Asociación entre carga laboral de enfermería, gravedad del paciente y mortalidad en pacientes críticos de un hospital público / Association between nursing workload, patient severity, and mortality in critically ill patients in a public hospital

OBJETIVO: Determinar la asociación entre la carga laboral de enfermería, gravedad del paciente, y mortalidad en una unidad de pacientes críticos (UPC) de un hospital público en Chile. METODOLOGÍA: Estudio retrospectivo, correlacional, que analizó fichas clínicas de pacientes de una UPC. Se recolectaron variables demográficas, clínicas, gravedad de paciente (APACHE II) y carga de trabajo de enfermería (TISS-28) al ingreso del paciente. Se realizaron análisis descriptivos y bivariados. Se utilizaron regresiones logísticas para identificar las variables asociadas a mortalidad en la UPC y hospitalaria. RESULTADOS: Se incluyeron 311 pacientes con una mediana de 7 días (RIQ=9,5) de estadía en la UPC. Un 48,9% ingreso desde el servicio de urgencia y un 25,7% tuvo un diagnostico neurológico. El puntaje TISS-28 se asoció positivamente con el del APACHE II (r=0,359, p<0,001) y los días de estadía en UPC (r=0,146, p<0,05). En los modelos de regresión, la mortalidad en UPC estuvo asociada con el puntaje APACHE II (OR=1,109, p<0,001) y el TISS-28 (OR=0,955, p<0,05). Los puntajes de APACHE II y TISS-28 no se asociaron significativamente con la mortalidad hospitalaria. CONCLUSIÓN: Una mayor gravedad del paciente critico se asoció con un aumento en la carga de trabajo de enfermería. La mortalidad en UPC se asoció negativamente con la carga de trabajo en enfermería, pero positivamente con la gravedad de paciente. La carga de trabajo de enfermería es una variable relevante en el desenlace del paciente crítico por lo que debe evaluarse regularmente y de este modo, asegurar dotaciones que respondan a las demandas asistenciales del paciente en la UPC.

OBJECTIVE: To determine the association among nursing workload, patient severity of illness, and mortality in an intensive care unit (ICU) of a public hospital in Chile. METHODS: Retrospective, correlational study that analyzed clinical records of ICU patients. Demographic, clinical, severity of illness (APACHE II), and nursing workload (TISS-28) variables were collected upon patient admission. Descriptive and bivariate analyses were performed. Logistic regressions were used to identify the variables associated with ICU and hospital mortality. RESULTS: 311 patients with a median of 7 days (IQR = 9.5) of stay at the ICU were included; 48.9% were admitted from the emergency department and 25.7% had a neurological diagnosis. The TISS-28 score was positively associated with the APACHE II score (r =0.359, p < 0.001) and ICU length of stay (r =0.146, p < 0.05). Deceased patients presented a higher APACHE II score than the survivors during their ICU stay (p < 0.001) and in the hospital (p < 0.01). In the regression models, ICU mortality was associated with the APACHE II (OR = 1.109, p < 0.001) and the TISS-28 (OR = 0.955, p < 0.05) score. APACHE II and TISS-28 scores were not significantly associated with hospital mortality. CONCLUSIONS: A greater severity of illness was associated with an increase in the nursing workload. Mortality in critical patient units was negatively associated with nursing workload, but positively associated with patient severity of illness. Nursing workload is a relevant variable in the outcome of the critically ill patient and must be regularly evaluated to ensure there are sufficient resources to respond to the ICU patient's care demands.

Aprendizaje de la seguridad asistencial en medicina intensiva / Patient safety´s learning in intensive medicine

Introducción: la seguridad asistencial (SA) es una competencia especialmente relevante en las Unidades de Cuidados Intensivos (UCI), ya que la gravedad de los pacientes y los tratamientos que reciben, generan situaciones de riesgo para eventos adversos (EA). Se presenta una revisión narrativa de los conceptos más importantes de SA, con énfasis en su enseñanza-aprendizaje en medicina intensiva (MI). Además, se describen los resultados de una experiencia piloto sobre formación en SA, para residentes de MI de la Pontificia Universi-dad Católica de Chile (UC). Métodos: para la revisión narrativa se utilizó una estrategia de búsqueda amplia en Pubmed, considerando artículos clínicos y de educación. También se revisó la literatura nacional, incluyendo libros de resúmenes de congresos. La experiencia piloto consistió en un taller de cinco sesiones, basado en aprendizaje en pequeño grupo. Resultados: iniciativas internacionales han tratado de estandarizar el aprendizaje de la SA. Para una atención de salud segura deben considerarse competencias como comuni-cación, liderazgo y trabajo en equipo; pues, 20-30% de los EAs están relacionados con estas. Al término del taller de formación en SA, se encontró que la adquisición de conocimientos fue adecuada; sin embargo, no hubo mejoría en la percepción de la importancia de esta competencia. Conclusión: la SA es fundamental para cualquier actividad clínica, siendo indispensable la capacitación de los intensivistas en esta competencia. La próxima versión del dispositivo de formación en SA para residentes de la subespecialidad de MI de la UC se optimizará, agregando un módulo de aprendizaje en el lugar de trabajo en la UCI.

Introduction: Patient Safety (PS) is a relevant competence in the Intensive Care Unit (ICU) since the severity of the patients and the treat-ments they receive generate risk situations for Adverse Events (AE). A narrative review of the most important concepts of PS is presented, with emphasis on its teaching-learning process in the area of intensive medicine (IM). Also, the results of a PS training pilot program for IM residents of Pontificia Universidad Católica de Chile (UC), are described. Methods: For the literature review, a broad search strategy in PubMed was used, including publications in English and Spanish; clinical and educational articles were considered. Local, national literature was also reviewed, including conference abstract-books. The pilot program consisted of a five-session workshop, based on a small group learning strategy. Results: International initiatives have tried to standardize PS learning. Other competencies, such as communication, leadership, and teamwork, must also be considered for safe healthcare, as 20-30% of AE are related to these. At the end of the IM-resident PS workshop, it was found that knowledge acquisition was adequate; however, there was no improvement in the perception of the im-portance of PS. Conclusion: PS is essential for any clinical activity, and training in it is mandatory for intensivists. The next version of the PS training program for IM residents of UC will be optimized by adding a workplace-based learning module in the ICU.

A randomized placebo-controlled phase II study of a Pseudomonas vaccine in ventilated ICU patients.

BACKGROUND: Currently, no vaccine against Pseudomonas is available. IC43 is a new, recombinant, protein (OprF/I)-based vaccine against the opportunistic pathogen, Pseudomonas aeruginosa, a major cause of serious hospital-acquired infections. IC43 has proven immunogenicity and tolerability in healthy volunteers, patients with burns, and patients with chronic lung diseases. In order to assess the immunogenicity and safety of IC43 in patients who are most at risk of acquiring Pseudomonas infections, it was evaluated in mechanically ventilated ICU patients. METHODS: We conducted a randomized, placebo-controlled, partially blinded study in mechanically ventilated ICU patients. The immunogenicity of IC43 at day 14 was determined as the primary endpoint, and safety, efficacy against P. aeruginosa infections, and all-cause mortality were evaluated as secondary endpoints. Vaccinations (100 µg or 200 µg IC43 with adjuvant, or 100 µg IC43 without adjuvant, or placebo) were given twice in a 7-day interval and patients were followed up for 90 days. RESULTS: Higher OprF/I IgG antibody titers were seen at day 14 for all IC43 groups versus placebo (P < 0.0001). Seroconversion (≥4-fold increase in OprF/I IgG titer from days 0 to 14) was highest with 100 µg IC43 without adjuvant (80.6%). There were no significant differences in P. aeruginosa infection rates, with a low rate of invasive infections (pneumonia or bacteremia) in the IC43 groups (11.2-14.0%). Serious adverse events (SAEs) considered possibly related to therapy were reported by 2 patients (1.9%) in the group of 100 µg IC43 with adjuvant. Both SAEs resolved and no deaths were related to study treatment. Local tolerability symptoms were mild and rare (<5% of patients), a low rate of treatment-related treatment-emergent adverse events (3.1-10.6%) was observed in the IC43 groups. CONCLUSION: This phase II study has shown that IC43 vaccination of ventilated ICU patients produced a significant immunogenic effect. P. aeruginosa infection rates did not differ significantly between groups. In the absence of any difference in immune response following administration of 100 µg IC43 without adjuvant compared with 200 µg IC43 with adjuvant, the 100 µg dose without adjuvant was considered for further testing of its possible benefit of improved outcomes. There were no safety or mortality concerns. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00876252 . Registered on 3 April 2009.

Transfusiones de glóbulos rojos en pacientes críticos / Red blood cell transfusions in critical patients

La anemia es muy frecuente en los pacientes críticos, pudiendo estar presente en casi el 100 por ciento después una semana de hospitalización en la Unidad de Cuidados Intensivos (UCI). Se ha descrito que la anemia es un factor de riesgo de mayor mortalidad y morbilidad para los pacientes críticos. La etiología de la anemia en UCI es multifactorial, destacando la anemia de la inflamación, los déficits nutricionales, la hemodilución y el aumento de las pérdidas. Dentro del aumento de las pérdidas destaca la toma seriada de exámenes de sangre. A pesar de lo deletéreo de la anemia, no se ha demostrado que las transfusiones de glóbulos rojos (GR) puedan mejorar el pronóstico de los pacientes con anemia. Por el contrario, hay estudios que han descrito un aumento de las complicaciones y mortalidad asociadas al aporte de GR. La evidencia actual sugiere que en pacientes críticos estables y que no presentan sangrado activo, las transfusiones deberían evitarse si la concentración de hemoglobina es mayor a 7 g/dL. Sin embargo, un umbral transfusional estricto puede no ser adecuado para todos los pacientes, por lo que también deberían considerarse las alteraciones de la perfusión y la condición cardíaca y respiratoria en la decisión de transfundir GR.(AU)

Anemia is very common in critically ill patients and may be present in almost 100 percent after a week of hospitalization in the Intensive Care Unit (ICU). It has been reported that anemia is a risk factor for increased mortality and morbidity in critically ill patients. The etiology of anemia in ICU is multifactorial, highlighting anemia of inflammation, nutritional deficits, hemodilution and increased losses. Within the increase of losses, serial blood samples results in important cause of anemization. Despite the deleterious effects of anemia, red cell transfusions (RBC) have not been shown to improve the prognosis of patients with anemia. In contrast, there are studies that have reported an increase in complications and mortality associated with RBC transfusions. Current evidence suggests that transfusions should be avoided if hemoglobin concentration is greater than 7 g/dL in critically ill not bleeding patients. However, a strict transfusional threshold may not be appropriate for all patients, so alterations in perfusion and cardiac and respiratory status should also be considered in the decision to transfuse RBC.(AU)

Transfusiones en trauma / Blood transfusions in trauma

En trauma, la principal causa de muerte es el sangrado no controlado. Para su prevención es fundamental corregir precozmente la coagulopatía aguda del trauma mediante la reanimación con control de daños. Hay evidencia que la administración precoz de todos los hemoderivados con una relación entre ellos cercana a 1:1, podría mejorar la sobrevida en los pacientes de trauma, aunque estos hallazgos deben corroborarse en estudios clínicos randomizados, junto con determinar cuál es la relación óptima. En pacientes estables una estrategia transfusional restrictiva es segura y adecuada. En el presente artículo se revisará el manejo transfusional de los pacientes de trauma, dando especial énfasis a aquellos que requieren transfusión masiva.

In trauma, the leading cause of death is uncontrolled bleeding. For early prevention is essential the correction the acute coagulopathy of trauma using damage-control resuscitation. There is evidence that early administration of 1:1 transfusion ratios of blood products are associated with increased survival in trauma patients with massive transfusion requirements. Although, these findings must be corroborated in randomized clinical trials, along with determining which is the optimum. In stable patients, restrictive transfusion strategy is safe and appropriate. In this article, we review the transfusion management of trauma patients with special emphasis on those requiring massive transfusion.