RESUMO
The 70 recommendations summarize the current status of preoperative risk evaluation of adult patients prior to elective non-cardiothoracic surgery. Based on the joint publications of the German scientific societies for anesthesiology and intensive care medicine (DGAI), surgery (DGCH), and internal medicine (DGIM), which were first published in 2010 and updated in 2017, as well as the European guideline on preoperative cardiac risk evaluation published in 2022, a comprehensive re-evaluation of the recommendation takes place, taking into account new findings, the current literature, and current guidelines of international professional societies. The revised multidisciplinary recommendation is intended to facilitate a structured and common approach to the preoperative evaluation of patients. The aim is to ensure individualized preparation for the patient prior to surgery and thus to increase patient safety. Taking into account intervention- and patient-specific factors, which are indispensable in the preoperative risk evaluation, the perioperative risk for the patient should be minimized and safety increased. The recommendations for action are summarized under "General Principles (A)," "Advanced Diagnostics (B)," and the "Preoperative Management of Continuous Medication (C)." For the first time, a rating of the individual measures with regard to their clinical relevance has been given in the present recommendation. A joint and transparent agreement is intended to ensure a high level of patient orientation while avoiding unnecessary preliminary examinations, to shorten preoperative examination procedures, and ultimately to save costs. The joint recommendation of DGAI, DGCH and DGIM reflects the current state of knowledge as well as the opinion of experts. The recommendation does not replace the individualized decision between patient and physician about the best preoperative strategy and treatment.
Assuntos
Anestesiologia , Cuidados Críticos , Procedimentos Cirúrgicos Eletivos , Cuidados Pré-Operatórios , Humanos , Cuidados Pré-Operatórios/normas , Cuidados Pré-Operatórios/métodos , Procedimentos Cirúrgicos Eletivos/normas , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Adulto , Anestesiologia/normas , Alemanha , Cuidados Críticos/normas , Medicina Interna/normas , Medição de Risco , Sociedades Médicas , Cirurgia Geral/normasRESUMO
Importance: Despite its importance to medical education and competency assessment for internal medicine trainees, evidence about the relationship between physicians' milestone residency ratings or the American Board of Internal Medicine's initial certification examination and their hospitalized patients' outcomes is sparse. Objective: To examine the association between physicians' milestone ratings and certification examination scores and hospital outcomes for their patients. Design, Setting, and Participants: Retrospective cohort analyses of 6898 hospitalists completing training in 2016 to 2018 and caring for Medicare fee-for-service beneficiaries during hospitalizations in 2017 to 2019 at US hospitals. Main Outcomes and Measures: Primary outcome measures included 7-day mortality and readmission rates. Thirty-day mortality and readmission rates, length of stay, and subspecialist consultation frequency were also assessed. Analyses accounted for hospital fixed effects and adjusted for patient characteristics, physician years of experience, and year. Exposures: Certification examination score quartile and milestone ratings, including an overall core competency rating measure equaling the mean of the end of residency milestone subcompetency ratings categorized as low, medium, or high, and a knowledge core competency measure categorized similarly. Results: Among 455â¯120 hospitalizations, median patient age was 79 years (IQR, 73-86 years), 56.5% of patients were female, 1.9% were Asian, 9.8% were Black, 4.6% were Hispanic, and 81.9% were White. The 7-day mortality and readmission rates were 3.5% (95% CI, 3.4%-3.6%) and 5.6% (95% CI, 5.5%-5.6%), respectively, and were 8.8% (95% CI, 8.7%-8.9%) and 16.6% (95% CI, 16.5%-16.7%) for mortality and readmission at 30 days. Mean length of stay and number of specialty consultations were 3.6 days (95% CI, 3.6-3.6 days) and 1.01 (95% CI, 1.00-1.03), respectively. A high vs low overall or knowledge milestone core competency rating was associated with none of the outcome measures assessed. For example, a high vs low overall core competency rating was associated with a nonsignificant 2.7% increase in 7-day mortality rates (95% CI, -5.2% to 10.6%; P = .51). In contrast, top vs bottom examination score quartile was associated with a significant 8.0% reduction in 7-day mortality rates (95% CI, -13.0% to -3.1%; P = .002) and a 9.3% reduction in 7-day readmission rates (95% CI, -13.0% to -5.7%; P < .001). For 30-day mortality, this association was -3.5% (95% CI, -6.7% to -0.4%; P = .03). Top vs bottom examination score quartile was associated with 2.4% more consultations (95% CI, 0.8%-3.9%; P < .003) but was not associated with length of stay or 30-day readmission rates. Conclusions and Relevance: Among newly trained hospitalists, certification examination score, but not residency milestone ratings, was associated with improved outcomes among hospitalized Medicare beneficiaries.
Assuntos
Certificação , Competência Clínica , Mortalidade Hospitalar , Medicina Interna , Internato e Residência , Readmissão do Paciente , Humanos , Medicina Interna/educação , Medicina Interna/normas , Readmissão do Paciente/estatística & dados numéricos , Estudos Retrospectivos , Internato e Residência/normas , Certificação/normas , Estados Unidos , Feminino , Masculino , Tempo de Internação/estatística & dados numéricos , Medicare , Idoso , Médicos Hospitalares/normas , Avaliação Educacional/normasRESUMO
BACKGROUND: Over the past two decades, several studies have been conducted that have tried to answer questions on management of patients with acute heart failure (AHF) in terms of diagnosis and treatment. Updated international clinical practice guidelines (CPGs) have endorsed the findings of these studies. The aim of this document was to adapt recommendations of existing guidelines to help internists make decisions about specific and complex scenarios related to AHF. METHODS: The adaptation procedure was to identify firstly unresolved clinical problems in patients with AHF in accordance with the PICO (Population, Intervention, Comparison and Outcomes) process, then conduct a critical assessment of existing CPGs and choose recommendations that are most applicable to these specific scenarios. RESULTS: Seven PICOs were identified and CPGs were assessed. There is no single test that can help clinicians in discriminating patients with acute dyspnoea, congestion or hypoxaemia. Performing of echocardiography and natriuretic peptide evaluation is recommended, and chest X-ray and lung ultrasound may be considered. Treatment strategies to manage arterial hypotension and low cardiac output include short-term continuous intravenous inotropic support, vasopressors, renal replacement therapy, and temporary mechanical circulatory support. The most updated recommendations on how to treat specific patients with AHF and certain comorbidities and for reducing post-discharge rehospitalization and mortality are provided. Overall, 51 recommendations were endorsed and the rationale for the selection is provided in the main text. CONCLUSION: Through the use of appropriate tailoring process methodology, this document provides a simple and updated guide for internists dealing with AHF patients.
Assuntos
Insuficiência Cardíaca , Medicina Interna , Humanos , Insuficiência Cardíaca/terapia , Insuficiência Cardíaca/diagnóstico , Doença Aguda , Medicina Interna/normas , EcocardiografiaRESUMO
Se realizó un estudio observacional descriptivo y transversal de 76 pacientes ingresados en los servicios de Medicina Interna y Caumatología del Hospital General Docente Dr Juan Bruno Zayas Alfonso de Santiago de Cuba durante el 2012, para evaluar los conocimientos, el desempeño y la satisfacción de 22 profesionales que prescribieron ciprofloxacino por vía parental. Los conocimientos y la satisfacción fueron evaluados a través de un examen de conocimientos y una encuesta de satisfacción, respectivamente; el desempeño, a partir de la información obtenida de las historias clínicas, relacionadas con tres criterios: individualización del tratamiento, esquema terapéutico y combinaciones medicamentosas. Para cada criterio se establecieron indicadores y estándares. Los prescriptores presentaron conocimientos adecuados sobre el medicamento en cuestión; sin embargo, el desempeño y la satisfacción de estos resultaron inadecuados. Se considera necesario realizar una intervención en aras de revertir las deficiencias identificadas y contribuir a elevar la calidad de la prescripción de medicamentos en ambos servicios de salud
A descriptive, cross-sectional and observational study of 76 patients admitted to the Internal Medicine and Caumatology services of Dr Juan Bruno Zayas Alfonso Teaching General Hospital was carried out in Santiago de Cuba during 2012, to evaluate the knowledge, performance and satisfaction of 22 professionals who prescribed parental ciprofloxacin. The knowledge and satisfaction were evaluated through a knowledge examination and a survey of satisfaction, respectively; the performance was evaluated, starting from the information obtained from the medical records, related to 3 criteria: individualization of the treatment, therapeutic schedule and medication combinations. For each opinion, indicators and standards were established. The prescribers presented appropriate knowledge on the specific medication; however, the performance and satisfaction of them were inadequate. It is necessary to carry out an intervention to revert the identified deficiencies and contribute to elevate the quality of the medications prescription in both health services
Assuntos
Humanos , Masculino , Feminino , Prescrições de Medicamentos , Unidades de Queimados/normas , Ciprofloxacina/administração & dosagem , Competência Clínica , Medicina Interna/normas , Análise e Desempenho de Tarefas , Estudos Transversais , Ética Profissional , Estudo ObservacionalRESUMO
Background: Patients admitted to internal medicine services receive multiple drugs and thus are at risk of medication errors. Aim: To determine the frequency of medication errors (ME) among patients admitted to an internal medicine service of a high complexity hospital. Material and Methods: A prospective observational study conducted in 225 patients admitted to an internal medicine service. Each stage of drug utilization system (prescription, transcription, dispensing, preparation and administration) was directly observed by trained pharmacists not related to hospital staff during three months. ME were described and categorized according to the National Coordinating Council for Medication Error Reporting and Prevention. In each stage of medication use, the frequency of ME and their characteristics were determined. Results: A total of 454 drugs were prescribed to the studied patients. In 138 (30,4%) indications, at least one ME occurred, involving 67 (29,8%) patients. Twenty four percent of detected ME occurred during administration, mainly due to wrong time schedules. Anticoagulants were the therapeutic group with the highest occurrence of ME. Conclusions: At least one ME occurred in approximately one third of patients studied, especially during the administration stage. These errors could affect the medication safety and avoid achieving therapeutic goals. Strategies to improve the quality and safe use of medications can be implemented using this information.
Assuntos
Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Medicina Interna/estatística & dados numéricos , Erros de Medicação/estatística & dados numéricos , Medicina Interna/normas , Erros de Medicação/prevenção & controle , Estudos ProspectivosRESUMO
El pie diabètico es la complicaciòn crònica de la diabetes mellitus con mayores implicaciones econòmicas y sobre la calidad de vida de los pacientes..
Assuntos
Medicina Interna/normas , Medicina Interna/tendências , ParaguaiRESUMO
Hay factores de riesgo que,son factores pronòstico de mayor probabilidad de que se desarrolle un evento.En epidemiologìa,los factores de riesgo son aquellas variables que se presentan asociados diversamente eon el evento estudiado..
Assuntos
Medicina Interna/normas , Medicina Interna/tendências , ParaguaiRESUMO
Todos os pacientes atendidos na Emergência do Hospital de Clínicas de Porto Alegre de março a maio de 2005 foram acompanhados prospectivamente, buscando verificar suas características epidemiológicas e fatores de retardo de internação, definidos como permanência hospitalar por motivos não clínicos. De 5530 pacientes triados neste período, 389 foram atendidos pelo Serviço de Medicina Interna. Destes, 314 são descritos nesta amostra. A idade mediana dos pacientes internados foi de 64 anos, com predomínio de mulheres. Da população estudada, 80 por cento eram provenientes de Porto Alegre e região metropolitana. Dez condições clínicas crônicas foram a causa de 83 por cento das internações, com neoplasias fora de opção terapêutica , complicações de SIDA e reinternações de pacientes com seqüelas neurológicas de doença cerebrovascular sendo as causas mais freqüentes. Diabete melito e doença pulmonar obstrutiva crônica corresponderam a 9,2 por cento e 6,4 por cento das internações. Os pacientes portadores de diabete melito e insuficiência cardíaca apresentaram os maiorestempos de espera por internação clínica (54,5 e 46,6 horas). Vinte e cinco por cento dos pacientes com angina do peito, infecção respiratória aguda ou complicações associadas ao diabete melito aguardaram mais de 60 horas por leito de internação. A realização de consultorias médicas foi fator de retardo na permanência, com tempo mediano de espera de 48 horas. O maior tempo de espera nos exames subsidiários foi resultado de pendência na liberação de laudos de anatomo-patológicos em biópsias, com mediana de 4,2 dias. Da mesma forma, a mediana da espera pela realização de tomografias computadorizadas foi de 5 dias para crânio, 4,2 dias para abdômen e 3,2 dias para tórax. Entre os dez motivos mais comuns de internação, apenas 21 (6,7 por cento) foram caracterizadas como condições clínicas agudas. Estes achados serviram de embasamento para a reformulação do Serviço de Emergência no HCPA, desencadeando açõe...