Reduction in the incidence of pressure ulcers upon implementation of a reminder system for health-care providers.

PURPOSE: To measure the clinical impact of the introduction of a reminder system for healthcare professionals to alert patients who are at risk for pressure ulcers (PU). METHODS: This was a pre- and post-test study of patients who were discharged from 6 medical-surgical units of the University Hospital of Fuenlabrada in 2009 and 2010. Beginning in January 2010, implementation of an on-screen list of reminders was automatically updated daily on the units' computers including patient arrival date, last assessment of ulceration risk and location of any PU. The cumulative incidence of PU was measured for patients discharged in 2009 (group A: healthcare professionals were not exposed to on-screen reminder) and 2010 (group B: healthcare professionals were exposed to on-screen reminder list). The relative risk (RR) was estimated. The study was completed with a stratified analysis and binary logistic regression. RESULTS: In group A, there were 84 cases of PU among 9263 patients discharged (0.9%); whereas in group B, there were 59 cases among 9220 patients discharged (0.6%). The RR of PU for group B/group A was 0.706 (p=0.038). In the logistic regression analysis, after adjusting for study variables, the odds ratio of PU B/A was 0.558. CONCLUSION: A list of on-screen reminders at the beginning of a healthcare professional's shift to inform them of patients at risk for developing a PU was effective at reducing the incidence of these clinical burdens.

[Validity of clinical register of pressure ulcers]. / La validez de un registro clínico de úlceras por presión.

BACKGROUND: To compare pressure ulcers (PU) found in this prospective observational study with PU recorded in the Electronic Medical Record (EHR). METHOD: We use a prospective observational study to record PU, with daily monitoring by an observer in the medical-surgical units of hospitalization, as well as a clinical record review of PU tracking. Patient monitoring was conducted between December 2008 and March 2009 at Fuenlabrada University hospital. We calculated the absolute and relative frequency of PU in the patients followed, as well as the association among qualitative variables and the validity of the registration in the EHR with regard to the reference standard, the observational study. RESULTS: Among the 1,001 patients followed-up in this study, 42 of them showed PU (4.2% of the total patients), compared to 25 (2.5%) patients who had registered PU in the Electronic Health Record, which means a statistically significant difference (p<0.001). The record of PU presents a Kappa index of 0.548, with a sensitivity of 47.62 % and a specificity of 99.48 %, with regard to the reference standard, the observational study. CONCLUSION: The number of patients with pressure ulcers almost doubled if the observational data collection is done by an expert nurse compared to what was recorded in the EHR.

Impacto de la implantación de recordatorios para disminuir eventos adversos en pacientes con accesos venosos periféricos / Impact of implementation of reminders to reduce adverse effects in patients with peripheral venous catheterizations

Fundamento. Medir el impacto clínico de la implantación de un sistema de recordatorios, que avise de los pacientes que tienen riesgo de presentar un evento adverso (EA) relacionado con los catéteres venosos periféricos. Métodos. A partir de los registros que se utilizan para seguimiento de los catéteres intravenosos se desarrolló una consulta automatizada que elabora un listado de los pacientes ingresados que incluye fecha de ingreso, fecha colocación, vía y tipo de vía. Se actualiza por turno en los ordenadores de la unidad. Se implantó en enero de 2010. Se ha realizado un estudio cuasi experimental midiendo la incidencia acumulada de flebitis, extravasaciones y obstrucciones en los pacientes dados de alta en 2009 y en 2010. Se ha evaluado la asociación entre variables cualitativas con el test de Chicuadrado, se ha estimado riesgo relativo (RR) y el número necesario de pacientes a tratar (NNT). Resultados. En el año 2009 fueron dados de alta en las unidades de estudio 9.263 pacientes y en 2010, 9.220 pacientes. Los resultados encontrados han sido: Pacientes que desarrollan flebitis 2010/2009: RR: 0,827 (p<0,001). Pacientes que presentan extravasaciones 2010/2009: RR: 0,804 (p<0,001).Pacientes que presentan obstrucciones 2010/2009: RR:0,954 (p=0,554). Conclusiones. Un listado de recordatorios que incluye los pacientes con acceso vascular y la fecha de éste, ha servido para disminuir el número de flebitis y extravasaciones, pero no las obstrucciones(AU)

Background. The main purpose of this paper is to measure the clinical impact of the implementation of a reminder system that would warn of patients who are at risk of presenting an adverse event (AE) related to the peripheral venous catheter. Method. On the basis of the registers used for monitoring intravenous catheters, an automated consultation was realized that elaborated a list of the patients admitted, including: date of admission, date of the insertion of the venous access device, and type of device. It was implanted in January 2010and updated three times a day with the computers of the unit. A quasi-experimental study has measured the cumulative incidence of phlebitis, extravasation and obstructions in the patients registered in 2009 and 2010. The association between qualitative variables was evaluated with the Chisquared test, and relative risk (RR) and Number Needed to Treat (NNT) were estimated. Results. Nine thousand two hundred and sixty-three patientswere registered in the studied units in the year 2009, and 9,220 patients in 2010. The results were the following: Patients with phlebitis 2010/2009: RR: 0.827 (p < 0.001). Patients with extravasations 2010/2009: RR: 0.804 (p < 0.001).Patients with obstructions 2010/2009: RR: 0.954 (p < 0.554).Conclusion. With the help of a reminder list (which includes the patients with vascular access and the date), there has been a decrease in the number of phlebitis and extravasations but not in the number of obstructions(AU)

[Impact of implementation of reminders to reduce adverse effects in patients with peripheral venous catheterizations]. / Impacto de la implantación de recordatorios para disminuir eventos adversos en pacientes con accesos venosos periféricos.

BACKGROUND: The main purpose of this paper is to measure the clinical impact of the implementation of a reminder system that would warn of patients who are at risk of presenting an adverse event (AE) related to the peripheral venous catheter. METHOD: On the basis of the registers used for monitoring intravenous catheters, an automated consultation was realized that elaborated a list of the patients admitted, including: date of admission, date of the insertion of the venous access device, and type of device. It was implanted in January 2010 and updated three times a day with the computers of the unit. A quasi-experimental study has measured the cumulative incidence of phlebitis, extravasation and obstructions in the patients registered in 2009 and 2010. The association between qualitative variables was evaluated with the Chi-squared test, and relative risk (RR) and Number Needed to Treat (NNT) were estimated. RESULTS: Nine thousand two hundred and sixty-three patients were registered in the studied units in the year 2009, and 9,220 patients in 2010. The results were the following: Patients with phlebitis 2010/2009: RR: 0.827 (p < 0.001). Patients with extravasations 2010/2009: RR: 0.804 (p < 0.001). Patients with obstructions 2010/2009: RR: 0.954 (p < 0.554). CONCLUSION: With the help of a reminder list (which includes the patients with vascular access and the date), there has been a decrease in the number of phlebitis and extravasations but not in the number of obstructions.

[Validity study of the current risk assessment scale for pressure ulcers in intensive care (EVARUCI)]. / Estudio de validez de la Escala de Valoración Actual del Riesgo de desarrollar Ulceras por presión en Cuidados Intensivos (EVARUCI).

UNLABELLED: Pressure ulcers (PU) are the most frequent injuries in critical patients whose management is the responsibility of the nurses. The first step for its prevention is to determine the patients at risk; however the usual risk assessment scales (Norton, Braden, etc.) do not have adequate specificity to do this. AIM: To study the validity of a current risk assessment scale of pressure ulcers in intensive care (EVARUCI). DESIGN: Prospective, descriptive study. SUBJECTS: Adult patients admitted to Intensive Care Unit (ICU) in the Hospital of Fuenlabrada without PU from February, the 1st, 2005 to January, the 31st, 2006. Demographic data were obtained from the admission records. Data on EVARUCI were daily collected and the patients were studied until they developed 1 of 2 outcomes: a) they developed a PU, or b) they left the ICU (death or exit to other nursing ward). METHODS: Four validity indexes were used: sensitivity, specificity, positive predictive value and negative predictive value. The area under the curve (AUC) of the receiver operating characteristic (ROC) was also used. These indicators were applied to the mean scores during the entire stay and to the initial and final scores in both groups (PU and NO PU). The SPSS v. 12.0 was used for the statistical analysis. RESULTS: A total of 97 patients were included, 62 of whom finished the study. Eleven patients (17.74%) developed PU. Of these, 57.69% were grade I. The most frequent site was in the sacral area (26.92%) and heels (23.08%). The results of the mean of the scores on the EVARUCI mean, initial and final data were: sensitivity (100%, 100%, 90.91%), specificity (68.63%, 49.02%, 92.16%), positive predictive value (40.74%, 29.73%, 71.43%) and negative predictive value (100%, 100%, 97.2%). AUC of ROC was 0.938, 0.909, 0.952, respectively. CONCLUSIONS: The EVARUCI scale is valid to detect patients at risk of development PU in ICU.

Estudio de validez de la Escala de Valoración Actual del Riesgo de desarrollar Úlceras por presión en Cuidados Intensivos (EVARUCI) / Validity study of the current risk assessment scale for pressure ulcers in intensive care (EVARUCI)

Las úlceras por presión (UPP) son lesiones másfrecuentes en los pacientes críticos y su manejo escompetencia de la enfermera. El primer paso para suprevención consiste en la determinación del riesgo ypara ello las escalas habituales (Norton, Braden, etc.)no tienen una adecuada especificidad.Objetivo. Determinar la validez de la Escala deValoración Actual del Riesgo de desarrollar Úlceraspor presión en Cuidados Intensivos (EVARUCI).Diseño. Estudio prospectivo descriptivo.Sujetos. Pacientes adultos ingresados en la Unidad deCuidados Intensivos (UCI) del Hospital deFuenlabrada sin UPP entre el 1 de febrero de 2005 yel 31 de enero de 2006. Los datos demográficosfueron obtenidos de admisión y diariamente se evaluóy registró la puntuación obtenida en EVARUCI. Lospacientes siguieron en el estudio hasta quedesarrollaron UPP (grupo UPP), o salieron de la UCIpor muerte o traslado (grupo NO UPP).Metodología. Se emplearon 4 indicadores de validez:sensibilidad, especificidad, valor predictivo positivo yvalor predictivo negativo. También se empleó el áreabajo la curva ROC (receiver operatingcharacteristic). Estos indicadores se aplicaron a lamedia de las puntuaciones durante toda la estancia, ya las puntuaciones iniciales y a las finales en ambosgrupos (UPP y NO UPP); para el análisis estadístico seaplicó el paquete SPSS v. 12.0.Resultados. Noventa y siete pacientes fueronincluidos, de los que 62 finalizaron el estudio.Desarrollaron UPP 11 pacientes (17,74%). El 57,69%fue de grado I; la localización más frecuente fue enzona sacra (26,92%) y talones 23,08%. Los resultadosde la media de las puntuaciones en EVARUCI, laspuntuaciones iniciales y finales fueron: sensibilidad(100%, 100%, 90,91%), especificidad (68,63%,49,02%, 92,16%), valor predictivo positivo (40,74%,29,73%, 71,43%), valor predictivo negativo (100%,100%, 97,2%). El área bajo la curva ROC fue de 0,938,0,909 y 0,952 respectivamente.Conclusiones. La escala EVARUCI es válida para detectarpacientes críticos con riesgo de desarrollar UPP

Aim. To study the validity of a current riskassessment scale of pressure ulcers in intensive care(EVARUCI).Design. Prospective, descriptive study.Subjects. Adult patients admitted to Intensive CareUnit (ICU) in the Hospital of Fuenlabrada withoutPU from February, the 1st, 2005 to January, the 31st,2006. Demographic data were obtained from theadmission records. Data on EVARUCI were dailycollected and the patients were studied until theydeveloped 1 of 2 outcomes: a) they developed a PU,or b) they left the ICU (death or exit to othernursing ward).Methods. Four validity indexes were used:sensitivity, specificity, positive predictive value andnegative predictive value. The area under the curve(AUC) of the receiver operating characteristic(ROC) was also used. These indicators were appliedto the mean scores during the entire stay and to theinitial and final scores in both groups (PU and NOPU). The SPSS v. 12.0 was used for the statisticalanalysis.Results. A total of 97 patients were included, 62 ofwhom finished the study. Eleven patients (17.74%)developed PU. Of these, 57.69% were grade I. Themost frequent site was in the sacral area (26.92%)and heels (23.08%). The results of the mean of thescores on the EVARUCI mean, initial and final datawere: sensitivity (100%, 100%, 90.91%), specificity(68.63%, 49.02%, 92.16%), positive predictive value(40.74%, 29.73%, 71.43%) and negative predictivevalue (100%, 100%, 97.2%). AUC of ROC was 0.938,0.909, 0.952, respectively.Conclusions. The EVARUCI scale is valid to detectpatients at risk of development PU in ICU

Masa mediastínica / Mediastinal mass

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Monitorización de la incidencia y prevalencia de los pacientes con úlceras por presión en un hospital de agudos / Monitoring of the incidence and prevalence of patients with pressure ulcers in a hospital for acute patients

En 1994 se formó un Grupo de Mejora de la Calidad que elaboró un Protocolo de Prevención y Tratamiento de las úlceras por presión (UPP) aplicable a la población del Área n. 1100 (Atención Primaria y Especializada) del Insalud Madrid así como un método para monitorizar la incidencia y prevalencia de UPP. Presentamos ahora los resultados de dos estudios descriptivos prospectivos transversales realizados durante 16 meses (año 1999 y 4 meses de 2000): uno para conocer la incidencia y prevalencia de UPP en el Hospital y otro para valorar el grado de cumplimentación del Protocolo en las Unidades de Enfermería cuyos pacientes presentan riesgo de desarrollar UPP. Los datos obtenidos son: Prevalencia Total de 4,11 por ciento e Incidencia de 2,33 por ciento. Los datos obtenidos del grado de cumplimentación del Protocolo, son: la valoración del riesgo (E. Norton) se llevó a cabo en un 90,8 por ciento de los casos, la pauta de medidas preventivas en pacientes de riesgo (E. Norton < 14) se registró en un 92,7 por ciento y la cumplimentación media de los registros de evolución de UPP se situó en un 85,6 por ciento. Monitorizar la incidencia y prevalencia de UPP en el Hospital resulta sencilla en relación esfuerzos/resultados y como indicador de la atención de enfermería facilita la toma de decisiones ante desviaciones de los estándares (AU)

[Usefulness of CO measurement in expired air in the study of tobacco consumption by youths and adolescents]. / Utilidad de la medida de CO en aire espirado en el estudio del consumo de tabaco por jóvenes y adolescentes.

The objective of our work was to know the relationship between carbon monoxide (CO) levels in expired air and smoking habits among school youths and the relationships that can be established between CO level and some peculiar attitudes regarding consume by youths, such as the number of cigarettes, inhaling technique and time elapsed since the last cigarette was smoked. The study, of cross-sectional design, was performed in two high school centres and a total of 777 students who answered a questionnaire and had an expired air CO sample in their own schoolroom tested were enrolled. CO determination in the schoolroom was a simple and attainable technique for the pupils, as only 32 cases (4.1%) had to be excluded due to poor collaboration or poor technique. The mean (mean and SD) CO level in the control group (n = 247), made up by non-smokers nor tobacco tasters was 4.75 (2.46) ppm, statistically lower than among smokers (p < 0.001), but with no differences compared with non smokers (n = 563), who had a CO level of 5.23 (3.4) ppm. This figure was also lower (p < 0.001) than that obtained in the smokers (12.6 [6.3] ppm), made up of 214 pupils, with a mean consume of 2.7 (1.69) cigarettes/day. Among smokers the mean abstinence time since the last cigarette was smoked was 26 (44) minutes and 54% of them admitted to have smoked in the last 10 minutes. CO in expired air correlated significantly with the number of smoked cigarettes (r = 0.58; p < 0.001). Likewise, it correlated significantly with abstinence minutes (r = -0.38; p < 0.001). The time required for CO level to decrease below 10 ppm was 140 minutes in four cases and 120 minutes in 33 cases.

[Compliance with antismoking laws in official institutions]. / Cumplimiento de la legislación antitabaco en instituciones oficiales.

The prevention of nicotine addiction involves a wide range of measures, including writing laws to preserve public health by protecting nonsmokers from smoke and discouraging smokers from consumption. Also important are campaigns to educate both parties (smokers and nonsmokers) about the negative effects of tobacco. The main antismoking law in Spain is the Health and Consumer Ministry's Royal Decree 192/1988 limiting the sale and use of tobacco with the aim of protecting public health. Other regulations have since been enacted by public administrations to complement that law. Research finding published in recent years have been the basis for major legal changes leading in two directions; toward standardizing laws existing in different countries and toward increasing restrictions on the advertising and sale of tobacco. Various scientific and social groups have demanded that current laws be made stricter. Little has been done, however, to assess the degree of vigilance and compliance, and consequently the efficacy, of current legislation. The aim of this study was to determine the level of compliance with the law in governmental institutions in Salamanca. We visited 30 centers and saw that while notices prohibiting smoking were visible in 80%, the number of smokers was high: 43% among workers (none of whom was in educational or medical centers) and 37% among the public. No posters warning of the dangers of tobacco were seen in any of the centers visited. It appears necessary to further restrict the sale and use of tobacco in public places, to enforce compliance with existing regulations and to increase the amount of information on the toxic effects of tobacco in order to gain the cooperation of both smokers and nonsmokers toward achieving smoke-free environments.

[Carboxyhemoglobin levels in relation with home heating]. / Niveles de carboxihemoglobina en relación con la calefacción doméstica.

To study carboxyhemoglobin levels (HbCO) associated with use of different types of home heating and to evaluate the usefulness of measuring hemoglobin oxygen saturation. Nonsmoking patients with chronic respiratory insufficiency who were initially prescribed home oxygen therapy were enrolled in the study. One hundred four patients were studied in winter and summer (when heating was not used). The control group consisted of 92 hospitalized patients not exposed to carbon monoxide. Of the 104 patients 74.1% were men. Mean age was 72.33 (range 17 to 97 years) and 57.9% lived in rural areas. Mean HbCO in the control group was 1.53 +/- 0.96% (p = 0.01). Among the 39% who burned slack coal for heat, the mean HbCO was 4.63 +/- 2.87%. The 23.7% with central heating had HbCO levels of 2.15 +/- 0.87% (p < 0.0001). Pulse oximetry (SpO2) estimated higher hemoglobin oxygen than direct measurement (SaO2): 87.12 +/- 6% and 83.3 +/- 8%, respectively (p < 0.001). High HbCO concentrations are related to chronic exposure to slack coal fumes. Pulse oximetry, as opposed to SaO2, overestimates hemoglobin oxygen saturation in such cases.

[Almitrine bismesylate treatment in chronic respiratory insufficiency]. / Tratamiento con bismesilato de almitrina en la insuficiencia respiratoria crónica.

This study was designed to evaluate the gasometric and functional respiratory responses in chronic bronchitic patients with chronic respiratory insufficiency (CRI) under ambulatory oxygen therapy (AOT) with almitrine bismesylate (AB). It was a double-blind, placebo-controlled, randomized, prospective study which lasted three months and with a dosage regime of 50-100 mg/day of AB. Fiftyfour patients completed the study (28 in AB and 24 in the placebo (P) groups, respectively). All patients were males, with a mean age or 65 +/- 6.1 years. In the study of pulmonary function only airway resistance (Raw) was changed, with a significant decrease at the third month in the AB group compared with the P group (0.83 +/- 0.31 vs. 1.07 +/- 0.46 kpa/L.S), with a p value of 0.05 (mean +/- SD) and PaO2 which improved from 8.15 +/- 0.88 to 8.81 +/- 2.3 kpa (61.17 +/- 6.6 to 66.10 +/- 10 mmHg), with a p value of 0.05. AB therapy was well tolerated.

[Pulmonary involvement in primary Sjogren syndrome]. / Afectación pulmonar en el síndrome de Sjögren primario.

We present 6 cases of patients diagnosed of Primary Sjögren's Syndrome (PSS) according to Fox's criteria (1986). Our goal was to document the pulmonary affection with bronchoalveolar lavage, transbronchial biopsy and respiratory functional assessment. We verified the double affection described for PSS: interstitial and airways. In all the cases, independently of the respiratory radiological or functional findings, we observed a variable lymphocytary alveolitis. We did not find any correlationship between this alveolitis and the histological findings. We conclude that bronchoalveolar lavage and transbronchial biopsy in the PSS are useful for the detection of early pulmonary pathology.

[Massive hemoptysis in a patient with an aortic pseudoaneurysm]. / Hemoptisis masiva en paciente con seudoaneurisma de aorta.

We present a case of non-fistulated, non-fissured arteriosclerotic pseudoaneurysm of the aorta in a patient with massive hemoptysis. The condition was resolved by resection, with the breach repaired with a Dacron patch. The diagnosis of thrombotic false aneurysm of the aorta was suspected after inspection of the digital angiograph and aortograph obtained by computed axial tomography. A review of the literature revealed 89 cases of non-surgically removable thoracic aortic aneurysm with hemoptysis; 72 of these cases involved aortobronchial fistulas. In only 1 case was the wall of the aneurysm intact, showing no fissures in spite of hemoptysis. The absence of fissuring or tearing in our patient may be accounted for by the delay of 10 days between the last bout of hemoptysis and surgical resection.

[The predictive parameters in the response to almitrine treatment]. / Parámetros predictivos en la respuesta al tratamiento con almitrina.

Almitrine bimesylate (AB) improves hypoxemia in an undetermined number of patients with respiratory failure. Our objective was to try to identify the patients likely to benefit from this treatment. We undertook a double blind study of AB (50-100 mg/day) vs placebo in 21 randomly chosen patients diagnosed as having chronic obstructive bronchitis who were receiving oxygen therapy in the home. The study lasted 3 months (T0 to T3). PaO2 rose from 51 +/- 5.3 to 58.5 +/- 10 mmHg (6.8 +/- 0.7 to 7.8 +/- 1.3 Kpa) in the 12 patients taking AB (p < 0.05). The remaining gasometric variables and results of functional respiratory exploration were unchanged. The 7 patients receiving AB who were defined as responding-whose PaO2 rose more than 5 mmHg (0.66 Kpa)-presented T0 values lower than those of the 7 non-responding patients in the same group, with respect to CO2 occlusion pressure, mean inspiratory flow and minute ventilation for both air and CO2. These variables can serve as predictors for gasometric response to AB.