Future directions for simulation in healthcare: A critical review.

There was a widespread discontinuation of simulation programs during and after the COVID-19 pandemic. The objective is to explore how to facilitate greater integration of simulation in healthcare organizations. A literature review was conducted in PubMed, MEDES, IBECS and DOCUMED databases. Twenty-three articles published after the pandemic were selected, categorized in seven themes and critically reviewed. In order to consistently and fully integrate simulation into the organizational culture it is recommended to prioritize the development of new strategies that enhance the efficiency and safety of healthcare delivery. And also strategies that enhance the satisfaction and well-being of all stakeholders.

Agricultural products from algal biomass grown in piggery wastewater: A techno-economic analysis.

The intensification of livestock activities lead to an increase in waste generation with high content of nutrients, as is the case of piggery wastewater. However, this type of residue can be used as culture media for algae cultivation in thin-layer cascade photobioreactors to reduce its environment impact and produce a valorizable algal biomass. Biostimulants were produced by enzymatic hydrolysis and ultrasonication of microalgal biomass, using membranes (Scenario 1) or centrifugation (Scenario 2) as harvesting methods. The co-production of biopesticides by solvent extraction was also evaluated using membranes (Scenario 3) or centrifugation (Scenario 4). The four scenarios were analyzed by a technoeconomic assessment estimating the total annualized equivalent cost and the production cost, i.e., the minimum selling price. Centrifugation provided biostimulants approximately 4 times more concentrated than membranes, but with higher expense due to the cost of the centrifuge (contribution of 62.2 % in scenario 2) and the electricity requirements. The biopesticide production resulted the highest contribution to investment cost in scenarios 3 and 4 (34 % and 43 % respectively). The use of membranes was also more advantageous to produce biopesticides, although it was 5 times more diluted than using centrifuge. The biostimulant production cost was 65.5 €/m3 with membranes and 342.6 €/m3 by centrifugation and the biopesticide production cost was 353.7 €/m3 in scenario 3 and 2,122.1 €/m3 in scenario 4. Comparing the treatment of 1 ha of land, the cost of the biostimulant produced in the four scenarios was lower than the commercial one (48.1 %, 22.1 %, 45.1 % and 24.2 % respectively). Finally, using membranes for biomass harvesting allowed economically viable plants with lower capacity and longer distance for biostimulant distribution (up to 300 km) than centrifuge (188 km). The algal biomass valorization for agricultural products production is an environmentally and economically feasible process with the adequate capacity of the plant and distribution distance.

[Interprofessional team training with in situ simulation to improve the quality of cardiopulmonary resuscitation]. / Entrenamiento de equipos interprofesionales con simulación in situ para mejorar la calidad de la reanimación cardiopulmonar.

INTRODUCTION: In situ simulation facilitates training in clinical settings under similar emotional pressure that occurs in real life situations. The objective of the present study was to assess the feasibility, implementation, facilitators self-confidence and teaching challenges of a training program of cardiopulmonary resuscitation through an in situ simulation plan. METHOD: A training program was designed for the facilitators. The number of professionals trained and in situ simulations performed were recorded, as well as the logistical challenges. An ad hoc survey was designed to assess facilitators self-confidence and educational challenge which were classified using the debriefing assessment for simulation in healthcare©. RESULTS: During a period of 3 years, 95 trained facilitators implemented 378 in situ simulations that allowed to train 1281 nursing professionals working at inpatient units. Integration of in situ simulations with daily activities and availability of facilitators were the main logistical challenges. Stablishing and maintaining a stimulating learning environment and structuring the debriefing in an organized way were the main educational challenges. CONCLUSIONS: In situ simulation helps to train the coordination of nursing teams taking care of patients in cardiorespiratory arrest and to identify the risks that may affect patient safety. Identifying the educational challenges during the implementation of in situ simulation facilitates the design of specific educational and monitoring strategies.

Real-World Cost-Effectiveness Analysis of Spinal Cord Stimulation vs Conventional Therapy in the Management of Failed Back Surgery Syndrome.

PURPOSE: Failed back surgery syndrome (FBSS) causes disability and lowers health-related quality of life (HRQoL) for patients. Many patients become refractory to conventional medical management (CMM) and spinal cord stimulation (SCS) is advised. However, comparative cost-effectiveness research of both clinical approaches still lacks further evidence. This probabilistic cost-effectiveness analysis compares CMM versus SCS plus CMM in FBSS patients for a 5-year period in Spain. PATIENTS AND METHODS: Patient-level data was obtained from a 2-year real-world study (SEFUDOCE) of adults diagnosed with FBSS who were treated with CMM or SCS. Incremental cost-effectiveness ratios (ICER) were estimated in terms of direct clinical cost and quality-adjusted life years (QALYs). Costs (€ for 2019) were estimated from the Spanish National Health Service (NHS) perspective. We applied a yearly discount rate of 3% to both costs and outcomes and performed a probabilistic sensitivity analysis using bootstrapping. RESULTS: After 2 years, the health-related quality of life measured by the EQ-5D displayed greater improvements for SCS patients (00.39) than for improved CMM patients (0.01). The proportion of SCS patients using medication fell substantially, particularly for opioids (-49%). In the statistical model projection, compared with the CMM group at year 5, the SCS group showed an incremental cost of € 15,406 for an incremental gain of 0.56 0.56 QALYs, for an ICER of € 27,330, below the €30,000 willingness-to-pay threshold for Spain. SCS had a 79% of probability of being cost-effective. CONCLUSION: SCS is a cost-effective treatment for FBSS compared to CMM alone based on real-world evidence.

24-month Real-World Study of Spinal Cord Stimulation in Failed Back Surgery Patients with Refractory Pain.

BACKGROUND: Failed Back Surgery Syndrome (FBSS) causes disability and lowers health-related quality of life (HRQoL) for patients. Many patients become refractory to Conventional Medical Management (CMM) and Spinal Cord Stimulation (SCS) is advised. However, comparative effectiveness research of both clinical approaches still lacks further evidence. OBJECTIVES: This study describes Comparative Effectiveness Research of CMM versus SCS to provide real world evidence regarding the appropriate means for FBSS management, in terms of Patient-Reported Outcomes Measures. STUDY DESIGN: Naturalistic, pragmatic, prospective observational multicenter SEFUDOCE-study. SETTING: FBSS patients attending clinical programmed visits in Pain Unit at Hospital Universitario de La Princesa and at Hospital General Universitario de Alicante (Spain). METHODS: Study evaluates the impact on pain, functional limitation, and HRQoL of CMM versus SCS in the management of FBSS. Patients completed Pain Detect Questionnaire, Oswestry Disability Index, EQ-5D-3L, Medical Outcomes Study Sleep Scale, and Hospital Anxiety and Depression Scale at baseline and at 3, 6, 12, 18 and 24 months. Longitudinal data were analysed with repeated-measures one-way analysis of variance adjusting by confounders. RESULTS: Eighty-five adults patients with FBSS receiving treatment according to current clinical practice were assessed. After 24 months, the PainDETECT Questionnnaire showed that CMM patients maintained similar scores, while SCS patients reduced their overall score (current pain: 6 CMM versus 4.21 SCS, P = 0.0091; intensity strongest pain: 7.77 CMM versus 6.07 SCS, P = 0.0103; average pain: 6.46 CMM versus 4.75 SCS, P = 0.0012). For the Oswestry Disability Index, the Medical Outcomes Study Sleep Scale, and the Hospital Anxiety and Depression Scale no significant inter-group differences were found. EQ-5D utility improved in SCS patients from baseline (baseline: 0.32 CMM versus 0.22 SCS; 24-month: 0.37 CMM versus 0.63 SCS, P = 0.026). Twenty-four month follow-up showed unlikely presence of neuropathic pain and moderate disability in SCS patients, whereas the CMM patients maintained baseline health state. LIMITATIONS: Given the nature of the intervention, conducting a blinded study was not considered practically feasible. A larger sample could also overcome having younger patients in the SCS arm. CONCLUSIONS: SCS may improve the HRQoL and functionality of FBSS patients with refractory pain in the long-term compared to CMM alone.

Effect of process parameters on the valorization of components from microalgal and microalgal-bacteria biomass by enzymatic hydrolysis.

Photobioreactors for wastewater treatment coupled with nutrient recovery from the biomass is a promising biorefinery platform but requires working with microalgae-bacteria consortia. This work compares the effect that hydrolysis time and different enzymes have on the solubilization and recovery of components from microalgae-bacteria grown in piggery wastewater and microalgae grown in synthetic media by enzymatic hydrolysis. Higher carbohydrate solubilizations were obtained from microalgae-bacteria than from pure microalgae (38.5% vs. 27% Celluclast, 5 h), as expected from the SEM images. Proteases solubilized xylose remarkably well, but xylose recovery was negligible in all experiments. Alcalase hydrolysis (5 h) provided the highest peptide recovery from both biomasses (≈34%), but the peptide sizes were lower than 10 kDa. Low peptide recoveries (<20%) but larger peptide sizes (up to 135 kDa) were obtained with Protamex. Pure microalgae resulted in remarkably higher losses, but similar amino acid profiles and peptide sizes were obtained from both biomasses.

Impact of clinical audits on cesarean section rate in a Spanish hospital: Analysis of 6 year data according to the Robson classification.

OBJECTIVES: The aim of this study is to analyze the impact of the introduction of an internal clinical audit on the cesarean section (CS) rate, evaluated according to the Robson Ten Group Classification System (TGCS), and to identify the main contributors to the overall CS rate in order to plan further interventions. STUDY DESIGN: In 2014, an internal clinic audit committee was established in our center. Modifications of clinical management protocols were also implemented. A retrospective review of clinical records was conducted and pre-audit (2011-2014) results were compared against audit (2015-2018) results. Patients were clustered according to the Robson TGCS and the analyzed outcomes were CS rate and maternal and neonatal results. RESULTS: Between January 2011 and December 2018, 12,766 women gave birth at our institution among which 2,281 CS were analyzed. After the establishment of the clinical audit, the overall CS rate decreased from 20.27% to 14.82 % (p < 0.01). The major contribution to the overall CS rate in both periods were made by Group 2a (nulliparous with a single cephalic pregnancy at term who underwent labor induction: 4.86 % of all cases), followed by Group 5 (patients with a previous C-section: 3.26 %) and Group 1 (nulliparous with a single cephalic pregnancy at term with spontaneous labor: 2.39 %), representing 59.6 % of all CS. The group that showed the greatest reduction to the overall Cs rate was Group 2 (5.77 % vs 3.96 %, OR 1.48 (p < 0.01). No differences in perinatal and maternal results were found between preaudit and audit group. CONCLUSION: Audit, feedback, and modification of clinical management protocols may be effective in changing clinical practice and reducing CS rates without worsening maternal and neonatal morbimortality. Robson TGCS allowed us to identify which groups had the greatest impact on CS rate in order to establish new strategies that may lead us to optimize the use of this intervention. It seems that efforts to reduce the overall CS rate should be directed on increasing vaginal birth after CS and reducing CS rates in nulliparous women with single cephalic full-term pregnancy.

[Clinical simulation for quality improvement in the care of postpartum haemorrhage]. / Simulación clínica para la mejora de la calidad en la atención a la hemorragia posparto.

OBJECTIVE: To analyse and redesign the care process for patients with severe post-partum haemorrhage using simulation and a human factors approach. METHODS: The project was developed between June 2016 and May 2017. The working group was created following the participatory leadership method and included professionals with knowledge and position to influence the organisation. The existing process and clinical protocols were reviewed. An in situ simulation was used to observe team performance in the hospital recovery room. Information was expanded through an open and structured interview with professionals selected for their experience in the subject matter. Task analysis was used to document the process, and a failure mode and effects analysis was made to assess system vulnerabilities. Results were mapped using a flow chart. RESULTS: The analysis identified six groups of people working on different tasks, their activities and sequence of action, the importance of naming an explicit coordinator, the way in which information is disseminated and transformed, and the stages where it is necessary to share information and make key clinical decisions. The existing clinical protocols and the aids established in order to use the available resources were integrated, including blood draws and haemostatic agents, as well as an administration guide. CONCLUSIONS: The analysis of the patient care process in post-partum haemorrhage using in situ simulation with a human factors perspective, including an analysis of the interaction between professionals and the system where they work, established a detailed and personalised map of the components that determine how work flows through the organisation.

[Towards a social determinants-oriented approach to public health: workshop report]. / Hacia una salud pública orientada desde los determinantes sociales de la salud: informe de un taller.

This article is the result of a workshop with public health experts held in Granada (Spain) in October 2015 in order to reflect upon the components of the framework that should be part of a public health approach based on the social determinants of health. Advocacy and training professionals in health advocacy were identified as key elements where this was needed. During the workshop, it was agreed that the gender perspective, the salutogenic approach, interdisciplinary work and particular attention to disadvantaged groups are crucial. The importance of working from a human rights' framework and promoting legislative changes were also mentioned. Moreover, the group mentioned that even though much progress has been made identifying social determinants of health and creating conceptual frameworks, there is limited knowledge about how to intervene to reduce health inequality gaps in our societies.

Simulation as a Tool to Facilitate Practice Changes in Teams Taking Care of Patients Under Investigation for Ebola Virus Disease in Spain.

INTRODUCTION: We analyzed the impact of simulation-based training on clinical practice and work processes on teams caring for patients with possible Ebola virus disease (EVD) in Cantabria, Spain. METHODS: The Government of Spain set up a special committee for the management of EVD, and the Spanish Ministry of Health and foreign health services created an action protocol. Each region is responsible for selecting a reference hospital and an in-house care team to care for patients under investigation. Laboratory-confirmed cases of EVD have to be transferred to the Carlos III Health Institute in Madrid. Predeployment training and follow-up support are required to help personnel work safely and effectively. Simulation-based scenarios were designed to give staff the opportunity to practice before encountering a real-life situation. Lessons learned by each team during debriefings were listed, and a survey administered 3 months later assessed the implementation of practice and system changes. RESULTS: Implemented changes were related to clinical practice (eg, teamwork principles application), protocol implementation (eg, addition of new processes and rewriting of confusing parts), and system and workflow (eg, change of shift schedule and rearrangement of room equipment). CONCLUSIONS: Simulation can be used to detect needed changes in protocol or guidelines or can be adapted to meet the needs of a specific team.