[Utility of the AGREE tool for the development and evaluation of clinical protocols: From theory to clinical practice]. / Utilidad del instrumento AGREE para la elaboración y la evaluación de protocolos clínicos: de la teoría a la práctica clínica.

INTRODUCTION AND OBJECTIVE: Clinical protocols are tools for the delivery of optimal and quality healthcare. However, there are often shortcomings in the quality of their design that invalidate their implementation. The aim of this study is to describe a systematic evaluation of clinical protocols, to analyse their quality in order to enable their implementation. MATERIALS AND METHODS: Descriptive study that included the clinical protocols assessed by the Committee of Reviewers of Clinical Practice Recommendations and Health Technologies of a tertiary hospital during 11years of its existence between 2013 and 2023. The AGREE instrument was used to assess the quality of the protocols received, calculating standardised scores by item and domain, and categorising them into: a)excellent (90-100%), b)good (70-89%), c)improvable (50-69%), d)very improvable (30-49%), e)deficient (10-29%), and f)very deficient: 0-9%. RESULTS: Of the 59 documents received by the Commission, 32 were subsidised for AGREE evaluation. The highest scoring domain was «Scope and objective¼, with excellent scores for 29 protocols; the remaining domains had scores ranging from 58.5%-100% for «Rigour in elaboration¼ and 0-100% for «Independence¼. By items, scores ranged from 85.7-100% for «Target users of the protocol are clearly defined¼ to 0-100% for the items «Potential costs of implementing recommendations¼ and «Conflict of interest¼. Of the 32 protocols, 9 were highly recommended, 22 were recommended with modifications/conditions and one was not recommended. CONCLUSIONS: The AGREE tool makes it possible to systematize both the drafting of clinical protocols by the authors and their evaluation by the Clinical Practice Recommendations and Health Technologies Review Committee. This makes it possible to have applicable and quality protocols in our hospital, which results in an improvement in the quality of healthcare.

[Critically ill patient isolation: risk or protection?] / Aislamiento del paciente crítico: ¿riesgo o protección?

INTRODUCTION: Isolation precautions are an effective measure to prevent the spread of multi-resistant microorganisms (MMR). However, its implementation is complex and can increase some risks to the patient. The aim of this study is to determine whether the implementation of isolation precautions increase the risk of patient safety incidents (PSI) in critically ill patients. MATERIAL AND METHODS: A retrospective observational study was conducted involving patients admitted to the ICU of a University Hospital, and that required isolation for more than 48h. Period of study: two years (from 2013/03/01 to 2015/03/31). Data source was the electronic medical record. The tools for evaluation were the Modular Review Form questionnaires (MRF1 and MRF2). An analysis was made of PSI and adverse events (AEs) during periods with and without isolation precautions, including the PSI type, severity, and preventability. RESULTS: The study included a total of 76 patients, 74 of whom had at least one PSI. A total of 798 PSI were detected (511 during isolation period), 599 were a No harm incident (NHI) and 199 were adverse AEs. The most frequent PSIs were associated with medication (316) and patient health care (279). Most of them were moderately or highly preventable. The incidence of PSI during periods with and without isolation was 27.3 (SD 33.8) and 29 (39.6) per 100 patient-days, respectively. CONCLUSIONS: PSIs in ICU are frequent, and the most of them are preventable. The adoption of isolation precautions does not constitute a risk factor for PSI. Improving patient safety culture is essential for an adequate prevention strategy.

[Perception of surgeons on the use of antimicrobial stewardships programs]. / Percepción de los cirujanos acerca de los programas PROA.

INTRODUCTION: The misuse and overuse of antimicrobials can contribute to an increase in antimicrobial resistance, increasing the risk of infections caused by drug-resistant bacteria. Most common surgical pathologies are infectious (either primary or as a complication), often being over-treated. Exploring the perception of surgeons on the use of implementing Antimicrobial stewardship programs (ASPs) is relevant in order to adapt the program to local context. OBJECTIVE: To determine the perception of surgeons on the management of infections and antibiotic (AB) prescription in a General Surgery Department (GSD). METHODS: A cross-sectional and descriptive study was conducted using an anonymous questionnaire that was distributed to assess the aspects related to AB management. RESULTS: A total of 42 questionnaires were completed, with a 65% response rate. The large majority (75%) considered that antimicrobial resistance was an important problem. The main situations considered with medium/high margin of improvement were: time from taking the specimen to receiving the results (70%), use of a wide spectrum AB, and excessive duration (88% and 89%), dose adjustment according to renal function (81%), unnecessary prolongation of intravenous AB treatment (87%) and excessive duration of it (89%), preference for intravenous AB administration until discharge of the patient (73%). There were also difficulties in ASP implementation, as well as established and solid AB patterns (84%) and the heterogeneity of the GSD (84%). CONCLUSIONS: Organisational aspects of the GSD constitute one of the problems to implement the ASPs. A specific multidisciplinary team has been constituted to address different training aspects. This will also serve as a forum of discussion of certain complex patients with difficulties in antibiotic management.

Recommendations of the Working Groups from the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of adult critically ill patients. / Recomendaciones para el tratamiento de los pacientes críticos de los Grupos de Trabajo de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC).

The standardization of the Intensive Care Medicine may improve the management of the adult critically ill patient. However, these strategies have not been widely applied in the Intensive Care Units (ICUs). The aim is to elaborate the recommendations for the standardization of the treatment of critical patients. A panel of experts from the thirteen working groups (WG) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2002 to 2016 was extracted. The clinical evidence was discussed and summarised by the experts in the course of a consensus finding of every WG and finally approved by the WGs after an extensive internal review process that was carried out between December 2015 and December 2016. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and are intended as a guide for the intensivists in the management of critical patients.

[Identification of adverse events in hospitalised influenza patients]. / Identificación de eventos adversos en pacientes hospitalizados por gripe.

OBJECTIVE: To test the inter-observer agreement in identifying adverse events (AE) in patients hospitalized by flu and undergoing precautionary isolation measures. METHODS: Historical cohort study, 50 patients undergoing isolation measures due to flu, and 50 patients without any isolation measures. RESULTS: The AE incidence ranges from 10 to 26% depending on the observer (26% [95%CI: 17.4%-34.60%], 10% [95%CI: 4.12%-15.88%], and 23% [95%CI: 14.75%-31.25%]). It was always lower in the cohort undergoing the isolation measures. This difference is statistically significant when the accurate definition of a case is applied. The agreement as regards the screening was good (higher than 76%; Kappa index between 0.29 and 0.81). The agreement as regards the accurate identification of AE related to care was lower (from 50 to 93.3%, Kappa index from 0.20 to 0.70). CONCLUSIONS: Before performing an epidemiological study on AE, interobserver concordance must be analyzed to improve the accuracy of the results and the validity of the study. Studies have different levels of reliability. Kappa index shows high levels for the screening guide, but not for the identification of AE. Without a good methodology the results achieved, and thus the decisions made from them, cannot be guaranteed. Researchers have to be sure of the method used, which should be as close as possible to the optimal achievable.

Analysis of contributing factors associated to related patients safety incidents in Intensive Care Medicine.

OBJECTIVE: To explore contributing factors (CF) associated to related critical patients safety incidents. DESIGN: SYREC study pos hoc analysis. SETTING: A total of 79 Intensive Care Departments were involved. PATIENTS: The study sample consisted of 1.017 patients; 591 were affected by one or more incidents. MAIN VARIABLES: The CF were categorized according to a proposed model by the National Patient Safety Agency from United Kingdom that was modified. Type, class and severity of the incidents was analyzed. RESULTS: A total 2,965 CF were reported (1,729 were associated to near miss and 1,236 to adverse events). The CF group more frequently reported were related patients factors. Individual factors were reported more frequently in near miss and task related CF in adverse events. CF were reported in all classes of incidents. The majority of CF were reported in the incidents classified such as less serious, even thought CF patients factors were associated to serious incidents. Individual factors were considered like avoidable and patients factors as unavoidable. CONCLUSIONS: The CF group more frequently reported were patient factors and was associated to more severe and unavoidable incidents. By contrast, individual factors were associated to less severe and avoidable incidents. In general, CF most frequently reported were associated to near miss.

[Out of hospital emergencies towards a safety culture]. / Las emergencias extrahospitalarias ante la cultura de seguridad.

OBJECTIVES: The aim of this study is to measure the degree of safety culture (CS) among healthcare professional workers of an out-of-hospital Emergency Medical Service. Most patient safety studies have been conducted in relation to the hospital rather than pre-hospital Emergency Medical Services. The objective is to analyze the dimensions with lower scores in order to plan futures strategies. MATERIAL AND METHODS: A descriptive study using the AHRQ (Agency for Healthcare Research and Quality) questionnaire. The questionnaire was delivered to all healthcare professionals workers of 061 Advanced Life Support Units of Aragón, during the month of August 2013. RESULTS: The response rate was 55%. Main strengths detected: an adequate number of staff (96%), good working conditions (89%), tasks supported from immediate superior (77%), teamwork climate (74%), and non-punitive environment to report adverse events (68%). Areas for improvement: insufficient training in patient safety (53%) and lack of feedback of incidents reported (50%). CONCLUSIONS: The opportunities for improvement identified focus on the training of professionals in order to ensure safer care, while extending the safety culture. Also, the implementation of a system of notification and registration of adverse events in the service is deemed necessary.

[Mortality due to heart involvement in the catastrophic antiphospholipid syndrome]. / Mortalidad por afectación cardiaca en el síndrome antifosfolípido catastrófico.

Catastrophic antiphospolipid syndrome (CAPS) is extremely rare antiphospolipid syndrome (APS) variety associated to higher mortality. When heart involvement appears has worsening pronostic. We reported a CAPS case, possibily afterward sting wasp triggering, with acute heart failure during evolution. The patient died despite angiographic stents, anticoagulation, corticoids and plasmaphereses treatment carried out.

[Middle cerebral artery ischemic stroke presentation of miliar tuberculosis]. / Infarto de la arteria cerebral media como forma de presentación de la tuberculosis miliar.

Presence of central nervous system by extrapulmonary tuberculosis is an infrequent disease specially among non HIV infected patients, and it is associated with poor prognosis and high mortality rates. We report a case with a middle cerebral artery ischemic strocke as a first symptom of miliar tuberculosis.

[A near-miss event. A new approach in the study of adverse events]. / Análisis de los <>. Un nuevo enfoque en el estudio de los acontecimientos adversos.

A near-miss event is defined as an event that could have resulted in an injury, fatality, or property damage if it had not been prevented. Analysis of near-miss events could be an efficient method in the study of adverse events. Reporting of near-misses has many benefits in the study of adverse events since near-misses occur more frequently than adverse events. In addition, as they have no consequences, fear that the professionals involved would have to report them is less. However, up to now, this method has been slow to develop. We present two clinical cases that help to understand the usefulness of the near-miss reporting system.

[Cerebral abscess by Rhodococcus equi in a HIV-negative patient]. / Absceso cerebral por Rhodococcus equi en paciente no VIH.

Rhodococcus equi is an unusual cause of infection in humans. Infection in immunocompetent host is extremely rare. This report describes a case of 57 years old patient Rhodococcus brain and pulmonary infection in a patient who did not have HIV or otherwise immunocompromised (either from disease, immunosuppressive medications, or both). He was admitted in the hospital due to neurological symptoms, and diagnosed after undergoing medical tests (brain CT scan and MR) with an intracranial neoplasia. No other disorders in the physical exploration or laboratory findings, included chest X ray were found. After this, he was admitted in Intensive Care Unit due to a respiratory failure, performing CT lung that showed pulmonary nodules. An stereoataxic brain biopsy was performed due to patient worsening. Pulmonary and brain cultures isolated Rhodococcus equi both. He was treated with intravenous vancomycin, cotrimoxazole and rifampicin. Despite the mortality rate among immunocompetent patients is really uncommon, the patient died.

[Takotsubo cardiomyopathy: transient apical dysfunction of the left ventricle]. / Cardiomiopatía de Takotsubo: disfunción transitoria apical de ventrículo izquierdo.

Transient apical dysfunction syndrome, ballooning or Takotsubo cardiomyopathy is a recently described syndrome. It is a disease with a partially known mechanism, characterized by the morphology adopted by the left ventricle secondary to hypokinesis and dyskinesis of the apical segments and hypercontractibility of the basal segments. In most of the cases published, it is a syndrome with ST segment elevation in the precordial leads, whose presentation form is also thoracic pain or dyspnea, with the possible existence of moderate elevation of cardiac biomarkers. On the contrary to the acute coronary syndrome, patients with left ventricle dysfunction do not have atherothrombotic disease in the coronary arteries. Furthermore, the alterations described have a reversible character. Some diagnostic clinical criteria have been proposed and there is presently some controversy on them and on the complementary examination needed to diagnose it.