Ruth Ester Assayag Batista

Nursing care based on risk assessment and classification: agreement between nurses and the institutional protocol

OBJECTIVE to verify the degree of agreement between the levels of priority given by baccalaureate nurses in care based on risk assessment and classification and the institutional protocol, and also among peers. METHOD descriptive study, using a questionnaire with thirty fictitious clinical cases based on the institutional protocol, which is considered the gold standard, answered by twenty baccalaureate nurses. RESULTS the agreement analysis through the Kappa Coefficient concluded that the agreement between baccalaureate nurses and the institutional protocol in relation to prioritizing the levels of severity was moderate. When the agreement among peers was evaluated, it was low, as represented by the colorimetric density in shades of light gray. CONCLUSION in Brazil, some institutions have developed their own protocol, which makes it necessary to develop tools in order to evaluate the accuracy of professionals in relation to the protocols, highlighting the need for capable people to perform this activity, thus contributing to patient safety.Objetivo: verificar el grado de concordancia entre los niveles de prioridad atribuidos en el acogimiento con evaluacion y clasificacion de riesgo cuando efectuado por los enfermeros, en comparacion con el protocolo institucional y entre los pares. Metodo: estudio descriptivo, utilizando un cuestionario con treinta casos clinicos ficticios, basado en el protocolo institucional, considerado la regla de oro, respondido por veinte enfermeros. Resultados: el analisis de concordancia a traves del Coeficiente Kappa concluyo que la concordancia entre la priorizacion de los niveles de gravedad entre los enfermeros y el protocolo institucional fue moderada. La concordancia entre los pares fue baja, representada por la densidad colorimetrica en las tonalidades de gris claro. Conclusion: en Brasil, algunas instituciones desarrollaron protocolos propios, lo que hace fundamental el desarrollo de herramientas para evaluar la precision de los profesionales respecto a los protocolos, evidenciando las necesidades de capacitacion para esta actividad, contribuyendo a la seguridad del paciente.

Admission-specific chronic disease scores as alternative predictors of surgical site infection for patients undergoing coronary artery bypass graft surgery

OBJECTIVE To evaluate the admission chronic disease score (ACDS) and a variant of the ACDS as predictors of surgical site infection (SSI) for study participants who underwent coronary artery bypass graft (CABG) surgery. DESIGN Retrospective case-control study. SETTING A 750-bed academic medical center. PARTICIPANTS All participants with an SSI that was identified through hospital-based surveillance (defined as case patients) and a random sample of participants without SSI following CABG surgery (defined as control subjects) between July 1, 1999, and June 30, 2001. RESULTS An ACDS based on medications ordered on the day of hospital admission was determined for 264 study participants admitted prior to the day of the surgical procedure. A preadmission chronic disease score (PACDS) based on outpatient medications was calculated for 281 participants, using the record of preadmission medications in the patients discharge summary. The ACDS and PACDS were significantly higher for case patients, compared with control subjects (P=.03 and P=.05, respectively). American Society of Anesthesiologists (ASA) score and the standard National Nosocomial Infection Surveillance system (NNIS) risk index were not significant predictors of SSI. In logistic regression models, only the ACDS (odds ratio, 1.02 per 100 ACDS points), the PACDS (odds ratio, 1.02 per 100 PACDS points), the highest PACDS quintile (odds ratio, 2.89 [compared with lowest quintile]), and a modified NNIS-PACDS score of 2 (odds ratio, 3.5 [compared with a score of 0]) were significant predictors of SSI. CONCLUSIONS Because preoperative medications are likely to reflect comorbidities that influence the risk of SSI, medication-based scoring systems such as the ACDS and PACDS may allow for better risk stratification than the standard NNIS risk index, particularly for patient populations with relatively homogenous wound classification and ASA score distributions.

Risk factors for catheter-related bloodstream infection: a prospective multicenter study in Brazilian intensive care units

INTRODUCTION Central venous catheters (CVC) are devices of great importance in health care. The advantages gained from the use of catheters outweigh the complications that might result from their use, among which bloodstream infections (BSI). In spite of its importance, few national studies have addressed this issue. OBJECTIVE The aim this study was to determine the incidence of BSI in patients with CVC, hospitalized in ICU, as well as the variables associated with this complication. METHODS Multicentric cohort study carried out at ICUs of three hospitals at Universidade Federal de São Paulo complex. RESULTS A total of 118 cases of BSI in 11.546 catheters day were observed: 10.22 BSI per 1,000 catheters day. On average, BSI was associated to seven additional days of hospital stay in our study (p < 0.001), with a significant difference between types of catheters. Concerning the place of insertion, there was no statistical difference in BSI rates. CONCLUSION We concluded that a patient who uses a catheter for longer than 13 days presents a progressive risk for infection of approximately three times higher in relation to a patient who uses the catheter for less than 13 days (p < 0.001). The median duration of catheter use was 14 days among patients with BSI and 9 days in patients without infection (p < 0.001). There was higher prevalence of gram-negative infections. The risk factors for BSI were utilization of multiple-lumen catheters, duration of catheterization and ICU length of stay.

Triage at the Emergency Department: association between triage levels and patient outcome

OBJETIVOIdentificar a associacao entre variaveis sociodemograficas, clinicas e categorias de triagem com desfechos do protocolo desenvolvido no Hospital Sao Paulo (HSP).METODOEstudo de coorte retrospectivo realizado com pacientes maiores de 18 anos submetidos ao protocolo de triagem em agosto de 2012. Utilizou-se regressao logistica para associar as categorias de risco aos desfechos (p-valor≤0,05).RESULTADOSHomens com idade mais avancada e atendidos pelas especialidades clinicas apresentaram maiores taxas de internacao e obito. Pacientes com alta prioridade apresentaram taxa de internacao e obitos cinco e 10,6 vezes maior, respectivamente (p<0,0001).CONCLUSAOO grupo de maior prioridade associou-se a maiores taxas de internacao e obitos. O protocolo foi capaz de detectar pacientes com condicoes mais urgentes e identificar fatores de risco para internacao hospitalar e obito.OBJECTIVE Identify association between sociodemographic, clinical and triage categories with protocol outcomes developed at Hospital São Paulo (HSP). METHODS Retrospective cohort study conducted with patients older than 18 years submitted to the triage protocol in August 2012. Logistic regression was used to associate the risk categories to outcomes (p-value ≤0,05). RESULTS Men with older age and those treated in clinical specialties had higher rates of hospitalization and death. Patients in the high-priority group had hospitalization and mortality rates five and 10.6 times, respectively (p < 0.0001). CONCLUSION The high-priority group experienced higher hospitalization and mortality rates. The protocol was able to detect patients with more urgent conditions and to identify risk factors for hospitalization and death.

Capacidade funcional e a gravidade do trauma em idosos

OBJECTIVE: Correlate functional capacity in elderly people with the severity of the trauma and compare it before and after the trauma. METHODS: Prospective observational study conducted in an emergency department, comprised of 55 elderly people, age 60 and over, of both sexes, who suffered trauma. The incapacity of patients with functional limitations of various origins was assessed. The research instruments applied at three different times were: the Functional Independence Measure and the Injury Severity Score to assess the severity of the trauma. RESULTS: Functional capacity within 48 hours of the trauma was significantly higher than functional capacity at discharge and after one month. The lower the severity of the trauma was the greater the functional capacity of the aged. CONCLUSION: The functional capacity of the elderly deteriorated during the time of hospital stay and one month after discharge.

Infecção ou colonização por micro-organismos resistentes: identificação de preditores

OBJETIVO: Identificar os fatores preditores de infeccao ou colonizacao por micro-organismos resistentes. METODOS: Foi realizado estudo quantitativo de coorte prospectivo. Foram realizadas a analise descritiva, para conhecimento da populacao do estudo, e a analise discriminante, para identificacao dos fatores preditores. RESULTADOS: Foram incluidos 85 pacientes com infeccoes por micro-organismos resistentes: Pseudomonas aeruginosas resistente aos carbapenemicos (24,7%), Acinetobacter resistente aos carbapenemicos (21,2%), Staphylococcus aureus resistente a meticilina (25,9%), Enterococcus spp. resistente a vancomicina (17,6%) e Klebsiella pneumoniae resistente aos carbapenemicos (10,6%). A analise discriminante identificou transferencias de outros hospitais e internacao na Unidade de Terapia Intensiva como fatores preditores para ocorrencia de infeccao pelos grupos S. aureus resistente a meticilina, Acinetobacter resistente aos carbapenemicos e K. pneumoniae resistente aos carbapenemicos. Nenhuma das variaveis estudadas foi discriminante para Enterococcus spp. resistente a vancomicina e P. aeruginosas resistente aos carbapenemico. CONCLUSAO: Os fatores preditores encontrados foram: internacao na UTI e a transferencias de outros hospitais.

Knowledge and attitudes about sexuality in the elderly with HIV/AIDS

ReSumo Objetivos: Avaliar o conhecimento e atitudes sobre sexualidade em idosos com HIV/AIDS atendidos em ambulatorio especializado; e Identificar o perfil epidemiologico desses pacientes. Metodos: Estudo de corte transversal, descritivo e analitico com amostra de 148 pessoas com 50 anos ou mais. Utilizou-se a Aging Sexual Knowledge and Attitudes Scale para avaliar o conhecimento e atitudes sobre a sexualidade dos idosos. Resultados: Participaram do estudo 148 idosos, sexo masculino (63,5%), solteiro (30,5%), aposentados e pensionistas (53%), classe economica baixa (60%), somente 21% possuiam ate ensino medio completo, renda familiar mensal 3,3 salarios, tempo de diagnostico 156 meses e forma de contagio predominante via sexual (66,2%). Escore da ASKAS de conhecimento foi 32,2 e de atitudes 15,5. Houve associacao significante entre ASKAS conhecimento e genero feminino, ser viuvo e mais de uma comorbidade e ASKAS atitudes com ensino medio completo e atividade fisica. Conclusao: Pacientes com HIV/AIDS demonstraram conhecimento e atitudes favoraveis sobre a sexualidade no idoso, e mulheres donas de casa apresentaram conhecimento significante. Descritores: Envelhecimento; Sexualidade; Sindrome de imunodeficiencia adquirida; Conhecimentos, atitudes e pratica em saudeOBJECTIVES: Assess the knowledge and attitudes about sexuality in the elderly with HIV/AIDS served in a specialized ambulatory clinic; and identify the epidemiological profile of these patients. METHODS: Cross-sectional, descriptive and analytical study with a sample of 148 people aged 50 years and over. The Aging Sexual Knowledge and Attitudes Scale was used to assess the knowledge and the attitudes about sexuality of the elderly. RESULTS: The study included 148 elderly, male gender (63.5%), single (30.5%), retired and pensioners (53%), low socioeconomic class (60%), only 21% have completed the Secondary Education, monthly family income 3.3 minimum wages, time since diagnosis 156 months and predominant form of infection via sexual (66.2%). ASKAS knowledge score was 32.2 and attitudes score was 15.5. There was significant association between the knowledge ASKAS with the female gender, being a widow and more than one comorbidity; and between the attitudes ASKAS with complete Secondary Education and physical activity. CONCLUSION: Patients with HIV/AIDS showed favorable knowledge and attitudes about sexuality in the elderly, and women that were housewives showed significant knowledge.

Factors associated with functional impairment of elderly patients in the emergency departments

ABSTRACT Objective: To assess the functional capacity of elderly patients in the emergency department as to Basic and Instrumental Activities of Daily Living. Methods: A cross-sectional study of 200 elderly patients admitted to the emergency department of a teaching hospital in São Paulo (SP), Brazil. The functional capacity of the elderly was assessed by the Katz index and Lawton & Brody scale. Statistical analyses were performed using analysis of variance, Bonferroni correction, χ2 test, or the likelihood ratio test. Results: Most seniors were independent (65%), and the degree of dependence was related to age, female gender, being single and widowed, and presence of cerebrovascular disease and dementia. The more dependent elderly for Instrumental Activities of Daily Living had increased dependence for Basic Activities. Conclusion: We emphasize the importance of assessing the functional capacity of the elderly in the emergency department as it provides data for the nursing care in order to minimize or to avoid their functional impairment.

Risk factors for morbidity and mortality of bloodstream infection in patients undergoing hemodialysis: a nested case–control study

BackgroundInfection is the leading cause of morbidity and the second most frequent cause of mortality among patients on renal replacement therapy. A major morbid event in this population is hospitalization because of infection. The aim of this study was to investigate the risk factors for morbidity and mortality related to bloodstream infection (BSI) among patients on hemodialysis.ResultsRisk factors for morbidity and mortality related to BSI in patients on hemodialysis were investigated retrospectively by nested case–control, from January 2010 to June 2013. Patients were divided into two groups: those who progressed to hospitalization or death due to BSI (Group 1) and those who developed BSI, but did not progress to the same outcome (Group 2). Data were collected through consultation of patient records. For statistical analysis, logistic regression was used. There were 32 patients in Group 1 and 61 in Group 2. Logistic regression verified that, for each year of age, the chance of death or hospitalization for BSI increased 1.05 times [95% confidence interval (CI): 1.02–1.09]. Patients with BSI caused by Staphylococcus aureus had an 8.67 times higher chance of progressing to death or hospitalization (95% CI: 2.5–30.06). The isolation of multiresistant microorganisms in blood cultures of hemodialysis patients increased morbidity and mortality by 2.75 times (95% CI: 1.01–7.48).ConclusionIndependent risk factors for morbidity and mortality among patients after developing BSI during hemodialysis were: age, blood culture positive for S. aureus, and antibiotic resistance. Control measures to prevent microbial dissemination, primarily the multiresistant ones, should be intensified in this population. More studies are needed to standardize specific measures not yet classically standardized, such as collection of surveillance culture samples, contact precautions, and decolonization.

Nursing staff sizing in the emergency room of a university hospital

OBJECTIVE To verify the adequacy of the professional nursing staff in the emergency room of a university hospital and to evaluate the association between categories of risk classification triage with the Fugulin Patient Classification System. METHOD The classification of patients admitted into the emergency room was performed for 30 consecutive days through the methodology proposed by Gaidzinski for calculating nursing requirements. RESULTS The calculation determines the need for three registered nurses and four non-registered nursing for each six hour shift. However, only one registered nurse and four non-registered nurse were available per shift. There was no correlation between triage risk classification and classification of care by the Fugulin Patient Classification System. CONCLUSION A deficit in professional staff was identified in the emergency room. The specificity of this unit made it difficult to measure. To find the best strategy to do so, further studies should be performed.OBJECTIVE To verify the adequacy of the professional nursing staff in the emergency room of a university hospital and to evaluate the association between categories of risk classification triage with the Fugulin Patient Classification System. METHOD The classification of patients admitted into the emergency room was performed for 30 consecutive days through the methodology proposed by Gaidzinski for calculating nursing requirements. RESULTS The calculation determines the need for three registered nurses and four non-registered nursing for each six hour shift. However, only one registered nurse and four non-registered nurse were available per shift. There was no correlation between triage risk classification and classification of care by the Fugulin Patient Classification System. CONCLUSION A deficit in professional staff was identified in the emergency room. The specificity of this unit made it difficult to measure. To find the best strategy to do so, further studies should be performed.