Sectorización del trabajo de Médicos Hospitalistas por área geográfica en un hospital universitario con servicios médico quirúrgicos indiferenciados. Proyecto de mejora de calidad / Geographic sectorization of hospitalized patients to health care teams. Impact on teamwork and patient satisfaction

Historically, the wards of hospitals were divided by services such as medicine, surgery and traumatology, among others. To optimize the use of beds, undifferentiated medical surgical services were implemented in different hospitals in the country. This work organization had consequences in several areas, such as teamwork, the sense of belonging, the quality of teaching and travel times, among other factors. In 2018, at a Clinical hospital, we started a quality improvement project that consisted of assigning low complexity internal medicine teams to limited geographic areas, aiming to have sectorized teams. Through some PlanStudy-Do-Act (PDSA) cycles of continuous improvement, more than 80% of the patients were quickly sectorized, however there were multiple threats during the project. Pre- and post-implementation surveys were conducted with nurses, internal medicine residents, and medical Staff, highlighting an improvement in multiple aspects concerning the quality of communication, interdisciplinary work, the time of visits, and satisfaction, among others.

[Geographic sectorization of hospitalized patients to health care teams. Impact on teamwork and patient satisfaction]. / Sectorización del trabajo de Médicos Hospitalistas por área geográfica en un hospital universitario con servicios médico quirúrgicos indiferenciados. Proyecto de mejora de calidad.

Historically, the wards of hospitals were divided by services such as medicine, surgery and traumatology, among others. To optimize the use of beds, undifferentiated medical surgical services were implemented in different hospitals in the country. This work organization had consequences in several areas, such as teamwork, the sense of belonging, the quality of teaching and travel times, among other factors. In 2018, at a Clinical hospital, we started a quality improvement project that consisted of assigning low complexity internal medicine teams to limited geographic areas, aiming to have sectorized teams. Through some PlanStudy-Do-Act (PDSA) cycles of continuous improvement, more than 80% of the patients were quickly sectorized, however there were multiple threats during the project. Pre- and post-implementation surveys were conducted with nurses, internal medicine residents, and medical Staff, highlighting an improvement in multiple aspects concerning the quality of communication, interdisciplinary work, the time of visits, and satisfaction, among others.

La importancia de la evidencia y de la adherencia a los protocolos clínicos en bienestar de los pacientes. Caso clínico de morbimortalidad

We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.

[Low molecular weight heparin-induced hyperkalemia and hyponatremia. Report of one case]. / Hiponatremia e hiperpotasemia persistente inducida por enoxaparina y revertida con hidrocortisona en paciente con metástasis lumbares.

Low molecular weight heparin-induced hyperkalemia is not an uncommon side effect. The development of hyponatremia is well described although it is less common. We report a 72-year-old woman with lumbar metastases who developed hyponatremia and hyperkalemia on the tenth day of hospitalization. Hyponatremia, with limited criteria for syndrome of inappropriate secretion of antidiuretic hormone, did not resolve with vigorous volume restriction. Hyperkalemia without an acid-base disorder or baseline renal failure, did not resolve after losartan was stopped. Enoxaparin-induced hypoaldosteronism was proposed and the drug was discontinued. After four days' persistence of the electrolyte disturbance, dexamethasone was changed to Hydrocortisone, and parameters normalized in 24 hours. The patient remained well until discharge and during outpatient control.

Hiponatremia e hiperpotasemia persistente inducida por enoxaparina y revertida con hidrocortisona en paciente con metástasis lumbares / Low molecular weight heparin-induced hyperkalemia and hyponatremia: report of one case

Low molecular weight heparin-induced hyperkalemia is not an uncommon side effect. The development of hyponatremia is well described although it is less common. We report a 72-year-old woman with lumbar metastases who developed hyponatremia and hyperkalemia on the tenth day of hospitalization. Hyponatremia, with limited criteria for syndrome of inappropriate secretion of antidiuretic hormone, did not resolve with vigorous volume restriction. Hyperkalemia without an acid-base disorder or baseline renal failure, did not resolve after losartan was stopped. Enoxaparin-induced hypoaldosteronism was proposed and the drug was discontinued. After four days' persistence of the electrolyte disturbance, dexamethasone was changed to Hydrocortisone, and parameters normalized in 24 hours. The patient remained well until discharge and during outpatient control.

[The importance of timely and safe care. Report of one case]. / La importancia de la evidencia y de la adherencia a los protocolos clínicos en bienestar de los pacientes. Caso clínico de morbimortalidad.

We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.

Resección quirúrgica de tapón de cianoacrilato variceal infectado posterior a esclerosis endoscópica de várices gástricas. Caso clínico

In patients with actively bleeding gastric varices, the treatment of choice is the endoscopic use of sclerosing agents such as cyanoacrylate. We report a 69-year-old man who, after being treated with cyanoacrylate, suffered from recurrent febrile episodes. After an extensive study and broad-spectrum antibiotic treatment, discarding other presumably infectious focus, the superinfection of the cyanoacrylate plug was suspected, and its surgical removal was decided. A partial gastrectomy of the gastric fundus, a splenectomy, and a distal pancreatectomy were performed. The patient evolved without fever and without new episodes of bacteremia, but with decompensation of his cirrhosis manifested by ascites, spontaneous bacterial peritonitis, pneumonia, and collections in the pancreatic bed. These complications were managed with medical treatment consisting in a long course of broad-spectrum antibiotics. Thereafter, the patient evolved satisfactorily.

[Removal of an infected gastric cyanoacrylate plug. Report of one case]. / Resección quirúrgica de tapón de cianoacrilato variceal infectado posterior a esclerosis endoscópica de várices gástricas. Caso clínico.

In patients with actively bleeding gastric varices, the treatment of choice is the endoscopic use of sclerosing agents such as cyanoacrylate. We report a 69-year-old man who, after being treated with cyanoacrylate, suffered from recurrent febrile episodes. After an extensive study and broad-spectrum antibiotic treatment, discarding other presumably infectious focus, the superinfection of the cyanoacrylate plug was suspected, and its surgical removal was decided. A partial gastrectomy of the gastric fundus, a splenectomy, and a distal pancreatectomy were performed. The patient evolved without fever and without new episodes of bacteremia, but with decompensation of his cirrhosis manifested by ascites, spontaneous bacterial peritonitis, pneumonia, and collections in the pancreatic bed. These complications were managed with medical treatment consisting in a long course of broad-spectrum antibiotics. Thereafter, the patient evolved satisfactorily.

[Risk of falls among patients admitted to a medical-surgical ward. Analysis of 376 medical records]. / Prevalencia de pacientes con alto riesgo de caídas en un servicio médico-quirúrgico de un hospital universitario.

BACKGROUND: Detecting patients at risk of falls during hospital stay is of utmost importance to implement preventive measures. AIM: To determine the frequency of patients with a high risk of falls admitted to a medical-surgical ward. To assess the preventive measures implemented. MATERIALS AND METHODS: Review of medical records of 376 patients aged 20 to 97 years (28% older than 70 years) admitted to a clinical hospital in a period of four months. RESULTS: Eleven percent of patients had a history of falls, 50% had a sensory deficit, 68% had unstable gait, 8% had a neurological risk condition, 8% had drowsiness or disorientation, 4% had psychomotor agitation or delirium, 86 % used high risk medications, 73% used 2 or more high risk drugs and 72% were using devices that decrease mobility. One hundred forty-one patients (38%) had a high risk of falling. The mean age of the latter was 77 years, 89% had a sensory deficit, 96% had unstable gait, 4% had psychomotor agitation or delirium and 98% used high risk drugs. Less than 1% had a medical prescription of a caregiver, physical restraints or antipsychotics, however, 21% of patients had a caregiver. CONCLUSIONS: The percentage of patients with a high risk of falling is important. The main risk factors were sensory deficit, unstable gait and the use of high risk medications. The low frequency of preventive measures prescriptions is striking.

Alteración de signos vitales dentro de las 72 h previas a la activación de código azul en pacientes adultos hospitalizados de un hospital universitario / Deterioration of vital signs as predictors of major medical emergencies in hospitalized patients

Background: Medical emergencies (ME) in hospitalized patients (cardiac and respiratory arrest, suffocation, asphyxia, seizures, unconsciousness) are associated with high morbidity and mortality. Most of these patients have signs of physiological deterioration prior to the appearance of the emergency. Early detection of warning signs by rapid response teams (RRT) may provide an opportunity for the prevention of major adverse events. Aim: To identify clinical signs predicting death, need for mechanical ventilation, or transfer to a more complex unit during the 72 hours prior to the activation of the ME code. To evaluate the association of each trigger with specific major adverse events. Patients and Methods: Medical records of 184 hospitalized adult patients in whom the ME code was activated between 2009 and 2014 were reviewed. Results: Seventy five percent patients who experienced a ME had predictive signs of poor clinical outcome. Polypnea and airway involvement were associated to mechanical ventilation. Hypotension and hypoxemia were associated with mortality. Conclusions: In the absence of RRT, special attention should be given to patients with polypnea, airway involvement, hypotension and desaturation, since these are associated with poor clinical outcomes.

Prevalencia de pacientes con alto riesgo de caídas en un servicio médico-quirúrgico de un hospital universitario / Risk of falls among patients admitted to a medical-surgical ward: analysis of 376 medical records

Background: Detecting patients at risk of falls during hospital stay is of utmost importance to implement preventive measures. Aim: To determine the frequency of patients with a high risk of falls admitted to a medical-surgical ward. To assess the preventive measures implemented. Materials and Methods: Review of medical records of 376 patients aged 20 to 97 years (28% older than 70 years) admitted to a clinical hospital in a period of four months. Results: Eleven percent of patients had a history of falls, 50% had a sensory deficit, 68% had unstable gait, 8% had a neurological risk condition, 8% had drowsiness or disorientation, 4% had psychomotor agitation or delirium, 86 % used high risk medications, 73% used 2 or more high risk drugs and 72% were using devices that decrease mobility. One hundred forty-one patients (38%) had a high risk of falling. The mean age of the latter was 77 years, 89% had a sensory deficit, 96% had unstable gait, 4% had psychomotor agitation or delirium and 98% used high risk drugs. Less than 1% had a medical prescription of a caregiver, physical restraints or antipsychotics, however, 21% of patients had a caregiver. Conclusions: The percentage of patients with a high risk of falling is important. The main risk factors were sensory deficit, unstable gait and the use of high risk medications. The low frequency of preventive measures prescriptions is striking.

[Deterioration of vital signs as predictors of major medical emergencies in hospitalized patients]. / Alteración de signos vitales dentro de las 72 h previas a la activación de código azul en pacientes adultos hospitalizados de un hospital universitario.

BACKGROUND: Medical emergencies (ME) in hospitalized patients (cardiac and respiratory arrest, suffocation, asphyxia, seizures, unconsciousness) are associated with high morbidity and mortality. Most of these patients have signs of physiological deterioration prior to the appearance of the emergency. Early detection of warning signs by rapid response teams (RRT) may provide an opportunity for the prevention of major adverse events. AIM: To identify clinical signs predicting death, need for mechanical ventilation, or transfer to a more complex unit during the 72 hours prior to the activation of the ME code. To evaluate the association of each trigger with specific major adverse events. PATIENTS AND METHODS: Medical records of 184 hospitalized adult patients in whom the ME code was activated between 2009 and 2014 were reviewed. RESULTS: Seventy five percent patients who experienced a ME had predictive signs of poor clinical outcome. Polypnea and airway involvement were associated to mechanical ventilation. Hypotension and hypoxemia were associated with mortality. CONCLUSIONS: In the absence of RRT, special attention should be given to patients with polypnea, airway involvement, hypotension and desaturation, since these are associated with poor clinical outcomes.

Identificación de gatillantes de sistema de respuesta rápida en pacientes de unidades de baja complejidad de un hospital universitario / Identification of rapid response system triggers in unit patients of low complexity of a university hospital

Las complicaciones graves de pacientes en unidades de baja complejidad habitualmente son precedidas por alteración en los signos vitales. Los equipos de respuesta rápida (ERR) atienden precozmente a pacientes con alteración de signos vitales que se relacionan con resultados adversos. Nuestro objetivo es determinar la tasa de gatillantes de ERR en pacientes hospitalizados en unidades de baja complejidad y su eventual relación con eventos adversos posteriores. Métodos: Observación de registros de una cohorte prospectiva de pacientes mayores de 18 años en unidades de baja complejidad de un hospital universitario. Resultados: Se encontraron gatillantes en 50 de 1144 pacientes (4,4 por ciento). La edad promedio fue de 58 años, y 58 por ciento fueron mujeres. Los gatillantes más frecuentes fueron: Hipotensión (40 por ciento), frecuencia respiratoria mayor a 25 por minuto (26 por ciento) y Saturación de oxígeno menor a 90 por ciento (24 por ciento). Presentaron eventos adversos mayores 6 pacientes (12 por ciento), 1 de ellos con desenlace fatal y los 6 fueron trasladados a unidad de mayor complejidad. No existió diferencia significativa entre quienes tuvieron 1 o 2 gatillantes en relación a eventos adversos mayores. Los 3 pacientes que presentaron compromiso de conciencia sufrieron eventos adversos mayores incluyendo la muerte de uno. Conclusión: Los gatillantes más frecuentes fueron hipotensión y taquipnea. La presencia de dos eventos gatillantes muestra una tendencia a un peor resultado, si bien no alcanza significancia estadística. Dado nuestra eventual tasa de activación de ERR si se justificaría la implementación de estos equipos en nuestro medio.(AU)

Serious patient complications in low complexity units are usually preceded by impaired vital signs. Rapid Response Teams (RRT) treat patients with impaired vital signs that are related to early adverse outcomes. Our objective is to determine the ERR trigger rates in hospitalized patients in low complexity units and their eventual relationship with subsequent adverse events. Methods: Recorded observation of a cohort of prospective patients older than 18 years in a University hospital´s low complexity units. Results: 50 out of 1.144 patients (4.4 percent) were found to have triggers. The mean age was 58 years, and 58 percent were women. The most frequent triggers were: Hypotension (40 percent), respiratory rate greater than 25 per minute (26 percent) and oxygen saturation less than 90 percent (24 percent). Major adverse events were in six patients (12 percent), one of them had a fatal outcome and six patients were transferred to a more complex unit. There was no significant difference between those who had one or two triggers and the relation to their major adverse events. The three patients who had compromised consciousness experienced major adverse events including death to one of them. Conclusion: The most frequent triggers were hypotension and tachypnea. The presence of two triggering events shows a tendency to a worse result, although it does not reach statistical significance. Considering our RRT´s eventual activation rate, the implementation of RRT teams would be justified in our environment.(AU)

[Human herpes virus 6 infection in an inmunocompetent patient with carbamazepine-induced DRESS syndrome]. / Infección por virus herpes humano 6 en un paciente inmunocompetente con síndrome DRESS secundario a carbamazepina.

DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) is an adverse life-threatening drug reaction characterized by a polymorphous rash associated with fever, lymphadenopathy and multiorgan involvement with eosinophilia. We present the case of an immunocompetent man with DRESS syndrome secondary to carbamazepine, that developed concomitantly meningoencephalitis caused by human herpes virus 6 (HHV-6), and a review of literature. The pathogenic role of HHV-6 in DRESS syndrome remains controversial. Given the diagnostic and possibly prognostic significance of HHV-6, the screening seems to be a good measure to use in the clinical management of these patients.

Infección por virus herpes humano 6 en un paciente inmunocompetente con síndrome DRESS secundario a carbamazepina / Human herpes virus 6 infection in an inmunocompetent patient with carbamazepine-induced DRESS syndrome

El síndrome DRESS (drug reaction with eosinophilia and systemic symptoms) constituye una reacción adversa a fármacos, potencialmente mortal, caracterizada por una erupción cutánea polimorfa asociada a fiebre, linfadeno-patías y compromiso multiorgánico con eosinofilia. Presentamos el caso clínico de un hombre inmunocompetente con un síndrome DRESS secundario a carbamazepina que cursó concomitantemente con una meningoencefalitis por virus herpes humano 6 (VHH-6). El rol patogénico del VHH-6 en el síndrome DRESS sigue siendo controversial; sin embargo, dada la importancia diagnóstica y eventualmente pronóstica de la infección por VHH-6, su tamizaje sería recomendable dentro del estudio de estos pacientes.

DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) is an adverse life-threatening drug reaction characterized by a polymorphous rash associated with fever, lymphadenopathy and multiorgan involvement with eosinophilia. We present the case of an immunocompetent man with DRESS syndrome secondary to carbamazepine, that developed concomitantly meningoencephalitis caused by human herpes virus 6 (HHV-6), and a review of literature. The pathogenic role of HHV-6 in DRESS syndrome remains controversial. Given the diagnostic and possibly prognostic significance of HHV-6, the screening seems to be a good measure to use in the clinical management of these patients.

[Erythema nodosum: Analysis of 91 hospitalized patients]. / Eritema nodoso: Causas más prevalentes en pacientes que se hospitalizan para estudio, y recomendaciones para el diagnóstico.

BACKGROUND: Erythema Nodosum (EN) is an acute nodular erythematous cutaneous eruption. It is presumed to be a hypersensitivity reaction and it may be idiopathic, or occur in association with diverse diseases and medications. AIM: To identify the main etiologies of EN among patients admitted to a medicine service of a clinical hospital. MATERIAL AND METHODS: Analysis of medical records of patients discharged with the diagnosis of EN during a ten years period. Patients were considered to have secondary EN when an underlying condition was found, and to have idiopathic EN when no such condition was found. RESULTS: One hundred twenty nine patients were identified, but 91, aged 38 ± 14 years (86% females) had available clinical information. The etiology was idiopathic in 32% and secondary in 68% of patients. The leading etiologies were post-Streptococcal in 32%, followed by sarcoidosis in 11%, primary tuberculosis in 7%, Mycoplasma infection in 3%, Bartonella infection in 3%, Behçet's syndrome in 2%, inflammatory bowel disease in 2%, drugs in 1% and other etiologies in 8%. Secondary cases of EN had higher levels of C Reactive Protein and leucocytes than idiopathic cases. CONCLUSIONS: The distribution of causes in our study population were similar to those reported in the literature (With smaller proportion of idiopathic), as was the man/woman (1/6) ratio, and the preponderance of cases in winter and spring. Infectious diseases were the leading causes of EN in this group of patients, and a reasonable initial approach in the hospital should include a diligent medical history and physical examination, complete blood count, ESR, titles ASO, PPD tuberculin skin test, chest X-ray or CT scan and, where deemed appropriate, specific autoimmune and infectious serology.

Eritema nodoso: Causas más prevalentes en pacientes que se hospitalizan para estudio, y recomendaciones para el diagnóstico / Erythema nodosum: Analysis of 91 hospitalized patients

Background: Erythema Nodosum (EN) is an acute nodular erythematous cutaneous eruption. It is presumed to be a hypersensitivity reaction and it may be idiopathic, or occur in association with diverse diseases and medications. Aim: To identify the main etiologies of EN among patients admitted to a medicine service of a clinical hospital. Material and Methods: Analysis of medical records of patients discharged with the diagnosis of EN during a ten years period. Patients were considered to have secondary EN when an underlying condition was found, and to have idiopathic EN when no such condition was found. Results: One hundred twenty nine patients were identified, but 91, aged 38 ± 14 years (86% females) had available clinical information. The etiology was idiopathic in 32% and secondary in 68% of patients. The leading etiologies were post-Streptococcal in 32%, followed by sarcoidosis in 11%, primary tuberculosis in 7%, Mycoplasma infection in 3%, Bartonella infection in 3%, Behçet’s syndrome in 2%, inflammatory bowel disease in 2%, drugs in 1% and other etiologies in 8%. Secondary cases of EN had higher levels of C Reactive Protein and leucocytes than idiopathic cases. Conclusions: The distribution of causes in our study population were similar to those reported in the literature (With smaller proportion of idiopathic), as was the man/woman (1/6) ratio, and the preponderance of cases in winter and spring. Infectious diseases were the leading causes of EN in this group of patients, and a reasonable initial approach in the hospital should include a diligent medical history and physical examination, complete blood count, ESR, titles ASO, PPD tuberculin skin test, chest X-ray or CT scan and, where deemed appropriate, specific autoimmune and infectious serology.

Hemólisis, exantema, serositis. Manifestaciones extrapulmonares del Mycoplasma pneumoniae: Reporte de un caso / Hemolysis, serositis and exanthema induced by Mycoplasma pneumoniae infection: Report of one case

Mycoplasma infections have extrapulmonary manifestations that may be associated with respiratory symptoms and may have skin, heart, gastrointestinal, rheumatologic, neurologic, hematologic involvement. Cold agglutinin mediated autoimmune hemolytic anemia is the most common hematological manifestation. We report a 27-year-old woman infected with Mycoplasma pneumoniae, who presented respiratory involvement with pneumonia, exanthema, serositis and acute hemolytic anemia that required transfusion. The key for the diagnosis were the extrapulmonary manifestations associated with respiratory involvement after five days of hospitalization.

[The discharge process]. / Proceso de alta hospitalaria, revisión de la literatura.

Discharge is one of the most important processes that hospitalized patients must endure. This process is complex, requires coordination among several professionals and transfers an overwhelming amount of information to patients. Often, it is limited to the writing of the discharge summary, with a primary emphasis on the drug list. Since the rise of hospitalism in 1996, a greater emphasis has been placed on understanding this process and in developing interventions to make it more effective and safe. In our country, little is known about how this process is taking place. Probably the absence of financial penalties for readmissions has influenced in the lack of study and development of this process. In the USA the knowledge of the discharge process is well advanced, and several strategies have been developed for reducing adverse events, medication errors, and 30-days readmissions. Other interventions have increased patient satisfaction and the degree of knowledge about their conditions. The aim of this paper is to do a comprehensive review of the literature, to provide healthcare teams with various tools that could improve both the discharge process as well as the discharge summary. The final objective is to optimize the safety and satisfaction of our patients and the hospital metrics of quality.

Proceso de alta hospitalaria, revisión de la literatura / The discharge process

Discharge is one of the most important processes that hospitalized patients must endure. This process is complex, requires coordination among several professionals and transfers an overwhelming amount of information to patients. Often, it is limited to the writing of the discharge summary, with a primary emphasis on the drug list. Since the rise of hospitalism in 1996, a greater emphasis has been placed on understanding this process and in developing interventions to make it more effective and safe. In our country, little is known about how this process is taking place. Probably the absence of financial penalties for readmissions has influenced in the lack of study and development of this process. In the USA the knowledge of the discharge process is well advanced, and several strategies have been developed for reducing adverse events, medication errors, and 30-days readmissions. Other interventions have increased patient satisfaction and the degree of knowledge about their conditions. The aim of this paper is to do a comprehensive review of the literature, to provide healthcare teams with various tools that could improve both the discharge process as well as the discharge summary. The final objective is to optimize the safety and satisfaction of our patients and the hospital metrics of quality.