initiation of organ support.

Mejora en la seguridad de un proceso clínico utilizando el análisis modal de fallos y efectos: profilaxis de la enfermedad tromboembólica venosa en pacientes críticos

OBJECTIVEnTo improve critical patient safety in the prevention of venous thromboembolic disease, using failure mode and effects analysis as safety tool.nnnDESIGNnA contemporaneous cohort study covering the period January 2014-March 2015 was made in 4 phases: phase 1) prior to failure mode and effects analysis; phase 2) conduction of mode analysis and implementation of the detected improvements; phase 3) evaluation of outcomes, and phase 4) (post-checklist introduction impact.nnnSETTINGnPatients admitted to the adult polyvalent ICU of a third-level hospital center.nnnPATIENTSnA total of 196 patients, older than 18 years, without thromboembolic disease upon admission to the ICU and with no prior anticoagulant treatment.nnnINTERVENTIONSnA series of interventions were implemented following mode analysis: training, and introduction of a protocol and checklist to increase preventive measures in relation to thromboembolic disease.nnnVARIABLES OF INTERESTnIndication and prescription of venous thrombosis prevention measures before and after introduction of the measures derived from the failure mode and effects analysis.nnnRESULTSnA total of 59, 97 and 40 patients were included in phase 1, 3 and 4, respectively, with an analysis of the percentage of subjects who received thromboprophylaxis. The failure mode and effects analysis was used to detect potential errors associated to a lack of training and protocols referred to thromboembolic disease. An awareness-enhancing campaign was developed, with staff training and the adoption of a protocol for the prevention of venous thromboembolic disease. The prescription of preventive measures increased in the phase 3 group (91.7 vs. 71.2%, P=.001). In the post-checklist group, prophylaxis was prescribed in 97.5% of the patients, with an increase in the indication of dual prophylactic measures (4.7, 6.7 and 41%; P<.05). There were no differences in complications rate associated to the increase in prophylactic measures.nnnCONCLUSIONSnThe failure mode and effects analysis allowed us to identify improvements in the prevention of thromboembolic disease in critical patients. We therefore consider that it may be a useful tool for improving patient safety in different processes.

Estimación de las necesidades de profesionales médicos en los servicios de medicina intensiva

Departments of Critical Care Medicine are characterized by high medical assistance costs and great complexity. Published recommendations on determining the needs of medical staff in the DCCM are based on low levels of evidence and attribute excessive significance to the structural/welfare approach (physician-to-beds ratio), thus generating incomplete and minimalistic information. The Spanish Society of Intensive Care Medicine and Coronary Units established a Technical Committee of experts, the purpose of which was to draft recommendations regarding requirements for medical professionals in the ICU. The Technical Committee defined the following categories: 1) Patient care-related aspects; 2) Activities outside the ICU; 3) Patient safety and clinical management aspects; 4) Teaching; and 5) Research. A subcommittee was established with experts pertaining to each activity category, defining criteria for quantifying the percentage time of the intensivists dedicated to each task, and taking into account occupational category. A quantitative method was applied, the parameters of which were the number of procedures or tasks and the respective estimated indicative times for patient care-related activities within or outside the context of the DCCM, as well as for teaching and research activities. Regarding non-instrumental activities, which are more difficult to evaluate in real time, a matrix of range versus productivity was applied, defining approximate percentages according to occupational category. All activities and indicative times were tabulated, and a spreadsheet was created that modified a previously designed model in order to perform calculations according to the total sum of hours worked and the hours stipulated in the respective work contract. The competencies needed and the tasks which a Department of Critical Care Medicine professional must perform far exceed those of a purely patient care-related character, and cannot be quantified using structural criteria. The method for describing the 5 types of activity, the quantification of specific tasks, the respective times needed for each task, and the generation of a spreadsheet led to the creation of a management instrument.

Relationship between transfusion of packed red blood cells, plasma free hemoglobin and storage time in patients with severe trauma

Transfusion is a treatment in continuing debate and controversy. In recent years, there has been an increased interest about the storage lesions and its possible clinical consequences, and in addition, there has been an increased concern about the effect of the age of packed red blood cells.Methods Prospective, descriptive, observational study on a cohort of patients with severe trauma, that were admitted more than 72 hours in the ICU of Trauma and Emergency of a high complexity hospital, without active bleeding. November 2012 to January 2014. It was measured hemoglobin (hb), hematocrit (hct), plasma free hemoglobin (fhb) by HemoCue, bilirrubin and LDH before and after transfusion of one packed red blood cells. The attending physician determined the transfusion requirement, individually. We collected data about storage and characteristics of packed red blood cells and their age (young blood” if it was less than 14 days and “old blood” if it was more than 14 days). Statistical data were analyzed by SPSS 16.0 considering statistically significant at P < 0.05. Results 34 transfusions were performed, with average threshold of 6.8 ± 0.3 g / dl for hb and 20.3% ± 1.6% for hematocrit. The most common blood group was the group O+ (56% of transfusions). The plasma free hemoglobin average pre-transfusion was 0.13 ± 0.06 g/dl compared to 0.19 ± 0.06 g/dl post-transfusion (p < 0.05). Increasing bilirrubin level was significant too, with a mean value of pre-transfusion 0.88 ± 0.90 mg/dl vs 1.14 ± 1.17 mg/dl post-transfusion. The average pre-transfusion LDH was 371.24 ± 197.75 U/L and posttransfusion was 396.39 ± 199.46 U/L (p = 0.06). These figures vary depending on the age of the blood, with an average increase fhb of 0.057 ± 0.11 g/dl for young blood versus 0.064 ± 0.062 g/dl for old blood (p > 0,05) Hb performance adjusted to body surface is higher in young versus old blood, with an average of 0.91g / dl per kg / m2 ± 0.58 vs 0,51g / dl per kg / m2 ± 0.13 for hb and 2.88% per Kg / m2 ± 1.84 vs 1.57% per Kg / m2 ± 0.52 for hematocrit (p < 0.001).

Venoarterial ecmo as bridge to heart transplantation. a good chance

Methods An observational prospective study was conducted from March 2010 to February 2015. We reviewed the clinical characteristics and evolution of patients who received venoarterial ECMO as bridge to heart transplant. We analyzed demographic variables, underlying cause of CS, complications and global survival. The quantitative variables are presented as mean ± SD or as median and 25 -75 percentile range and as percentage.Veno-arterial extracorporeal membrane oxigenation (VA-ECMO) is a increasingly device used in patients with a refractory cardiogenic shock. The most important decision before the implantation is to establish the best moment and what is the objective on the basis of INTERMACS criteria.

Dynamics of the dosage of citrate-calciuminfusion regimens as anticoagulation in continuous venovenous hemodiafiltration

Methods A descriptive and comparative study about a prospective data basis is made. All the patients with CRRT requirements, admitted in ICU from September 2014 to March 2015 are included. Variables as motive of therapy, daily dosage of the therapy, days of therapy, half-life of systems on the first three days, global half-life of systems, type of anticoagulation, daily mean dosage of citrate-calcium, number of daily changes in these dosages and complications are analysed. The number of changes of citratecalcium and the day of therapy is compared, such as the filter’s length and the kind of anticoagulation.

Pilot study about the incidence of missed injuries after implantation of protocol of tertiary survey in patients with severe trauma

Despite of primary and secondary survey in patients with severe trauma, missed injuries can occur, so some authors consider that the tertiary survey could reduce its incidence.Methods Prospective, descriptive, observational study, in patients with severe trauma (Injury Severity Score (ISS) > 15), who were admitted to the Trauma and Emergency ICU of a high complexity hospital from May 2013 to January 2014. The tertiary survey was performed at 24-48 hours of admission patient and it was conducted by an experienced staff and a resident not involved in the initial patient care. We collected demographic variables, initial Glasgow Coma Score (GCS), Injury Severity Score, hemodynamic status on admission, length of stay in ICU, days of Mechanical Ventilation (MV), complications and mortality. Furthermore, we collected missed injuries and their impact on patients outcomes. Quantitative variables were expressed as mean ± standard deviation. For qualitative variables we used percentages. Statistical data were analyzed by SPSS 16.0 considering statistically significant P < 0.05.

Prophylaxis of thromboembolic disease: patient safety protocoL.

Critically ill patients have a high risk of deep venous thrombosis and pulmonary embolism, which comprise venous thromboembolic disease (VTED). Prevention during critical illness is a widely used quality metric and safety initiative for these patients.Methods We designed a three phases prospective study of patients admitted to a general ICU of a tertiary university hospital. During first 4 months, weekly collection days are established, gathering demographic variables, reason for admission, severity scores, risk factors for hemorrhage and thrombosis as well as VTED prophylactic measures prescribed. Data were analyzed using a Failure Mode and Effects Analysis (FMEA) from which a set of measures were developed and the implementation of a VTED prophylaxis protocol. After that, we collected data during 5 months to compare the effectiveness of the protocol. Finally, a checklist was introduced to facilitated the adherence to these measures. The impact of this checklist was evaluated for 2 more months. All results were analyzed using the SPSS v22.0.0 statistical analysis software.

Use of transcutaneous capnography in critically ILL patients

Assess alveolar ventilation is a routine when patients are mechanically ventilated. Transdermal devices that measure CO2 pressure (PtcCO2) are can be used but should be evaluated in critically ill patients with altered tissue perfusion.Methods A prospective-observational, single-center study was carried out in the medical-surgical intensive care unit (ICU) at university hospital. Population: All patients over 16 years old, who required respiratory support with invasive mechanical ventilation, the measurement of PtcC02 is done by SenTec Digital Monitor and their results were compared with samples of blood gas analysis (PaC02) in patients with different hemodynamic conditions. Study period: June 2014 to December 2014. Demographic and clinical date included reason for admission, body temperature, requirement of vasoactive drugs, neuromuscular blockers and maneuvers using for treat to the refractory hypoxemia such as prone position ventilation and veno-venous extracorporeal membrane oxygenation (ECMOv-v). Statistical analysis of the results was performed using SPSS software version 22. Quantitative variables were expressed as mean and SD. Qualitative variables were expressed as percentages. Agreement between PaC02 and PtcC02 was evaluated using lineal regression analysis. Results A total of 78 samples were analyzed. Mean age was 58 (SD 9.9) years, with an average stay in ICU of 24.8 (SD 13.3) days, the main reason for admission was respiratory distress syndrome (ARDS) with 42.3% of the patients, 24.3% of them were ventilated in prone position and 48.4% received support with ECMO v-v. Mean of PtcC02 vs PaC02 was 54.2 (SD 11.2) mmHg / 55.4 (SD 12.8) mmHg respectively. PtcC02 was highly correlated with PaC02 (r = 0.79; p < 0.001), as determined to by lineal regression analysis. 37.2% of the samples under support with vasoactive drugs did not affect PtcC02 accuracy (r = 0.75; p < 0.001) relative to the PaC02.