Miquel Sánchez

Analysis of patient flow in the emergency department and the effect of an extensive reorganisation.

Objectives: To evaluate the different internal factors influencing patient flow, effectiveness, and overcrowding in the emergency department (ED), as well as the effects of ED reorganisation on these indicators. Methods: The study compared measurements at regular intervals of three hours of patient arrivals and patient flow between two comparable periods (from 10 February to 2 March) of 1999 and 2000. In between, a structural and staff reorganisation of ED was undertaken. The main reason for each patient remaining in ED was recorded and allocated to one of four groups: (1) factors related to ED itself ; (2) factors related to ED-hospital interrelation; (3) factors related to hospital itself; and (4) factors related to neither ED nor hospital. The study measured the number of patients waiting to be seen and the waiting time to be seen as effectiveness markers, as well as the percentage of time that ED was overcrowded, as judged by numerical and functional criteria. Results: Effectiveness of ED was closely related with some ED related and hospital related factors. After the reorganisation, patients who remained in ED because of hospital related or non-ED-non-hospital related factors decreased. ED reorganisation reduced the number of patients waiting to be seen from 5.8 to 2.5 (p<0.001) and waiting time from 87 to 24 minutes (p<0.001). Before the reorganisation, 31% and 48% of the time was considered to be overcrowded in numerical and functional terms respectively. After the reorganisation, these figures were reduced to 8% and 15% respectively (p<0.001 for both). Conclusions: ED effectiveness and overcrowding are not only determined by external pressure, but also by internal factors. Measurement of patient flow across ED has proved useful in detecting these factors and in being used to plan an ED reorganisation.

Conocimiento de la enfermedad y del testamento vital en pacientes con insuficiencia cardiaca

Introduccion y objetivos Investigar en pacientes con insuficiencia cardiaca atendidos en urgencias su conocimiento de las posibilidades evolutivas y del testamento vital (TV) y su predisposicion a redactarlo. Metodos Estudio transversal con inclusion prospectiva y consecutiva, multicentrico, sin intervencion. Se consignaron caracteristicas clinico-demograficas de cada paciente y, tras el control de sus sintomas, se realizo una encuesta acerca de aspectos de conocimiento y opinion de su enfermedad. Como variables dependientes, se consideraron tener buen conocimiento objetivo de su enfermedad y la predisposicion a redactar un TV. Se investigaron los factores asociados. Resultados Se incluyo a 309 pacientes: el 79% se consideraba subjetivamente bien informado, el 51,5% lo estaba realmente, el 39,8% desearia mas informacion y el 54,7%, participar mas en la toma de decisiones; el 13,3% sabia en que consistia un TV; al 4,9% su medico le habia informado y el 28,8% se mostraba partidario de redactarlo. Estar objetivamente bien informado y estar dispuesto a redactar un TV se asociaron de forma reciproca e independiente; ademas, con la primera variable se asociaron el ingreso en intensivos, considerarse bien informado y haber participado suficientemente en la toma de decisiones, y con la segunda, tener menos de 75 anos, desear mas informacion, saber en que consiste el TV y el centro de procedencia. Conclusiones El conocimiento de los pacientes con insuficiencia cardiaca respecto a sus posibilidades evolutivas es suboptimo, como tambien lo es su conocimiento del TV y su predisposicion a redactarlo. Debe mejorarse la informacion de estos aspectos como parte esencial de la relacion medico-paciente.

Quality and effectiveness of an emergency department during weekends

Objective: To evaluate whether the quality and effectiveness of an emergency department (ED) are modified during weekends. Methods: Quality and effectiveness markers were determined during 539 consecutive days, comparing them according to the day of the week. Quality markers were the daily percentage of patients who died in the internal medical unit (deaths, D), leave ED without being seen (flights, F); returned to the ED (revisits, R), and the percentage of registered complaints (C). Effectiveness markers were: the “number of patients waiting to be seen” (WP), the “waiting time to be seen” (WT), and the “length of visit” (LV). Results: Quality and effectiveness of ED do not worsen during weekend days and some markers significantly improved during such days: C experienced a 26% decrease (p = 0.001), WT decreased 65% (p<0.001), WP 59% (p<0.001), and LV 24% (p<0.01). Assessing the relation between daily number of visits to ED and the quality and effectiveness markers, a significant and direct association was found of the number of visits with D, F, R, and WP. Conclusion: Some of the quality and effectiveness markers of the ED improved during weekend days compared with workdays.

The utility of copeptin in the emergency department as a predictor of adverse outcomes in non-ST-elevation acute coronary syndrome: the COPED-PAO study

Aims To test the utility of a single copeptin determination at presentation to the emergency department (ED) as a short-term prognosis marker in patients with non-ST-elevation acute coronary syndrome (NSTEACS). To compare the results with those achieved with conventional troponin. Methods A multicentric, prospective, observational, longitudinal, cohort study involving 15 Spanish EDs. Inclusion: consecutive patients with chest pain (<12 h) finally diagnosed of NSTEACS. Measurements: copeptin and troponin at arrival. Cut-off point for copeptin: 25.9 pmol/l. Follow-up: within 2 months after ED attendance to identify 30-day adverse events. Discriminatory capacity of copeptin and troponin was compared by receiver operating characteristic (ROC) curves. Results We included 377 patients with NSTEACS. Adverse events: 11 (2.9%) patients died, 27 (7.2%) had an adverse coronary event, 14 (3.7%) had a stroke, and 48 (12.7%) a composite endpoint. The initial copeptine value was over 25.9 pmol/l in 114 patients, and they presented a higher mortality rate (OR: 4.2, (95% CI 1.2 to 14.8); p=0.03). This association disappeared after adjusting by clinical variables or troponin level. No significant differences were found for the remaining endpoints. The area under the curve of the ROC curve of 30-day mortality was 0.73 (95% CI 0.58 to 0.87) for copeptin, and 0.80 (95% CI 0.73 to 0.87) for troponin. Conclusions In patients with NSTEACS, determination of copeptin at presentation to the ED is associated with risk of death during the subsequent month. This association, however, disappears after adjusting by baseline features or troponin level, so copeptin does not add complementary prognostic information over that provided by troponin.

Comparación del manejo del infarto de miocardio sin elevación del ST durante la asistencia urgente en función del sexo del paciente

The atypical characteristics of acute coronary syndrome in women lead to differences in management and treatment. We investigated these differences in the urgent management of non-ST-segment acute myocardial infarction (NSTEMI). Data on 39 variables were collected from 539 patients with NSTEMI treated at 97 Spanish emergency departments. After adjustment for 10 baseline differences, the only significant differences were that time-to-arrival at the emergency department was longer for women (odds ratio [OR]=0.52; 95% confidence interval [CI], 0.28-0.95) and that they received more clopidogrel (OR=1.65; 95% CI, 1.06-2.56). The trend to fewer admissions to coronary or intensive care units (42.9% vs 55.6%) and fewer catheterization procedures (29.7% vs 40.7%) disappeared after adjustment. We conclude that there are virtually no differences in treatment in women with N-STEMI in prehospital and emergency care.

Comentarios acerca del documento de voluntades anticipadas

Navarro-Bravo et al han publicado recientemente en Atención Primaria un trabajo en el que demuestran que tanto los médicos de atención primaria como las personas mayores, no disponen de información suficiente sobre el documento de voluntades anticipadas (DVA) y recomiendan que, para mejorar esta situación, debieran realizarse campañas informativas y/o actividades de formación específicas que constituyeran una alternativa a las consultas de atención primaria1. Coincidimos con los autores en que la población española en general y la de los pacientes mayores en particular se encuentran poco informadas respecto a los DVA. Nuestra experiencia nos permite aportar algún dato cuantitativo que refuerza las apreciaciones de Navarro-Bravo et al. Hemos comprobado repetidamente cómo más del 40% de los pacientes con enfermedades crónicas que consultan a un servicio de urgencias hospitalario (SUH) no están bien informados sobre la cronicidad y el carácter evolutivo de su enfermedad. Además, el conocimiento del DVA está presente en menos del 25% de ellos2—4, pese a ser este un subgrupo de población en el que cabría esperar un mayor conocimiento y utilización de los mismos. Y algo parecido hemos observado en las personas que acompañan al paciente durante su consulta al SUH. Esta situación, además, no parece haber mejorado, ni en estos pacientes ni en sus acompañantes, durante los últimos 8 años5. Coincidimos también con Navarro-Bravo et al en que es preciso poner en marcha campañas y programas transversales de gran alcance para que la información llegue a segmentos más amplios de la población. Sin embargo, no creemos que los médicos que habitualmente controlan a pacientes con enfermedades crónicas evolutivas, ya sea en atención primaria o especializada, ya sea en el centro de salud o de consultas externas hospitalarias, puedan ignorar el abordaje de forma abierta con el paciente y sus familiares del pronóstico de la enfermedad, sus posibilidades evolutivas y los DVA. No parece justo tener que hacerlo en el SUH, un lugar con espacios limitados, problemas de saturación frecuentes,