Combatting resistance in intensive care: the multimodal approach of the Spanish ICU "Zero Resistance" program.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2015 and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/annualupdate2015. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Are Spanish primary care professionals aware of patient safety?

BACKGROUND: Knowledge about safety culture improves patient safety (PS) in health-care organizations. The first contact a patient has with health care occurs at the primary level. We conducted a survey to measure patient safety culture (PSC) among primary care professionals (PCPs) of health centres (HCs) in Spain and analyzed PS dimensions that influence PSC. METHODS: We used Agency for Healthcare Research and Quality (AHRQ) Medical Office Survey on Patient Safety Culture translated and validated into Spanish to conduct a cross-sectional anonymous postal survey. We randomly selected a sample of 8378 PCPs at 289 HCs operated by 17 Regional Health Services. Statistical analysis was performed on sociodemographic variables, survey items, PS dimensions and a patient safety synthetic index (PSSI), calculated as average score of the items per dimension, to identify potential predictors of PSC. We used AHRQ data to conduct international comparison. RESULTS: A total of 4344 PCPs completed the questionnaire. The response rate was 55.69%. Forty-two percent were general practitioners, 34.9% nurses, 18% administrative staff and 4.9% other professionals. The highest scoring dimension was 'PS and quality issues' 4.18 (4.1-4.20) 'Work pressure and pace' was the lowest scored dimension with 2.76 (2.74-2.79). Professionals over 55 years, with managerial responsibilities, women, nurses and administrative staff, had better PSSI scores. Professionals with more than 1500 patients and working for more than 11 years at primary care had lower PSSI scores. CONCLUSIONS: This is the first national study to measure PSC in primary care in Spain. Results may reflect on-going efforts to build a strong PSC. Further research into its association with safety outcomes and patients' perceptions is required.

Chemotherapy versus best supportive care for extensive small cell lung cancer.

BACKGROUND: Combination chemotherapy has been the mainstay of treatment for extensive stage small celI lung cancer (SCLC) over the last 30 years even though it only gives a short prolongation in median survival time. The main goal for these patients should be palliation with the aim of improving their quality of life. OBJECTIVES: To evaluate the effectiveness of chemotherapy in extensive SCLC compared with best supportive care (BSC) or placebo treatment. SEARCH STRATEGY: MEDLINE (1966 to July 2008), EMBASE (1974 to week 31, 2008), and the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2008). Experts in the field were contacted. SELECTION CRITERIA: Randomised controlled trials in which any chemotherapy treatment was compared with placebo or BSC in patients with extensive SCLC, as first or second therapy at relapse. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed study quality. We resolved disagreements by discussion. Additional information was obtained from one study author. MAIN RESULTS: Two studies were included for first-line chemotherapy. A total of 65 patients were randomised to receive either placebo or ifosfamide. Ifosfamide gave an extra mean survival of 78.5 days compared with placebo. Partial tumour response was greater with the active treatment. Toxicity was only seen in the chemotherapy group.Two studies were included for second-line chemotherapy at relapse. A total of 531 patients were randomised to receive either methotrexate-doxorubicin or symptomatic treatment, or to receive oral topotecan versus BSC. The methotrexate-doxorubicin treatment gave a median survival of 63 days longer than in the symptomatic treatment group, and 21 days longer for patients allocated to receive four or eight cycles of first-line chemotherapy, respectively.Treatment with topotecan gave a median survival of 84 days longer than in the BSC group (log-rank P = 0.01). The adjusted hazard ratio for overall survival was 0.61 (95% CI, 0.43 to 0.87). Partial or complete response in the methotrexate-doxorubicin group was 22.3%. Five patients (7%, 95% CI, 2.33 to 15.67) showed a partial response with topotecan. Toxicity was worst in the chemotherapy group. Quality of life was better in the topotecan group. AUTHORS' CONCLUSIONS: Chemotherapeutic treatment prolongs survival in comparison with placebo in patients with advanced SCLC. Nevertheless, the impact of first-line chemotherapy on quality of life and in patients with poor prognosis is unknown. Well-designed, controlled trials are needed to further evaluate the risks and benefits of different chemotherapeutic schedules in patients with advanced SCLC.

[Relationship between quality of life and various models of home care in terminal oncology patients from a health area of Madrid]. / Relación de la calidad de vida con diferentes modelos de atención domiciliaria en enfermos oncológicos terminales de un área sanitaria de Madrid.

BACKGROUND: This study assesses the effectiveness of the palliative home care for the purpose of ascertaining whether terminal cancer patients treated by Homecare Support Teams have a better quality of life than those treated by Primary Care Teams. METHODS: A quasi-experimental prospective study conducted in Madrid Healthcare District 4 on patients referred from the hospital to Homecare Support Teams or to Primary Care Teams. The main study variable was the quality of life gauged using the Rotterdam Symptom Check List and the Hospital Anxiety and Depression Scale. Statistical differences were evaluated by MANOVA, repeated measures ANOVA and Friedman test. RESULTS: A total of 165 patients were treated by Homecare Support Teams and 56 by Primary Care Teams. The patients treated by the Homecare Support Teams showed better point scores on the overall scale (mean difference: 9.5; CI 95%; 2.3-16.67) and pain scale Symptom Check List during the first week of the study. The effect size was greater on the Homecare Support Team group. The prescription of drugs and the place of death were different between both groups. CONCLUSIONS: At the start of the study, the patients treated by Homecare Support Teams showed a better perception of the health condition than those treated by the Primary Care Teams. However, the great number of patients lost along the study makes it necessary be cautious when considering these results.

Reliability and concurrent validity of the Palliative Outcome Scale, the Rotterdam Symptom Checklist, and the Brief Pain Inventory.

BACKGROUND: Some domains of the questionnaires used to measure symptoms and quality of life (QOL) in patients with advanced cancer seem to measure similar dimensions or constructs, so it would be useful for clinicians to demonstrate the interchangeability of equivalent domains of the questionnaires in measuring the same constructs. OBJECTIVE: This study investigated the reliability and concurrent validity of the Palliative Outcome Scale (POS), the Rotterdam Symptom Checklist (RSCL), and the Brief Pain Inventory (BPI), used to measure symptom control in patients with advanced cancer. DESIGN: This was an evaluative study. SETTING/SUBJECTS: Subjects were patients with advanced cancer attended by Spanish primary care physicians. MEASUREMENTS: Secondary analysis was performed of 117 outpatients who completed the POS, BPI, and RSCL at two different times, with an interval of 7 to 10 days. Bland and Altman analyses and plot, repeatability coefficient, as well as Spearman correlations were carried out. RESULTS: There were 117 included patients. Mean age was 69.4 (11.5) years, gender was 60% male, 37.6% completed only elementary school, diagnoses were mainly digestive and lung cancer, with a low functional rate and presence of oncologic pain. First and second questionnaire rounds showed significant correlations and agreement. Agreement was shown between pain intensity of BPI and pain and physical scales of RSCL, and between physical symptoms of RSCL and of POS, with significant correlations in equivalent dimensions. CONCLUSION: BPI, POS, and RSCL have shown adequate reliability and moderate concurrent validity among them.

Clinical effectiveness of online training in palliative care of primary care physicians.

BACKGROUND: Primary care physicians (PCPs) have a major responsibility in the management of palliative patients. Online palliative care (PC) education has not been shown to have a clinical impact on patients that is equal or different to traditional training. OBJECTIVE: This study tested the clinical effectiveness of online PC education of physicians through impact on symptom control, quality of life (QOL), caregiver satisfaction, and knowledge-attitude of physicians at 18 months of the intervention. METHODS: We conducted a randomized clinical trial. Subjects were 169 physicians randomly assigned to receive the online model or traditional training. Consecutive patients with advanced cancer requiring PC were included. Physicians and patients completed the Palliative Care Outcome Scale (POS), and patients the Brief Pain Inventory (BPI) and the Rotterdam Symptom Checklist (RSCL) twice, 7 to 10 days apart. Caregivers completed the SERVQUAL. Physicians' level of knowledge-attitude was measured at 18 months. RESULTS: Sixty-seven physicians enrolled 117 patients. The intervention group had reduced scores for pain, symptoms, and family anxiety. The global RSCL scale showed a difference between groups. There was no significant difference in the questionnaires used. Caregiver satisfaction was comparable between groups. Physicians in the intervention group significantly increased their knowledge without any differences in attitude. Online training was completed by 86.6% in the intervention group, whereas 13.4% in the control group accessed traditional training. CONCLUSIONS: Participation in an online PC education program by PCPs improved patient scores for some symptoms and family anxiety on the POS and also showed improved global QOL. Significant differences were found in physicians' knowledge at short and long term.

[Social network analysis: a method to improve safety in healthcare organizations]. / El análisis de las redes sociales: un método para la mejora de la seguridad en las organizaciones sanitarias.

Patient safety depends on the culture of the healthcare organization involving relationships between professionals. This article proposes that the study of these relations should be conducted from a network perspective and using a methodology called Social Network Analysis (SNA). This methodology includes a set of mathematical constructs grounded in Graph Theory. With the SNA we can know aspects of the individual's position in the network (centrality) or cohesion among team members. Thus, the SNA allows to know aspects related to security such as the kind of links that can increase commitment among professionals, how to build those links, which nodes have more prestige in the team in generating confidence or collaborative network, which professionals serve as intermediaries between the subgroups of a team to transmit information or smooth conflicts, etc. Useful aspects in stablishing a safety culture. The SNA would analyze the relations among professionals, their level of communication to communicate errors and spontaneously seek help and coordination between departments to participate in projects that enhance safety. Thus, they related through a network, using the same language, a fact that helps to build a culture. In summary, we propose an approach to safety culture from a SNA perspective that would complement other commonly used methods.

[Adverse events in general and digestive surgery departments in Spanish hospitals]. / Sucesos adversos en cirugía general y de aparato digestivo en los hospitales españoles.

OBJECTIVE: To determine the incidence of patients with adverse events (AE) in Spanish general surgery units, describe the immediate causes of AE, identify avoidable AE, and determine the impact of these events. MATERIAL AND METHOD: We performed a retrospective cohort study of a randomized stratified sample of 24 hospitals. Six of the hospitals were small (fewer than 200 beds), 13 were medium-sized (between 200 and 499 beds) and five were large (500 or more beds). Patients admitted for more than 24 hours to the selected hospitals and who were discharged between the 4th and 10th of June 2005 were included. AE detected during hospitalization and those occurring as a consequence of previous admissions in the same hospital were analyzed. RESULTS: The incidence of patients with AE associated with medical care was 10.5% (76/735; 95%CI: 8.1%-12.5%). The presence of intrinsic risk factors increased the risk of AE (14.8% vs 7.2%; P=.001). Likewise, 16.2% of patients with an extrinsic risk factor had an AE compared with 7.0% of those without these risk factors (P< .001). Comorbidity influenced the occurrence of AE (33.7% of AE vs. 2.2% without comorbidity; P< .001). The severity of the AE was related to ASA risk (P=.036). AE were related to nosocomial infection (41.7%), procedures (27.1%) and medication (24%). A total of 31.3% of the AE were mild, 39.6% were moderate, and 29.2% were severe. Preventable AE accounted for 36.5%. AE caused an additional 527 days of stay (6.3 additional days of stay per patient), of which 216 were due to preventable AE. CONCLUSIONS: Patients in general and digestive surgery units have an increased risk of AE. Risk factors for these events are age, comorbidity, and the use of external devices. A substantial number of AE are related to nosocomial infection (especially surgical wound infection) and to surgical procedures. AE have an important impact on patients and a considerable proportion of these events are preventable. AE have strong health, social and economic repercussions and until recently have constituted a silent epidemic in Spain. Consequently, study of these events should be a public health priority.