Cross-cultural adaptation of the SCORE survey and evaluation of the impact of Real-Time Random Safety Audits in organizational culture: A multicenter study.

OBJECTIVE: To establish a cross-cultural adaptation of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and to use this instrument to evaluate the impact of a safety intervention. DESIGN: Cross-cultural adaptation and before-and-after evaluation study. SETTING: 5 ICU. PARTICIPANTS: Medical residents, attending physicians, and nurses at those ICU. INTERVENTIONS: Adaptation of the SCORE survey to Spanish culture. The adapted survey was used to assess all safety-culture-related domains before and one-year after implementing the use of a safety tool, Real-Time Random Safety Audits (in Spanish: Análisis Aleatorios de Seguridad en Tiempo Real, AASTRE). MAIN OUTCOME MEASURE: Adaptabiliy of the Spanish version of SCORE survey in the ICU setting and evaluation of the effect of AASTRE on their domains. RESULTS: The cross-cultural adaptation was adequate. Post-AASTRE survey scores [mean (standard deviation, SD)] were significantly better in the domains learning environment [50.55 (SD 20.62) vs 60.76 (SD 23.66), p<.0001], perception of local leadership [47.98 (SD 23.57) vs 62.82 (SD 27.46), p<.0001], teamwork climate [51.19 (SD 18.55) vs 55.89 (SD 20.25), p=.031], safety climate [45.07 (SD 17.60) vs 50.36 (SD 19.65), p=.01], participation decision making [3 (SD 0.82) vs 3.65 (SD 0.87), p<.0001] and advancement in the organization [3.21 (SD 0.77) vs 4.04 (SD 0.77), p<.0001]. However, post-AASTRE scores were significantly worse in the domains workload and burnout climate. CONCLUSIONS: The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. The application of the AASTRE is associated with improvements in six SCORE domains, including the safety climate.

Cross-cultural adaptation of the SCORE survey and evaluation of the impact of Real-Time Random Safety Audits in organizational culture: A multicenter study.

OBJECTIVE: To establish a cross-cultural adaptation of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and to use this instrument to evaluate the impact of a safety intervention. DESIGN: Cross-cultural adaptation and before-and-after evaluation study. SETTING: 5 ICU. PARTICIPANTS: Medical residents, attending physicians, and nurses at those ICU. INTERVENTIONS: Adaptation of the SCORE survey to Spanish culture. The adapted survey was used to assess all safety-culture-related domains before and one-year after implementing the use of a safety tool, Real-Time Random Safety Audits (in Spanish: Análisis Aleatorios de Seguridad en Tiempo Real, AASTRE). MAIN OUTCOME MEASURE: Adaptabiliy of the Spanish version of SCORE survey in the ICU setting and evaluation of the effect of AASTRE on their domains. RESULTS: The cross-cultural adaptation was adequate. Post-AASTRE survey scores [mean (standard deviation, SD)] were significantly better in the domains learning environment [50.55 (SD 20.62) vs 60.76 (SD 23.66), p<.0001], perception of local leadership [47.98 (SD 23.57) vs 62.82 (SD 27.46), p<.0001], teamwork climate [51.19 (SD 18.55) vs 55.89 (SD 20.25), p=.031], safety climate [45.07 (SD 17.60) vs 50.36 (SD 19.65), p=.01], participation decision making [3 (SD 0.82) vs 3.65 (SD 0.87), p<.0001] and advancement in the organization [3.21 (SD 0.77) vs 4.04 (SD 0.77), p<.0001]. However, post-AASTRE scores were significantly worse in the domains workload and burnout climate. CONCLUSIONS: The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. The application of the AASTRE is associated with improvements in six SCORE domains, including the safety climate.

Relationship between acute kidney injury and serum procalcitonin (PCT) concentration in critically ill patients with influenza infection.

INTRODUCTION: Serum procalcitonin (PCT) concentration could be increased in patients with renal dysfunction in the absence of bacterial infection. OBJECTIVE: To determine the interactions among serum renal biomarkers of acute kidney injury (AKI) and serum PCT concentration, in patients admitted to the intensive care unit (ICU) due to lung influenza infection. DESIGN: Secondary analysis of a prospective multicentre observational study. SETTING: 148 Spanish ICUs. PATIENTS: ICU patients admitted with influenza infection without bacterial co-infection. Clinical, laboratory and hemodynamic variables were recorded. AKI was classified as AKI I or II based on creatinine (Cr) concentrations (≥1.60-2.50mg/dL and Cr≥2.51-3.99mg/dL, respectively). Patients with chronic renal disease, receiving renal replacement treatment or with Cr>4mg/dL were excluded. Spearman's correlation, simple and multiple linear regression analysis were performed. INTERVENTIONS: None. RESULTS: Out of 663 patients included in the study, 52 (8.2%) and 10 (1.6%) developed AKI I and II, respectively. Patients with AKI were significantly older, had more comorbid conditions and were more severally ill. PCT concentrations were higher in patients with AKI (2.62 [0.60-10.0]ng/mL vs. 0.40 [0.13-1.20]ng/mL, p=0.002). Weak correlations between Cr/PCT (rho=0.18) and Urea (U)/PCT (rho=0.19) were identified. Simple linear regression showed poor interaction between Cr/U and PCT concentrations (Cr R2=0.03 and U R2=0.018). Similar results were observed during multiple linear regression analysis (Cr R2=0.046 and U R2=0.013). CONCLUSIONS: Although PCT concentrations were slightly higher in patients with AKI, high PCT concentrations are not explained by AKI and could be warning sign of a potential bacterial infection.

Real-time random safety audits: A transforming tool adapted to new times. / Análisis aleatorios de seguridad en tiempo real, una herramienta transformadora adaptada a los nuevos tiempos.

Real-time random safety audits constitute a tool designed to transfer knowledge from the sources of scientific evidence to the patient bedside. It has proven useful in critically ill patients, improving safety in the process of critical patient care, turning unsafe situations into safe ones in daily practice, and ensuring adherence to scientific evidence. In parallel, the design and methodology involved affords process indicators that will make it possible to know how we provide care for our patients, evolution over time (with regular feedback for professionals), the impact of our interventions, and benchmarking.

Feasibility and utility of the use of real time random safety audits in adult ICU patients: a multicentre study.

PURPOSE: The two aims of this study were first to analyse the feasibility and utility (to improve the care process) of implementing a new real time random safety tool and second to explore the efficacy of this tool in core hospitals (those participating in tool design) versus non-core hospitals. METHODS: This was a prospective study conducted over a period of 4 months in six adult intensive care units (two of which were core hospitals). Safety audits were conducted 3 days per week during the entire study period to determine the efficacy of the 37 safety measures (grouped into ten blocks). In each audit, 50% of patients and 50% of measures were randomized. Feasibility was calculated as the proportion of audits completed over those scheduled and time spent, and utility was defined as the changes in the care process resulting from tool application. RESULTS: A total of 1323 patient-days were analysed. In terms of feasibility, 87.6% of the scheduled audits were completed. The average time spent per audit was 34.5 ± 29 min. Globally, changes in the care process occurred in 5.4% of the measures analysed. In core hospitals, utility was significantly higher in 16 of the 37 measures, all of which were included in good clinical practice guidelines. Most of the clinical changes brought about by the tool occurred in the mechanical ventilation and haemodynamics blocks. Multivariate analyses demonstrated that changes in the care process in each block were associated with the core hospital variable, staffing ratios and severity of patient disease. CONCLUSIONS: Real time safety audits improved the care process and adherence to the clinical practice guidelines and proved to be most useful in situations of high care load and in patients with more severe disease. The effect was greater in core hospitals.

Profound and persistent decrease of circulating dendritic cells is associated with ICU-acquired infection in patients with septic shock.

PURPOSE: Septic shock induces a decrease in dendritic cells (DCs) that may contribute to sepsis-induced immunosuppression. We analyzed the time course of circulating DCs in patients with septic shock and its relation to susceptibility to intensive care unit (ICU)-acquired infections. METHODS: We enrolled adult patients with septic shock (n = 43), non-septic shock (n = 29), and with sepsis without organ dysfunction (n = 16). Healthy controls (n = 16) served as reference. Blood samples were drawn on the day of shock (day 1), then after 3 and 7 days. Myeloid (mDC) and plasmacytoid (pDC) DCs were counted by flow cytometry. Cell surface HLA-DR expression was analyzed in both DC subsets. RESULTS: At day 1, median mDC and pDC counts were dramatically lower in septic shock patients as compared to healthy controls (respectively, 835 mDCs and 178 pDCs/ml vs. 19,342 mDCs and 6,169 pDCs/ml; P < 0.0001) but also to non-septic shock and sepsis patients (P < 0.0001). HLA-DR expression was decreased in both mDCs and pDCS within the septic shock group as compared to healthy controls. DC depletion was sustained for at least 7 days in septic shock patients. Among them, 10/43 developed ICU-acquired infections after a median of 9 [7.5-11] days. At day 7, mDC counts increased in patients devoid of secondary infections, whereas they remained low in those who subsequently developed ICU-acquired infections. CONCLUSION: Septic shock is associated with profound and sustained depletion of circulating DCs. The persistence of low mDC counts is associated with the development of ICU-acquired infections, suggesting that DC depletion is a functional feature of sepsis-induced immunosuppression.

[Dendritic cells in sepsis: an approach to post-infectious immunosuppression]. / Células dendríticas en la sepsis: una aproximación a la inmunosupresión postinfecciosa.

Dendritic cells (DCs) play a decisive role in the immune system, especially in the initial events that determine coordination between the innate and adaptive response. Moreover, they are antigen-presenting cells which, through contact with T cells, determine the type of immune responses towards inflammatory or anti-inflammatory. Currently, the hypothesis that attributes importance to the development of a post-infectious immunosuppression in the prognosis of the septic patient is growing stronger. It has been possible to verify the role played by these cells in this type of immunosuppression by the significant decrease in the number of DCs and by the dysfunctions in the functional capacity that include, on the one hand, the abnormal cytokine production and, on the other hand, the alterations in communication between the DCs and T cells that constitute an essential immunological fact. Further research into the knowledge regarding the DCs, in the context of severe infection, may help to consolidate some encouraging data that indicate these cells as: 1) an effective tool for monitoring the acute infection, 2) a discriminatory variable that may help determine the risk of nosocomial infection and 3) in a longer term, a treatment target that would restore the immunological abnormalities that occur in sepsis.

Percutaneous tracheostomy: Ciaglia Blue Rhino versus Griggs' Guide Wire Dilating Forceps. A prospective randomized trial.

BACKGROUND: Percutaneous tracheostomy (PT) has gained widespread acceptance to control the airway in patients requiring prolonged mechanical ventilation. Since 1985, new techniques for PT have been described. It was the aim of this investigation to compare two different PT techniques: the Ciaglia Blue Rhino (CBR) and the Guide Wire Dilating Forceps (GWDF). METHODS: A prospective randomized trial was performed in four intensive care units. After informed consent, 53 consecutive patients were randomized to undergo CBR or GWDF. Procedural complications were evaluated and specific symptoms of the upper airway tract in survivors were assessed. RESULTS: Twenty-seven patients were randomly assigned to CBR and 26 to GWDF. Patients mean ages were 62.7 +/- 15.8 years and 62.2 +/- 18.3, respectively. Mean APACHE II scores were 20.6 +/- 6.8 and 21.2 +/- 7.2, respectively. Median duration of the procedure was 7 min (range: 4-17 min) with GWDF and 9 min (range: 5-32 min) with CBR (P = 0.16). Seven patients in the group undergoing GWDF had complications (desaturation: two; mild bleeding: one; infected stoma: one; inability to complete the procedure: three). Two patients had complications in the group undergoing CBR (mild bleeding) (P = 0.07). Survivors were followed up after discharge. Three patients (all of them having undergone GWDF) were symptomatic (two with mild hoarseness and one with a persistent foreign body sensation), but laryngotracheoscopy was negative. CONCLUSIONS: Our results show no differences between both techniques regarding surgical duration or procedural complications. Late symptoms were encountered in three patients undergoing GWDF, however, laryngotracheoscopy failed to document anatomical or functional abnormalities.