Spanish transcultural adaptation of the 4AT score for the evaluation of delirium in the emergency department: a prospective diagnostic test accuracy study.

BACKGROUND: Delirium is one of the most common adverse events in older people during hospitalization, especially in the emergency department. Reliable, easy-to-use instruments are necessary to properly manage delirium in this setting. This study aims to evaluate the diagnostic validity of the Spanish version of the 4 'A's Test (4AT) in the ED. METHODS: A diagnostic accuracy study was conducted in patients over 65 years old admitted to the Emergency Department who did not have a formal diagnosis of dementia or a severe mental health disorder. Face and content validity were evaluated by an expert panel. Emergency nurses performed the evaluation with 4AT, whilst blinded and trained researchers assessed patients with the Revised Delirium Rating Scale as the gold standard. The content validity index, sensitivity, specificity, positive and negative predictive values, likelihood ratios, Youden's Index and ROC curves were calculated to evaluate the diagnostic accuracy of the instrument. RESULTS: Of 393 eligible patients, 380 were finally analyzed. Content validity yielded a median content validity index of 4 (interquartile range: 0). The Spanish 4AT sensitivity (95.83%; 95% ECI: 78.9-99.9%), specificity (92.98%; 95% CI: 89.8-95.4%), positive predictive value (47.92%) and negative predictive value (99.7%) were satisfactory. Youden's index was 0.89. Positive likelihood ratio was 13.65, and negative likelihood ratio 0.045. The area under the curve was 0.97. CONCLUSIONS: The Spanish version of the 4AT for use in the Emergency Departments is easy-to-use and applicable. The validation results indicate that it is a valid instrument with sufficient predictive validity to identify patients at risk of delirium in the Emergency Departments. Moreover, it is a tool that facilitates the management of an adverse event that is associated with increased mortality and morbidity.

Relation between hyponatraemia and falls by acute hospitalised patients: A case-control study.

AIMS AND OBJECTIVES: To investigate the possible association between hyponatremia and falls, in a sample of hospitalised adult patients. BACKGROUND: In-hospital falls are a problem of major importance, provoking a significant decline in the quality of life of many patients. Recent studies have identified a relationship between such falls and the presence of hyponatremia. DESIGN: Analytical retrospective observational case-control study. METHODS: The study population consisted of hospitalised patients who had suffered an in-hospital fall during the period 2014-2016. For each case, two controls who had not suffered any such fall were recruited. These cases and controls were matched according to gender, age, hospitalisation unit and date of admission. Study data were obtained from the hospital's record of falls, regarding the patients' socio-demographic factors, physical and psychological conditions and blood levels of sodium, potassium, urea and creatinine. The study is reported in accordance with STrengthening the Reporting of OBservational studies in Epidemiology guidelines. RESULTS: The study sample consisted of 555 patients (185 cases and 370 controls). Hyponatraemia was detected in 57 cases (30.8%). A statistically significant relationship was found between the presence of hyponatraemia and the occurrence of falls: OR = 2.04. Other risk factors for falls were hypercreatinaemia OR 2.49, hyperuraemia OR 1.82, disorientation, need for ambulatory assistance and longer hospital stay. CONCLUSIONS: From the study findings, we conclude that hyponatraemia is a predictor of falls by acute hospitalised patients. Further research is needed on the relationship between hypercreatinaemia, hyperuraemia and falls. RELEVANCE TO CLINICAL PRACTICE: The assessment of risk factors for falls, such as hyponatraemia, can alert us to the possibility of this event occurring and facilitate the implementation of preventive measures. This parameter should be included as a significant new factor in assessment instruments designed to assess the risk of falls, thus enhancing the reliability and diagnostic validity of these instruments.

A protocol for a randomized trial measuring flowmetry in risk areas for pressure ulcer: Hyperoxygenated fatty acids vs olive oil.

BACKGROUND: Pressure ulcers are a common adverse event in healthcare. To date, no flowmetry studies have been conducted to compare hyperoxygenated fatty acids (HFA) vs. extra-virgin olive oil (EVOO) in alleviating this condition. AIMS: To determine and evaluate the effect of the application of HFA vs. EVOO on tissue oxygenation and perfusion in heels under pressure, in healthy persons and in hospitalised patients. DESIGN: Two-phase experimental study. METHODS: Phase 1 will be conducted with healthy subjects, using a randomised, open study design, evaluating an intrasubject control group. Phase 2 will focus on hospitalised subjects, with a randomised, open study group vs. a control group. DISCUSSION: This Project is undertaken to identify the mechanisms that intervene in the genesis of pressure ulcers and to determine whether there are differences in outcomes between the application of HFA vs. EVOO as a preventive measure The results of this study are of economic importance (due to the price difference between the products used) and will also impact on usual clinical practice for patients with impaired mobility and liable to suffer from pressure ulcers, by considering an alternative to established preventive measures.

Validation of living with chronic illness scale in a type 2 diabetes mellitus population.

BACKGROUND: Worldwide, type 2 diabetes mellitus (T2DM) is one of the most prevalent chronic diseases and one of those producing greatest impact on patients' day-to-day quality of life. Our study aim is to validate the "Living with Chronic Illness Scale" for a Spanish-speaking T2DM population. METHODS: In this observational, international, cross-sectional study, 582 persons with T2DM were recruited in primary care and outpatient hospital consultations, in Spain and Colombia, during the period from May 2018 to June 2019. The properties analysed were feasibility/acceptability, internal consistency, reliability, precision and (structural) content-construct validity including confirmatory factor analysis. The COSMIN checklist was used to assess the methodological/psychometric quality of the instrument. RESULTS: The scale had an adequate internal consistency and test retest reliability (Cronbach's alpha = 0.90; intraclass correlation coefficient = 0.96, respectively). In addition, the instrument is precise (standard error of measurement = 3.34, with values < ½SD = 8.52) and correlates positively with social support (DUFSS) (rs = 0.56), quality of life (WHOQOL-BREF) (rs = 0.51-0.30) and ssatisfaction with life (SLS-6) (rs = 0.50-0.38). The original 26-items version of the scale did not support totally the confirmatory factor analysis. The COSMIN checklist is favourable for all the properties analysed, although weaknesses are detected for structural validity. CONCLUSIONS: The LW-CI-T2DM is a valid, reliable and accurate instrument for use in clinical practice to determine how a person's life is affected by the presence of diabetes. This instrument correlates well with the associated constructs of social support, quality of life and satisfaction. Additional research is needed to determine how well the questionnaire structure performs when robust factor analysis methods are applied.

Impact of a nurse-led intervention on quality of life in patients with chronic non-malignant pain: An open randomized controlled trial.

AIMS: To determine the effect of a comprehensive nurse-led programme for patients with chronic non-malignant pain, on quality of life, level of pain, anxiety, and depression, as primary outcomes and patients' satisfaction as a secondary end point. DESIGN: An open-label randomized controlled trial was carried out. METHODS: The experimental group received both a nurse-led intervention on healthy lifestyles, education on self-esteem, pain awareness, communication, and relaxation techniques. The control group received usual care. Quality of life, level of pain, anxiety, and depression were the main outcomes. Data were obtained at baseline, immediately after the intervention, and 6 and 9 months. The study was carried out from 2015-2017. RESULTS: The sample was composed of 279 patients. At 9 months, the effect size (non-parametric effect size statistic A) favoured the intervention group for SF-36 mental health score (A = 0.79; 95% CI: 0.73-0.85), anxiety (A = 0.58; 95% CI: 0.51-0.65), pain intensity (A = 0.57; 95% CI: 0.51-0.64), and depression (A = 0.58; 95% CI: 0.51-0.65). Smaller differences were found on physical scores between the intervention and the usual care group. Patients showed a high level of satisfaction with the introduced intervention. CONCLUSION: A comprehensive nurse-led programme for patients with chronic non-malignant pain has a positive impact on their quality of life, level of pain, and mental health. IMPACT: Studies have reported that the problem of chronic pain is not optimally controlled. A structured nurse-led programme has been tested to facilitate healthy behaviours to help patients manage their chronic pain and to provide them with the necessary tools for their self-care. This nurse-led intervention improved their mental health and decreased their level of pain.

Tissue temperature, flux and oxygen of sacral and trochanteric area under pressure of healthy subjects: A quasi-experimental study.

AIM: To evaluate the changes that take place in the perfusion, oxygenation and local temperature of the skin of the sacrum and trochanter when subjected to direct pressure for 2 h. METHODS: Quasi-experimental study in the preclinical phase with healthy subjects acting as their own controls (intrasubject control). The outcome variables were measured with a laser Doppler system (local temperature and oxygenation) and by near-infrared spectroscopy (perfusion). The pressure exerted was measured with a capacitive pressure sensor. No more than one week elapsed between the sacrum and trochanter measurements. RESULTS: The study sample consisted of 18 persons. The comparative analysis of the fluctuations in the parameters measured on the skin of the trochanters and sacrum, according to the time elapsed, revealed a statistically significant increase in temperature and in the pressure exerted. On the other hand, the changes in capillary blood flow and in SaO2 were not statistically significant. CONCLUSION: Our study results show that changes found in terms of temperature and pressure should be taking into account when planning personalised repositioning to patients according to biomechanical and biological situations that vary between anatomical areas. In future research, the changes reported could be evaluated in patients with risk factors for the development of pressure ulcers, thus facilitating the introduction of more personalised planning in the care and prevention of these injuries.

Effectiveness of a hydrophobic dressing for microorganisms' colonization of vascular ulcers: Protocol for a randomized controlled trial (CUCO-UV Study).

AIM: To determine the effectiveness of a hydrophobic dressing (Cutimed Sorbact® ) against a silver dressing (Aquacel® Ag Extra) in the level of colonization of chronic venous leg ulcers. The secondary endpoints are health-related quality of life, level of pain, and time to complete healing. DESIGN: Open randomized controlled trial, with blinded endpoint. METHODS: Patients with chronic venous leg ulcers with signs of critical colonization will be randomized in a concealed sequence using computer software to receive one of the alternative dressings. A total of 204 participants recruited in Primary Health Care and nursing homes will be necessary to assure statistical power. Measures will include sociodemographic variables, wound-related variables (area, exudate, and time to healing), level of pain, adverse effects, and health-related quality of life. Smear samples will be collected from the ulcers and will be subject to DNA-typing technique through polymerase chain reaction to obtain the level of colony-forming units. Measures will be collected at baseline, 4, 8, and 12 weeks. DISCUSSION: Elevated levels of microorganisms prevent wound healing and favour its chronification. The main target when colonization is present is to reduce the bacterial load to levels that promote immune system mobilization. Hydrophobic dressings prevent the formation of biofilm in the wound by means of physical effect, so that the possibility of antimicrobial resistance is significantly reduced. IMPACT: Current evidence about the effectiveness of dressings to minimize venous leg ulcers colonization is very limited. Previous studies have important methodological flaws. This study will permit to obtain the effectiveness of hydrophobic dressings against silver dressings with a robust design based on conditions of routine clinical practice in Primary Health Care and nursing homes.

Perfusion, tissue oxygenation and peripheral temperature in the skin of heels of healthy participants exposed to pressure: a quasi-experimental study.

AIM: To evaluate the relationship between the pressure exerted on the heel of one foot resting directly on a mattress, versus that exerted on the other heel, protected by a pillow beneath the Achilles tendon area and the changes thus produced in perfusion, oxygenation and temperature in the skin of heels of healthy volunteers lying in a supine position. DESIGN: Experimental study in a pre-clinical phase, with healthy volunteer participants and intrapeople control. METHODS: The study was carried out from November 2017 - May 2018. A pressure measurement surface was placed between the participant and the constant low-pressure support surface. Doppler laser devices were used to measure local temperature and perfusion. The degree of oxygenation was determined using an infrared beam close to the pressure zone in each heel. Both feet rested immobile on the bed, in a natural position, for 2 hr. To ensure intrapeople control, in every case the left heel was raised slightly, compared with the right. RESULTS: Eighteen participants took part in this study. Analysis of the results obtained showed that capillary blood flow was significantly reduced in the heel subjected to pressure, compared with the other heel, while no significant effects on oxygen saturation or temperature were observed. The variables associated with greater oxygen saturation were capillary blood flow, local temperature and pressure exerted. Fat-free mass, fat mass and duration of exposure to pressure were all significantly associated with reduced oxygen saturation. CONCLUSIONS: In healthy participants, when the heel is subjected to constant pressure against a constant low-pressure support surface, there is a significant reduction in blood flow, compared with the heel where pressure is relieved. However, there are no significant differences in temperature or tissue oxygenation. IMPACT: Significant reductions in vascular flow were observed; however, the oxygenation and temperature of the heel tissues remained unchanged. These findings, corroborated in real patients, would advance our understanding and facilitate decision-making on measures to prevent pressure ulcers, such as repositioning or tissue protection. TRIAL REGISTRATION: The protocol is registered in ClinicalTrials.gov (NCT02736838).

Pressure levels in the trochanter area according to repositioning at different degrees of inclination in healthy subjects.

OBJECTIVES: Patient repositioning is a recommended intervention to prevent or treat pressure ulcers (PUs). One option under consideration is the tailored repositioning according to patient characteristics, but more knowledge is needed on how different repositioning patterns influence on skin pressure. To determine what degree of inclination of the body in bed generates more pressure in the trochanteric region. Additionally, to analyze the influence of factors such as gender, age and anthropometric characteristics in the variations of this pressure. METHODS: Analytical cross-sectional study. Body Mass Index (BMI), lean mass and fat mass were measured in healthy volunteers subject to different inclinations (90°, 60° and 30°) in right lateral decubitus. Pressure was measured with a capacitive surface. RESULTS: In total, 146 subjects were included, of which 45 were men and 101 women. The results showed pressure differences due to the inclination according to gender and anthropometric values, being statistically significant in men at 90° and 60°, and in women at 30°. (hombres 90° p = 0,026, 60° p = 0,049; mujeres 30° p = 0,036) según prueba Brown-Forsythe. CONCLUSIONS: There are differences in the pressures of the trochanteric zone depending on anthropometric factors and by gender, in different body positions. Obese people exerted a higher pressure in the trochanter area at 30° of body inclination than overweight, normal weight and underweight people, respectively. From the clinical point of view, these findings invite to consider a possible differentiation in the repositioning interventions of the patients, according to gender and BMI, as a preventive strategy for PUs.

Peripheral perfusion and oxygenation in areas of risk of skin integrity impairment exposed to pressure patterns. A phase I trial (POTER Study).

AIM: The aim of this study was to analyse the change in peripheral oxygenation and microvascular flow in tissues subjected to different pressure regimes in healthy subjects and in hospitalized patients. BACKGROUND: The presence of pressure ulcers in hospitalized patients is a common complication that has a negative impact on health and often prolongs hospital stay and increases healthcare costs. DESIGN: Experimental non-controlled, non-randomized study in two phases: pre-clinical and clinical. METHODS: The pre-clinical phase will be conducted in healthy volunteers and the clinical phase, in patients at risk of impaired skin integrity. Vascular flow, tissue oxygenation and local temperature in areas at risk of pressure ulcers will be evaluated by Doppler laser in subjects lying on a capacitive surface to measure pressure at 10,249 points. Different levels of pressure will be generated by changes in body position and changes in tissue perfusion and oxygenation will be monitored for up to 4 hours, to determine the implications for repositioning interventions in patients at risk. This study was funded in July 2015. The protocol is registered in ClinicalTrials.gov (NCT02736838). DISCUSSION: Pressure ulcer is a significant and complex health problem in long-term bedridden patients and there is currently no effective treatment or efficient prevention method. The information provided by our study will provide an accurate assessment of different thresholds for the onset of damage to the skin, associated with different body positions and pressure levels. TRIAL REGISTRATION: The protocol is registered in ClinicalTrials.gov (NCT02736838).

Diagnostic validity of the STRATIFY and Downton instruments for evaluating the risk of falls by hospitalised acute-care patients: a multicentre longitudinal study.

BACKGROUND: Falls are major adverse events in hospitals. The appropriateness of using risk assessment instruments for falls in hospitals has recently been questioned, although the research performed in this respect presents some methodological shortcomings. The purpose of the present study is to evaluate the accuracy of the Downton and STRATIFY instruments to determine the risk of falls and to predict their incidence in acute care hospitals in the public health system in Andalusia (Spain). METHODS: A longitudinal, multicentre prospective study was made of a cohort of patients recruited between May 2014 and March 2016. The risk of falls was assessed using each of the above instruments during the first 24 h after hospital admittance, with later re-evaluations every 72 h until discharge. Descriptive statistics were obtained, bivariate and multivariate analysis were performed. The diagnostic validity of the process was assessed by calculations of sensitivity, specificity, positive and negative predictive values and ratios of positive and negative likelihood. ROC curve analysis was performed for both instruments. RESULTS: For this study, 1247 patients were recruited, of whom 977 completed all the follow-up assessments. Twenty-three of these patients (2.35%) suffered 24 falls. ROC curve analysis showed that the optimal cut-off point for each assessment instrument was below that described by the authors: AUC STRATIFY = 0.69 (95% CI: 0.57-0.8); AUC Downton = 0.6 (95% CI: 0.48-0.72). With a cut-off point of 1, the sensitivity of STRATIFY was 47.6% and its specificity, 85%. With a cut-off point of 2, Downton presented a sensitivity of 66.7% and a specificity of 55.3%. CONCLUSIONS: The Downton and STRATIFY falls risk assessment instruments presented little utility as means of detecting the risk of falls among a sample of adult patients admitted to acute care hospitals. Fall prevention in hospitals should be based on the study of individual risk factors.

Development and psychometric validation of a questionnaire to evaluate nurses' adherence to recommendations for preventing pressure ulcers (QARPPU).

AIM OF THE STUDY: The main objective of this work is the development and psychometric validation of an instrument to evaluate nurses' adherence to the main recommendations issued for preventing pressure ulcers. MATERIAL AND METHODS: An instrument was designed based on the main recommendations for the prevention of pressure ulcers published in various clinical practice guides. Subsequently, it was proceeded to evaluate the face and content validity of the instrument by an expert group. It has been applied to 249 Spanish nurses took part in a cross-sectional study to obtain a psychometric evaluation (reliability and construct validity) of the instrument. The study data were compiled from June 2015 to July 2016. RESULTS: From the results of the psychometric analysis, a final 18-item, 4-factor questionnaire was derived, which explained 60.5% of the variance and presented the following optimal indices of fit (CMIN/DF: 1.40 p < 0.001; GFI: 0.93; NFI: 0.92; CFI: 0.98; TLI: 0.97; RMSEA: 0.04 (90% CI 0.025-0.054). CONCLUSIONS: The results obtained show that the instrument presents suitable psychometric properties for evaluating nurses' adherence to recommendations for the prevention of pressure ulcers.

Validation of the STRATIFY falls risk-assessment tool for acute-care hospital patients and nursing home residents: study protocol.

AIM: To evaluate the accuracy of the STRATIFY tool in detecting and predicting fall risk in acute-care hospitals and nursing homes for the older people. BACKGROUND: Falls are the predominant cause of injury in people aged over 65 years. Testing the falls risk-assessment tools in settings other than those for which they were originally developed obtained conflicting results and has highlighted difficulties in their adoption for widespread use. Current guidelines for practice call into question the appropriateness of using these instruments. DESIGN: Two-stage study: a cross-cultural adaptation and psychometric validation; and a longitudinal, prospective follow-up of the cohort of patients recruited. METHODS: A cross-cultural adaptation of STRATIFY, followed by its empirical validation will be performed, on a total sample of 2097 patients. The diagnostic validity will be assessed by calculating the sensitivity, specificity, positive and negative predictive values and the ratios of positive and negative probability. Data for statistical reliability and the internal consistency of the instrument will be calculated; construct validity will be assessed by factor analysis and criterion validity determined according to the Downton index. The incidence and the hazard ratio of falls will be analysed for the study factors included. Funding of the review was confirmed in December 2013. DISCUSSION: The rigorous assessment of STRATIFY using large samples, in populations with different levels of risk and implementing a longitudinal follow-up to determine the effect of revaluation on the incidence of falls, will give stronger evidence for the establishment of future recommendations in Clinical Practice Guidelines.

Design and validation of the INICIARE instrument, for the assessment of dependency level in acutely ill hospitalised patients.

AIMS AND OBJECTIVES: The aim of this study was to establish the validity and reliability of an instrument (Inventario del NIvel de Cuidados mediante IndicAdores de clasificación de Resultados de Enfermería) used to assess the dependency level in acutely hospitalised patients. This instrument is novel, and it is based on the Nursing Outcomes Classification. BACKGROUND: Multiple existing instruments for needs assessment have been poorly validated and based predominately on interventions. Standardised Nursing Languages offer an ideal framework to develop nursing sensitive instruments. DESIGN: A cross-sectional validation study in two acute care hospitals in Spain. METHODS: This study was implemented in two phases. First, the research team developed the instrument to be validated. In the second phase, the validation process was performed by experts, and the data analysis was conducted to establish the psychometric properties of the instrument. RESULTS: Seven hundred and sixty-one patient ratings performed by nurses were collected during the course of the research study. Data analysis yielded a Cronbach's alpha of 0·91. An exploratory factorial analysis identified three factors (Physiological, Instrumental and Cognitive-behavioural), which explained 74% of the variance. CONCLUSIONS: Inventario del NIvel de Cuidados mediante IndicAdores de clasificación de Resultados de Enfermería was demonstrated to be a valid and reliable instrument based on its use in acutely hospitalised patients to assess the level of dependency. RELEVANCE TO CLINICAL PRACTICE: Inventario del NIvel de Cuidados mediante IndicAdores de clasificación de Resultados de Enfermería can be used as an assessment tool in hospitalised patients during the nursing process throughout the entire hospitalisation period. It contributes information to support decisions on nursing diagnoses, interventions and outcomes. It also enables data codification in large databases.

Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review and meta-analysis.

BACKGROUND: Falls are a serious problem for hospitalized patients, reducing the duration and quality of life. It is estimated that over 84% of all adverse events in hospitalized patients are related to falls. Some fall risk assessment tools have been developed and tested in environments other than those for which they were developed with serious validity discrepancies. The aim of this review is to determine the accuracy of instruments for detecting fall risk and predicting falls in acute hospitalized patients. METHODS: Systematic review and meta-analysis. Main databases, related websites and grey literature were searched. Two blinded reviewers evaluated title and abstracts of the selected articles and, if they met inclusion criteria, methodological quality was assessed in a new blinded process. Meta-analyses of diagnostic ORs (DOR) and likelihood (LH) coefficients were performed with the random effects method. Forest plots were calculated for sensitivity and specificity, DOR and LH. Additionally, summary ROC (SROC) curves were calculated for every analysis. RESULTS: Fourteen studies were selected for the review. The meta-analysis was performed with the Morse (MFS), STRATIFY and Hendrich II Fall Risk Model scales. The STRATIFY tool provided greater diagnostic validity, with a DOR value of 7.64 (4.86 - 12.00). A meta-regression was performed to assess the effect of average patient age over 65 years and the performance or otherwise of risk reassessments during the patient's stay. The reassessment showed a significant reduction in the DOR on the MFS (rDOR 0.75, 95% CI: 0.64 - 0.89, p = 0.017). CONCLUSIONS: The STRATIFY scale was found to be the best tool for assessing the risk of falls by hospitalized acutely-ill adults. However, the behaviour of these instruments varies considerably depending on the population and the environment, and so their operation should be tested prior to implementation. Further studies are needed to investigate the effect of the reassessment of these instruments with respect to hospitalized adult patients, and to consider the real compliance by healthcare personnel with procedures related to patient safety, and in particular concerning the prevention of falls.

Instruments for assessing the risk of falls in acute hospitalized patients: a systematic review protocol.

AIM: The purpose of this article is to present the research protocol of a systematic review about fall risk assessment tools in acute hospitalized patients. BACKGROUND: Various risk assessment tools for falls have been developed, but with uncertainties derived from validation in heterogeneous environments and variations in their sensitivity, specificity and predictive validity. DESIGN: Systematic review and meta-analysis. METHODS: Two independent reviewers will extract data in a blinded process. Quality of studies will be assessed using various standardized instruments. A meta-analysis will be performed if applicable. For all studies, sensitivity, specificity, positive and negative predictive values, together with the positive and negative likelihood ratios and Youden index will be calculated. The diagnostic odds ratio of the studies and the hierarchical summary Relative Operating Characteristic curve and bivariate model will be applied. Calculations will be made from random effects models. Forest-plot diagrams for sensitivity and specificity and likelihood ratios, in addition to Cochrane's Q test and the I(2) statistic, will be calculated. Funding of the review was confirmed in December 2010. DISCUSSION: The results of this review will help to clarify some uncertainties provoked by earlier research findings and enable informed choice of a validated, reproducible instrument for assessing the risk of falls by hospital patients, so that preventive action may be taken to minimize this risk.

Clinical and functional assessment in patients admitted with pluripathological dysphagia according to the mode of feeding: Through a gastrostomy tube or oral.

INTRODUCTION: Multipathological patients are a vulnerable population with high comorbidity, functional impairment, and nutritional risk. Almost 50% of these hospitalized patients have dysphagia. There is no consensus on whether placement of a percutaneous endoscopic gastrostomy (PEG) tube provides greater clinical benefit. The purpose of this study was to know and compare 2 groups of multipathological patients with dysphagia according to the mode of feeding: PEG vs. oral. METHOD: Retrospective descriptive study with hospitalized patients (2016-19), pluripathological, with dysphagia, nutritional risk, over 50 years with diagnoses of: dementia, cerebrovascular accident (CVA), neurological disease, or oropharyngeal neoplasia. Terminally ill patients with jejunostomy tube or parenteral nutrition were excluded. Sociodemographic variables, clinical situation, and comorbidities were evaluated. Bivariate analysis was performed to compare both groups according to their diet, establishing a significance level of p < .05. RESULTS: 1928 multipathological patients. The PEG group consisted of 84 patients (n122). A total of 84 were randomly selected to form the non-PEG group (n434). This group had less history of bronchoaspiration/pneumonia (p = .008), its main diagnosis was stroke versus dementia in the PEG group (p < .001). Both groups had more than a 45% risk of comorbidity (p = .77). CONCLUSIONS: multipathological patients with dysphagia with PEG usually have dementia as their main diagnosis, however, stroke is the most relevant pathology in those fed orally. Both groups have associated risk factors, high comorbidity, and dependence. This causes their vital prognosis to be limited regardless of the mode of feeding.

Patient transfers from emergency departments to other in-hospital areas: a failure mode and effects analysis. / Análisis modal de fallos y efectos en las transferencias de pacientes de urgencias a hospitalización.

OBJECTIVES: To perform an in-depth analysis of the process of transferring patients from an emergency department (ED) to other areas inside a hospital and identify possible points of failure and risk so that strategies for improvement can be developed. MATERIAL AND METHODS: We formed a multidisciplinary group of ED and other personnel working with hospitalized adults. The group applied failure mode and effects analysis (FMEA) to understand the in-hospital transfer processes. A risk priority scoring system was then established to assess the seriousness of each risk and the likelihood it would appear and be detected. RESULTS: We identified 8 transfer subprocesses and 14 critical points at which failures could occur. Processes related to administering medications and identifying patients were the components that received the highest risk priority scores. Improvement strategies were established for all risks. The group created a specific protocol for in-hospital transfers and a checklist to use during handovers. CONCLUSION: The FMEA method helped the group to identify points when there is risk of failure during patient transfers and to define ways to improve patient safety.

OBJETIVO: Este estudio analiza en profundidad el proceso de transferencia de pacientes de urgencias a hospitalización y posibles fallos para evitar problemas de seguridad mediante la identificación de líneas de mejora. METODO: Se conformó un grupo de trabajo multidisciplinar compuesto por profesionales asistenciales de urgencias y hospitalización de adultos que, mediante la metodología de análisis modal de fallos y efectos (AMFE), analizó pormenorizadamente el proceso de transferencia de pacientes de urgencias a hospitalización. Para los puntos críticos identificados se estableció el índice de prioridad del riesgo (IPR) en base a su gravedad, probabilidad de aparición y de detección. RESULTADOS: Se identificaron 8 subprocesos y 14 puntos críticos que podrían generar fallos en el proceso de transferencia. Los aspectos relacionados con la administración de medicamentos y el proceso de identificación fueron los que obtuvieron mayores puntuaciones de IPR. Para todos ellos se establecieron acciones de mejora. Se elaboró un procedimiento específico de transferencia de pacientes entre estas áreas y un listado de verificación de ingresos en hospitalización. CONCLUSIONES: Con la metodología AMFE se ha conseguido desgranar un proceso de especial vulnerabilidad como es la transferencia de pacientes de urgencias a hospitalización y definir acciones de mejora en aras de incrementar la seguridad de los pacientes.

Development of a Clinical Prediction Rule for Adverse Events in Multimorbid Patients in Emergency and Hospitalisation.

(1) Background: There is currently a global consensus that the quality of comprehensive care for acutely hospitalised elderly people should include addressing functionality and mobility, cognitive status, prevention of pressure ulcers, urinary incontinence, falls and delirium, as well as pain control and medication-related problems. The aim of this study is to develop and validate a clinical prediction rule for multimorbid patients admitted to an acute care hospital unit for any of the five adverse events included in our vulnerability pentad: falls, pressure ulcers, urinary incontinence, pain and delirium. (2) Methods: Longitudinal analytical clinimetric study, with two cohorts. The study population will consist of multimorbid patients hospitalised for acute care, referred from the Emergency Room. A clinical prediction rule will be proposed, incorporating predictive factors of these five adverse outcomes described. This study has received funding, awarded in November 2020 (PI-0107-2020), and was approved in October 2019 by the Research Ethics Committee ″Costa del Sol″. (3) Conclusions: Preventing adverse events in hospitalised patients is particularly important for those with multimorbidity. By applying a clinical prediction rule to detect specific risks, an estimate can be obtained of their probability of occurrence.