Characterization of cardiac arrest in the emergency department of a Brazilian University Reference Hospital: A prospective study.

BACKGROUND & OBJECTIVES: Sudden cardiac arrest (CA) represents one of the greatest challenges for medicine due to the vast number of cases and its social and economic impact. Despite advances in cardiopulmonary resuscitation (CPR) techniques, mortality rates have not significantly decreased over decades. This study was undertaken to characterize patients that have suffered CA and to identify factors related to mortality. METHODS: This prospective study was conducted at Emergency Department of São Paulo Hospital, Brazil. Two hundred and eighty five patients were followed for one year after treatment for CA. The mean age was 66.3±17.2 yr, and they were predominantly male (55.8%) and Caucasian (71.9%). Mortality rate and factors associated with mortality were the primary and secondary outcome measures. Data were collected using an in-hospital Utstein-style report. A logistic regression analysis was used to determine which variables were related to mortality. RESULTS: Regarding the characteristics of CPR, 76.5 per cent occurred in hospital, respiratory failure was the most common presumed immediate cause of CA (30.8%) and pulseless electrical activity was the most frequent initial rhythm (58.7%). All attempts at CPR utilized chest compressions and ventilation and the most utilized interventions were epinephrine (97.2%) and intubation (68.5%). Of all patients treated, 95.4 per cent died. Patients with pulseless electrical activity had a higher risk of death than those patients with ventricular fibrillation. INTERPRETATION & CONCLUSIONS: The findings of the study highlighted that the mortality rate among CA patients was high. The variable that best explained mortality was the initial CA rhythm.

[Triage at the Emergency Department: association between triage levels and patient outcome]. / Triagem no serviço de emergência: associação entre as suas categorias e os desfechos do paciente.

OBJECTIVE: Identify association between sociodemographic, clinical and triage categories with protocol outcomes developed at Hospital São Paulo (HSP). METHODS: Retrospective cohort study conducted with patients older than 18 years submitted to the triage protocol in August 2012. Logistic regression was used to associate the risk categories to outcomes (p-value ≤0,05). RESULTS: Men with older age and those treated in clinical specialties had higher rates of hospitalization and death. Patients in the high-priority group had hospitalization and mortality rates five and 10.6 times, respectively (p < 0.0001). CONCLUSION: The high-priority group experienced higher hospitalization and mortality rates. The protocol was able to detect patients with more urgent conditions and to identify risk factors for hospitalization and death.

[Nursing staff sizing in the emergency room of a university hospital]. / Dimensionamento de enfermagem em sala de emergência de um hospital-escola.

OBJECTIVE: To verify the adequacy of the professional nursing staff in the emergency room of a university hospital and to evaluate the association between categories of risk classification triage with the Fugulin Patient Classification System. METHOD: The classification of patients admitted into the emergency room was performed for 30 consecutive days through the methodology proposed by Gaidzinski for calculating nursing requirements. RESULTS: The calculation determines the need for three registered nurses and four non-registered nursing for each six hour shift. However, only one registered nurse and four non-registered nurse were available per shift. There was no correlation between triage risk classification and classification of care by the Fugulin Patient Classification System. CONCLUSION: A deficit in professional staff was identified in the emergency room. The specificity of this unit made it difficult to measure. To find the best strategy to do so, further studies should be performed.

[Advantages of a cohort study on cardiac arrest conducted by nurses]. / Vantagens do estudo de coorte realizado por enfermeiros em parada cardiorrespiratória.

OBJECTIVE: Identifying factors associated to survival after cardiac arrest. METHOD: An experience report of a cohort study conducted in a university hospital, with a consecutive sample comprised of 285 patients. Data were collected for a year by trained nurses. The training strategy was conducted through an expository dialogue lecture. Collection monitoring was carried out by nurses via telephone calls, visits to the emergency room and by medical record searches. The neurological status of survivors was evaluated at discharge, after six months and one year. RESULTS: Of the 285 patients, 16 survived until hospital discharge, and 13 remained alive after one year, making possible to identify factors associated with survival. There were no losses in the process. CONCLUSION: Cohort studies help identify risks and disease outcomes. Considering cardiac arrest, they can subsidize public policies, encourage future studies and training programs for CPR, thereby improving the prognosis of patients.

Effect of video on satisfaction and self-confidence in simulation training: a randomized clinical trial.

OBJECTIVES: to identify the effect on satisfaction and self-confidence of undergraduate nursing students after using a validated bed bath video during the simulation. METHODS: blinded parallel randomized clinical trial. Participants were allocated to the control group (simulation with tutor) or intervention (simulation with video). After the interventions, the Student Satisfaction and Self Confidence with Learning Scale was used to assess satisfaction and self-confidence. The study was approved by the Ethics Committee and Brazilian Registry of Clinical Trials. Mann Whitney, Fisher Exact and Student t statistical tests were used. A significance level of 5% was adopted. Results: fifty eight students (30, control; and 28, intervention) were evaluated. There was no significant difference between the groups regarding satisfaction (p=0.832) and self-confidence (p>0.999). CONCLUSIONS: satisfaction and self-confidence were similar between the groups, and the two strategies could be used in the simulated practice of bed bathing.

COVID-19: Association of risk classification with the Modified Early Warning Score and hospital outcomes. / COVID-19: Asociación entre la clasificación de riesgo y el Modified Early Warning Score y los resultados hospitalarios.

OBJECTIVE: to evaluate the association of the risk classification categories with the Modified Early Warning Score and the outcomes of COVID-19 patients in the emergency service. METHOD: a crosssectional study carried out with 372 patients hospitalized with a COVID-19 diagnosis and treated at the Risk Classification Welcoming area from the Emergency Room. In this study, the patients' Modified Early Warning Score was categorized into without and with clinical deterioration, from 0 to 4 and from 5 to 9, respectively. Clinical deterioration was considered to be acute respiratory failure, shock and cardiopulmonary arrest. RESULTS: the mean Modified Early Warning Score was 3.34. In relation to the patients' clinical deterioration, it was observed that, in 43%, the time for deterioration was less than 24 hours and that 65.9% occurred in the Emergency Room. The most frequent deterioration was acute respiratory failure (69.9%) and the outcome was hospital discharge (70.3%). CONCLUSION: COVID-19 patients who had a Modified Early Warning Scores > 4 were associated with the urgent, very urgent and emergency risk classification categories, had more clinical deterioration, such as respiratory failure and shock, and evolved more to death, which shows that the Risk Classification Protocol correctly prioritized patients at risk of life.

Association of the Charlson index with risk classification, clinical aspects, and emergency outcomes.

OBJECTIVE: To exam the association of the age-adjusted Charlson comorbidity index with the categories of risk classification, the clinical aspects, and the patient outcomes in the emergency department. METHOD: Cross-sectional, analytical study that analyzed the medical records of 3,624 patients seen in the emergency department. Charlson index scores greater than 2 showed a high rate of comorbidity (mortality risk). T-test and analysis of variance were applied in the analyses. RESULTS: There was a significant difference between the Charlson comorbidity index and the risk classification, with higher scores found in patients classified in the white (2.57) and red (2.06) categories. Patients with vascular, endocrine, neurological, cardiologic, or device problems, and those who underwent a head tomography had a high rate of comorbidity. In addition, those admitted, transferred, or who died in the emergency room had significantly higher index scores compared to those who were discharged from the hospital. CONCLUSION: The high rate of comorbidity was associated with the categories of risk classification, main and nonspecific complaints, performance of a head tomography, and patient outcomes in the emergency room.

Factors associated with risk, perception and knowledge of falls in elderly people.

OBJECTIVE: To verify the factors associated with risk, perception, and knowledge of falls; and pain among older adults. METHOD: A cross-sectional study carried out in the Emergency Service of a teaching hospital in the city of São Paulo between September 2019 and March 2020. We selected 197 older adults aged 65 and over, who were not disoriented or confused, of both genders. The instruments Awareness Questionnaire on the Risk of Falls, Morse Fall Scale and Numerical Pain Scales were applied. Mann-Whitney and Kruskal-Wallis tests were used. RESULTS: Interviewees with a high risk of falls in older adults (p = 0.0041); those with a support network had a lower perception and knowledge about the risk of falls (p = 0.0025) and lower percentage of severe pain (p = 0.0033). CONCLUSION: Factors associated with risk, perception and knowledge of falls and pain among older adults were age, family income, number of dependents, caregiver, support network, hypertension, impaired walking, antihypertensive medication, lipid-lowering medication, level of education, comorbidities and religion.

Assessment of the implementation of a nurse-initiated pain management protocol in the emergency department.

OBJECTIVES: to assess the implementation of a nurse-initiated pain management protocol for patients triaged as semi-urgent, and its impact in pain intensity, in the Emergency Department. METHODS: a prospective cohort study for adult patients with pain who had been triaged as semi-urgent and admitted to the hospital's Emergency Department. Patients who received the intervention (pain-management protocol with analgesic administration) were compared to those who were managed using the conventional approach (physician evaluation prior to analgesic administration). RESULTS: of the 185 patients included, 55 (30%) received the intervention, and 130 (70%) were managed conventionally. Patients in the intervention group were more likely to have taken pain medication in the 4 hours prior to admission, and reported higher levels of pain at admission and more significant reductions in pain level. CONCLUSIONS: despite low protocol adherence, the intervention resulted in higher reported pain relief.

Manchester Triage System: assessment in an emergency hospital service.

OBJECTIVES: to analyze demographic data, clinical profile and outcomes of patients in emergency services according to Manchester Triage System's priority level. METHODS: a cross-sectional, analytical study, carried out with 3,624 medical records. For statistical analysis, the Chi-Square Test was used. RESULTS: white individuals were more advanced in age. In the red and white categories, there was a higher percentage of men when compared to women (p=0.0018) and higher prevalence of personal history. Yellow priority patients had higher percentage of pain (p<0.0001). Those in red category had a higher frequency of altered vital signs, external causes, and death outcome. There was a higher percentage of exams performed and hospitalization in the orange category. Blue priority patients had a higher percentage of non-specific complaints and dismissal after risk stratification. CONCLUSIONS: a higher percentage of altered vital signs, number of tests performed, hospitalization and death were evidenced in Manchester protocol's high priority categories.

Interprofessional communication in an emergency care unit: a case study. / Comunicação interprofissional em unidade de emergência: estudo de caso.

OBJECTIVE: To map internal and external factors in an emergency care unit that interfere with interprofessional communicative practice. METHOD: This is a single case study carried out in the emergency care unit of a general hospital. Data were collected through participant observation, document analysis, and semi-structured interviews, and were triangulated and subjected to thematic analysis, out of categories defined a priori, based on the SWOT matrix. RESULTS: Twenty-two health care professionals participated in the study. As for the strengths and opportunities, it was found that professionals understand the importance of communication as a safety measure, and they use the shift change and written communication to share information. However, overcrowding, work overload, the lack of behaviors standardization, the inexperience of professionals, and the deficit in the interprofessional relationship are factors that hinder effective communication. CONCLUSION: The fragile interprofessional communicative process hampers interaction and information sharing for shared decisions that allow the safe continuity of care.

Evaluation of the Manchester Triage System quality indicator: service time.

OBJECTIVE: to verify the conformity of the time interval between the end of the risk classification and the beginning of medical care with that recommended by the Manchester protocol and to relate the times of care and the risk categories with the outcome. METHOD: Cross-sectional, retrospective, and analytical study. The t test, the analysis of variance and the generalized linear model were used. RESULTS: The average time for medical care in the red and orange categories was 3 and 39.5 minutes, respectively. Death outcome was associated with the red category, with an average time to start the classification of 5.5 minutes and an average length of stay of 2.3 hours. CONCLUSION: The waiting time for medical care in the high priority categories was longer than recommended, which suggests the need to continuously monitor the system. Shorter waiting times for classification and permanence were related to the red category and the outcome of death.

Construction and validation of an in-hospital transport simulation scenario.

OBJECTIVE: To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. METHODS: A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. RESULTS: Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. CONCLUSION: In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

Functional capacity and quality of life of elderly people admitted to emergency service. / Capacidade funcional e qualidade de vida de pessoas idosas internadas no serviço de emergência.

OBJECTIVE: To correlate the functional capacity and quality of life of elderly people admitted to emergency service. METHOD: This is a cross-sectional and analytical study carried out with elderly patients admitted to a university hospital's emergency service in the city of São Paulo, between December 2015 and January 2017. Data were collected through interviews using a structured questionnaire, the Medical Outcome Study 36, the Katz of Independence in Activities of Daily Living, and the Functional Independence Measure. RESULTS: Two hundred fifty elderly people with a mean age of 71.9 years, male (56.8%), white in color (67.2%), married (54.0%), with low education (32.0%), low income (58.0%), with comorbidities (81.2%) and home providers (53.6%) have participated. The most compromised Quality of Life dimensions were physical aspect (11.4%), emotional aspect (21.6%) and functional capacity (25.2%). Concerning functional capacity, independence was characterized for Basic Activities of Daily Living and moderate dependence for Instrumental Activities of Daily Living. The higher the scores of the Functional Independence Measure, the higher the quality of life scores. CONCLUSION: The more independent the elderly the better their quality of life.

Interprofessional Practice in the Emergency Service: specific and shared assignments of nurses.

OBJECTIVE: To map and categorize, according to the Nursing Interventions Classification (NIC), the specific assignments of the nurses and to identify the assignments shared with doctors and physiotherapists in the Emergency Service. METHOD: Descriptive exploratory study, carried out in two phases: first, the analysis of dissertations /theses from the database of the Center for Studies and Research of the Brazilian Nursing Association; Second, the use of the Delphi Technique to reach the consensus about which assignments were specific to the nurse and which were shared with physiotherapists and doctors. RESULTS: The results were 45.7% for specific to the nurses, 14.2% for shared with physiotherapists and/or doctors, and in 40% (n=42) there was no consensus about the sharing of assignments. CONCLUSION: The sharing of actions among professionals shows an increase in the scope of the practice of professions and the constitution of a common sphere of work, but the high number of assignments with no consensus among specialists can be a potential factor in conflicts due to the lack of definition of these assignments.

Discharge guidance and telephone follow-up in the therapeutic adherence of heart failure: randomized clinical trial. / Orientação de alta e acompanhamento telefônico na adesão terapêutica da insuficiência cardíaca: ensaio clínico randomizado.

OBJECTIVE: to evaluate the effectiveness of the behavioral intervention of discharge guidance and telephone follow-up in the therapeutic adherence, re-hospitalization and mortality of patients with heart failure. METHOD: randomized clinical trial without blinding, including 201 patients diagnosed with heart failure admitted to the emergency room, who were randomized in Control Group and Intervention Group. Intervention was carried out with specific discharge guidance in the Intervention Group, who were contacted for solving doubts via phone calls after 7 and 30 days, and the adherence to treatment was evaluated after 90 days with the Morisky test, the Brief Medical Questionnaire and the non-drug adherence test in both groups. The Generalized Estimating Equations Model was used (p<0.05%). RESULTS: One-hundred and one patients were randomly sorted in the Control Group and in the Intervention Group, their average age being 62.6±15.2. The Intervention Group had higher drug and non-drug therapeutic adherence compared to the Control Group (p<0.001) and there were lower re-hospitalization and death rates in the Intervention Group after 90 days. CONCLUSION: discharge guidance with telephone follow-up was effective and resulted in greater therapeutic adherence, as well as in decrease of re-hospitalization and death rates in patients with heart failure. Clinical Trial Registration (REBEC): RBR- 37n859.

Health literacy and adherence to treatment of patients with heart failure.

OBJECTIVE: To relate the level of functional health literacy with adherence and barriers to non-adherence, rehospitalization, readmission and death in patients with heart failure. METHOD: A cross-sectional, analytical study with patients admitted to the emergency room with a diagnosis of heart failure. Literacy was assessed by the Newest Vital Sign. Patient adherence to medication treatment and barriers to non-compliance were assessed 90 days after discharge by the Morisky-Green test and the Brief Medical Questionnaire, respectively. RESULTS: 100 patients participated in the study. The mean age was 63.3 years (± 15.2), with a predominance of white women. Medication adherence was low in 41.1% of participants, of which 55.9% presented inadequate literacy. Re-hospitalization and death were present in patients with inadequate literacy (p<0.001). CONCLUSION: The low level of literacy was directly related to lower adherence and the presence of barriers to medication adherence, as well as higher rehospitalization rates and death.

Good practices for preventing ventilator-associated pneumonia in the emergency department.

OBJECTIVE: To evaluate the conformity of the set of good practices for preventing ventilator-associated pneumonia (VAP) in the emergency department of a university hospital. METHOD: A cross-sectional analytical study with a quantitative approach, conducted in a university hospital in the city of São Paulo. The study sample consisted of opportunities for care observations that comprise the set of good practices for preventing ventilator-associated pneumonia provided to intubated patients hospitalized in the emergency department. RESULTS: A total of 209 observations were performed in 42 patients. Of the hospitalized patients, 23.8% developed VAP, and 52.4% died. Of the five recommended measures for preventing VAP, only two presented compliance above 50%. CONCLUSION: The care provided to patients is not in line with what is recommended in the literature, which demonstrates the need for periodic renewal of the team's educational practices and the development of auditing projects to ensure improvements in the care process.

Functional capacity and quality of life of hospitalized octogenarians.

OBJECTIVE: To evaluate the ability to perform activities of daily living (ADL) and to correlate functional capacity with quality of life (QoL) of hospitalized octogenarians. METHOD: A cross-sectional study with 128 patients using the quality of life instruments WHOQOL-OLD and WHOQOL-BREF and the Katz Scale. RESULTS: The majority of patients was fully dependent; patients with higher schooling had less independence; older adults with partial dependence and independence had higher scores in perceived QoL; in the domains of autonomy, past, present and future activities; and better overall QoL than those with full dependence. Partially dependent patients had higher scores in the death and dying domain than independent patients. CONCLUSION: Older adults' QoL is associated with the maintenance of autonomy and functional capacity. Older adults experience a health decline during the hospitalization process, due to the limitation in performing their ADL and lack of encouragement by the health team.

Evaluation of delirium in aged patients assisted at emergency hospital service.

OBJECTIVE: identify the occurrence of delirium in aged patients assisted in emergency services and verify its relationship with sociodemographic and clinical variables. METHOD: cross-sectional, prospective study with a quantitative approach. Two hundred aged hospitalized patients participated. The Confusion Assessment Method was used for data collection. For statistical analysis, chi-square tests, likelihood ratio and Fisher's test were used, with a significance level of 5%. RESULTS: male gender and mean age of 71.8 years were predominant. In the first 24 hours of hospitalization, 56 (28%) aged individuals presented delirium. An association of the disease with lack of physical activity, presence of a caregiver, hypertension, dyslipidemia and cerebrovascular diseases was identified. CONCLUSION: Delirium was associated with no physical activity, the need of a caregiver, and the presence of comorbidities. The importance of conducting other studies that may lead to early identification of the condition to prevent its complications is emphasized.