[Integration of the nursing process in the electronic health record in an university hospital]. / Integración del proceso enfermero en la historia clínica electrónica de un hospital universitario.

AIM: To describe the process of implementation of Individualized Care Plan in the Electronic Health Record and its impact on the University Hospital Alcorcón Foundation. METHODOLOGY: Working groups of staff nurses who analyzed activities usually performed to create a catalog of diagnoses, outcomes and interventions. A group of referents that refined the catalog to make it manageable was created. A training plan, nursing assessment forms and the Nursing Discharge Report were designed. RESULTS: In February 2016 the new methodology was implemented in inpatient units of adults. Between 74.86 and 88.18% of the patients underwent a care plan with the new methodology. Between 69.41 and 76.25% of patients are discharged with a Nursing Discharge Report accordance with regulations. An increase of 24.1% of patients with Nursing Discharge Report after implantation is observed (P=.000; RR: 1.46; 95% CI 1.36-1.56). A total of 116 nurses has been trained. CONCLUSIONS: In the study conditions, the use of nursing taxonomies has generated thinking skills and allowed nurses to issue judgments, ensure quality of care, and implementing interventions with a planned results. The nursing taxonomy and care plan in the Electronic Health Record have increased interprofessional communication to improve continuity of care through improved Nursing Discharge Report.

Conventional versus Rosemont endoscopic ultrasound criteria for chronic pancreatitis: interobserver agreement in same day back-to-back procedures.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound (EUS) is a commonly used and fairly sensitive method of assessing changes of chronic pancreatitis (CP) when routine noninvasive imaging has not shown overt features of CP. The aim of this study is to evaluate the interobserver agreement (IOA) for the classic (MSC) and the Rosemont (RC) criteria for the diagnosis of chronic pancreatitis on the basis of clinical practice. PATIENTS AND METHODS: Two experienced endosonographers evaluated on the same day patients referred for EUS in a blinded fashion. Data from the sonographic criteria of both MSC and RC were collected. Agreement was calculated using k statistics. RESULTS: A total of 69 patients were evaluated. The study population included mainly patients without pancreatic diseases, resulting in a low number of sonographic findings. Agreement for the final diagnosis was moderate for both classification systems of chronic pancreatitis (k = 0.53 for conventional and k = 0.46 for Rosemont). CONCLUSIONS: The IOA of EUS in the diagnosis of CP is moderate. The concordance values obtained in clinical practice are similar to those obtained in multicenter studies. The RC does not seem to improve the IOA of MSC.

Clinical impact of high-definition endoscopic ultrasonography (EUS) in a district hospital.

OBJECTIVES: Evaluation of the impact of EUS in clinical practice. METHODS: All exploration performed during the first 18 months of implementation of the technique were analyzed. Agreement was assessed by radiographic techniques or surgical specimens in those cases allowed. RESULTS: 277 exploration were performed. There have been only 2 complications and they were related to sedation in both cases. The demand increased gradually, reaching 70 scans per 100,000 inhabitants. Main indications were bile (34.3%) and pancreatic processes. No pathology was found in 10% of cases; 29 cases had choledocholithiasis (93% confirmed and treated endoscopically). Chronic pancreatitis was diagnosed in 19 cases (only 15.78% of the cases were diagnosed by computed tomography). 32 patients with idiopathic acute pancreatitis were evaluated: 20 of them had evidence of microlithiasis (80% cholecystectomized and asymptomatic after a mean follow-up of 21.5 months), two cases of choledocholithiasis, 1 with chronic pancreatitis and 9 cases remained free of filial etiology. We performed 56 punctures: 39 samples of pancreas in 33 patients (81.1% of the samples were diagnostic; adenocarcinoma and serous cystadenoma were the most common diagnoses), 13 enlarged nodes and 4 abdominal masses. CONCLUSIONS: EUS is a growing demand technique that has low risks and leads to better decision-making in a significant number of patients with different diseases. Therefore, its inclusion in routine clinical practice must be considered.

[Polyps of the biliary tract: is their preoperative diagnosis possible?]. / Pólipos de la vía biliar: es posible su diagnóstico preoperatorio?

Bile duct polyps are a very uncommon cause of obstructive jaundice. We present our experience of three patients diagnosed in the last 10 years. Initial presentation usually takes the form of obstructive jaundice associated with abdominal pain, which simulates biliary lithiasis. The diagnosis is usually surgical. Although in some cases radiological studies and endoscopic retrograde cholangiopancreatography (ERCP) may sometimes detect bile duct polyps, exact diagnosis before surgery is very unusual. The radiological signs that suggest the existence of a bile duct polyp in the ERCP seem to be the presence of repletion defects, fixed unilaterally to the biliary conduit, without meniscus and without circumferential stenosis of the affected conduit. The most frequently found polyps are fibroinflammatory, and less frequently adenomatous.