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3.
Curr Opin Anaesthesiol ; 33(2): 162-169, 2020 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-32022730

RESUMEN

PURPOSE OF REVIEW: The availability of large datasets and computational power has prompted a revolution in Intensive Care. Data represent a great opportunity for clinical practice, benchmarking, and research. Machine learning algorithms can help predict events in a way the human brain can simply not process. This possibility comes with benefits and risks for the clinician, as finding associations does not mean proving causality. RECENT FINDINGS: Current applications of Data Science still focus on data documentation and visualization, and on basic rules to identify critical lab values. Recently, algorithms have been put in place for prediction of outcomes such as length of stay, mortality, and development of complications. These results have begun being implemented for more efficient allocation of resources and in benchmarking processes, to allow identification of successful practices and margins for improvement. In parallel, machine learning models are increasingly being applied in research to expand medical knowledge. SUMMARY: Data have always been part of the work of intensivists, but the current availability has not been completely exploited. The intensive care community has to embrace and guide the data science revolution in order to decline it in favor of patients' care.


Asunto(s)
Macrodatos , Cuidados Críticos/organización & administración , Unidades de Cuidados Intensivos/organización & administración , Benchmarking , Humanos , Aprendizaje Automático
4.
BMC Health Serv Res ; 19(1): 797, 2019 Nov 05.
Artículo en Inglés | MEDLINE | ID: mdl-31690304

RESUMEN

BACKGROUND: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people. Frail older patients are particularly vulnerable to the adverse effects of hospitalisation, including deconditioning, immobility and loss of independence (Chong et al, J Am Med Dir Assoc 18:638.e7-638.e11, 2017). The 'Systematic Approach to improving care for Frail older patients' (SAFE) study co-designed, with public and patient representatives, quality improvement initiatives aimed at enhancing the delivery of care to frail older patients within an acute hospital setting. This paper describes quality improvement initiatives which resulted from a co-design process aiming to improve service delivery in the acute setting for frail older people. These improvement initiatives were aligned to five priority areas identified by patients and public representatives. METHODS: The co-design work was supported by four pillars of effective and meaningful public and patient representative (PPR) involvement in health research (Bombard et al, Implement Sci 13:98, 2018; Black et al, J Health Serv Res Policy 23:158-67, 2018). These pillars were: research environment and receptive contexts; expectations and role clarity; support for participation and inclusive representation and; commitment to the value of co-learning involving institutional leadership. RESULTS: Five priority areas were identified by the co-design team for targeted quality improvement initiatives: Collaboration along the integrated care continuum; continence care; improved mobility; access to food and hydration and improved patient information. These priority areas and the responding quality improvement initiatives are discussed in relation to patient-centred outcomes for enhanced care delivery for frail older people in an acute hospital setting. CONCLUSIONS: The co-design approach to quality improvement places patient-centred outcomes such as dignity, identity, respectful communication as well as independence as key drivers for implementation. Enhanced inter-personal communication was consistently emphasised by the co-design team and much of the quality improvement initiatives target more effective, respectful and clear communication between healthcare personnel and patients. Measurement and evaluation of these patient-centred outcomes, while challenging, should be prioritised in the implementation of quality improvement initiatives. Adequate resourcing and administrative commitment pose the greatest challenges to the sustainability of the interventions developed along the SAFE pathways. The inclusion of organisational leadership in the co-design and implementation teams is a critical factor in the success of interventions targeting service delivery and quality improvement.


Asunto(s)
Cuidados Críticos/organización & administración , Vías Clínicas/organización & administración , Fragilidad/terapia , Mejoramiento de la Calidad/organización & administración , Anciano , Anciano de 80 o más Años , Participación de la Comunidad , Anciano Frágil/psicología , Anciano Frágil/estadística & datos numéricos , Personal de Salud/psicología , Investigación sobre Servicios de Salud , Humanos , Participación del Paciente
5.
BMC Health Serv Res ; 19(1): 766, 2019 Oct 29.
Artículo en Inglés | MEDLINE | ID: mdl-31665004

RESUMEN

BACKGROUND: To address deficits in the delivery of acute services in Ireland, the National Acute Medicine Programme (NAMP) was established in 2010 to optimise the management of acutely ill medical patients in the hospital setting, and to ensure their supported discharge to primary and community-based care. NAMP aims to reduce inappropriate hospital admissions, reduce length of hospital stay and ensure patients receive timely treatment in the most appropriate setting. It does so primarily via the development of Acute Medical Assessment Units (AMAUs) for the rapid assessment and management of medical patients presenting to hospitals, as well as streamlining the care of those admitted for further care. This study will examine the impact of this programme on patient care and identify the factors influencing its implementation and operation. METHODS: We will use a multistage mixed methods evaluation with an explanatory sequential design. Firstly, we will develop a logic model to describe the programme's outcomes, its components and the mechanisms of change by which it expects to achieve these outcomes. Then we will assess implementation by measuring utilisation of the Units and comparing the organisational functions implemented to that recommended by the NAMP model of care. Using comparative case study research, we will identify the factors which have influenced the programme's implementation and its operation using the Consolidated Framework for Implementation Research to guide data collection and analysis. This will be followed by an estimation of the impact of the programme on reducing overnight emergency admissions for potentially avoidable medical conditions, and reducing length of hospital stay of acute medical patients. Lastly, data from each stage will be integrated to examine how the programme's outcomes can be explained by the level of implementation. DISCUSSION: This formative evaluation will enable us to examine whether the NAMP is improving patient care and importantly draw conclusions on how it is doing so. It will identify the factors that contribute to how well the programme is being implemented in the real-world. Lessons learnt will be instrumental in sustaining this programme as well as planning, implementing, and assessing other transformative programmes, especially in the acute care setting.


Asunto(s)
Enfermedad Aguda/terapia , Cuidados Críticos/organización & administración , Investigación sobre Servicios de Salud/métodos , Hospitales , Humanos , Irlanda , Programas Nacionales de Salud , Evaluación de Programas y Proyectos de Salud
6.
Crit Care Clin ; 35(4): 535-550, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445603

RESUMEN

The "daily disasters" within the ebb and flow of routine critical care provide a foundation of preparedness for the less-frequent, larger events that affect most health care organizations at some time. Although large disasters can overwhelm, those who strengthen processes and habits through daily practice will be the best prepared to manage them.


Asunto(s)
Cuidados Críticos , Planificación en Desastres , Servicio de Urgencia en Hospital , Unidades de Cuidados Intensivos , Cuidados Críticos/organización & administración , Planificación en Desastres/organización & administración , Desastres , Servicio de Urgencia en Hospital/organización & administración , Humanos , Unidades de Cuidados Intensivos/organización & administración , Incidentes con Víctimas en Masa , Capacidad de Reacción/organización & administración , Triaje
7.
Crit Care Clin ; 35(4): 551-562, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445604

RESUMEN

Critical care teams can face a dramatic surge in demand for ICU beds and organ support during a disaster. Through effective preparedness, teams can enable a more effective response and hasten recovery back to normal operations. Disaster preparedness needs to balance an all-hazards approach with focused hazard-specific preparation guided by a critical care-specific hazard-vulnerability analysis. Broad stakeholder input from within and outside the critical care team is necessary to avoid gaps in planning. Evaluation of critical care disaster plans require frequent exercises, with a mechanism in place to ensure lessons learned effectively prompt improvements in the plan.


Asunto(s)
Planificación en Desastres , Unidades de Cuidados Intensivos , Cuidados Críticos/organización & administración , Planificación en Desastres/organización & administración , Desastres , Humanos , Unidades de Cuidados Intensivos/organización & administración
8.
Crit Care Clin ; 35(4): 563-573, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445605

RESUMEN

A health care facility must develop a comprehensive disaster plan that has a provision for critical care services. Mass critical care requires surge capacity: augmentation of critical care services during a disaster. Surge capacity involves staff, supplies, space, and structure. Measures to increase critical care staff include recalling essential personnel, using noncritical care staff, and emergency credentialing of volunteers. Having an adequate supply chain and a cache of critical care supplies is essential. Virtual critical care or tele-critical care can augment critical care capacity by assisting with patient monitoring, specialized consultation, and in pandemics reduces staff exposure.


Asunto(s)
Cuidados Críticos , Planificación en Desastres , Cuidados Críticos/organización & administración , Planificación en Desastres/organización & administración , Desastres , Fuerza Laboral en Salud/organización & administración , Humanos , Incidentes con Víctimas en Masa
9.
Crit Care Clin ; 35(4): 647-658, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445611

RESUMEN

Anthropogenic disasters may be defined as any disaster caused by human action or inaction. Natural disasters occur without human interference. Injuries caused by terrorists and related criminal activities may be broadly grouped into 3 categories: blunt, blast, and penetrating trauma. Most terrorist and criminal activities that create a mass-casualty situation are performed using the weapons most readily available, such as firearms or explosives. A consistent pattern, comparing terrorism with interpersonal violence, is the greater severity of impact on the victim.


Asunto(s)
Cuidados Críticos , Planificación en Desastres , Desastres , Terrorismo , Violencia , Traumatismos por Explosión/epidemiología , Traumatismos por Explosión/terapia , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Humanos , Incidentes con Víctimas en Masa , Heridas no Penetrantes/epidemiología , Heridas no Penetrantes/terapia , Heridas Penetrantes/epidemiología , Heridas Penetrantes/terapia
10.
Crit Care Clin ; 35(4): 659-675, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445612

RESUMEN

Children are affected by all types of disasters disproportionately compared with adults. Despite this, planning and readiness to care for children in disasters is suboptimal locally, nationally, and internationally. These planning gaps increase the likelihood that a disaster will have a greater negative impact on children when compared with adults. New voluntary regional coalitions have been developed to fill this gap. Some are pediatric focused or have pediatrics well integrated into the greater coalition. This article discusses key points of pediatric disaster planning, specific vulnerabilities, and the care of children in general and in specific disaster situations.


Asunto(s)
Cuidados Críticos , Planificación en Desastres , Desastres , Niño , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Humanos , Triaje
11.
Crit Care Clin ; 35(4): 677-695, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445613

RESUMEN

Special populations, which include the morbidly obese and patients with chronic, complex medical conditions that require long-term health care services and infrastructure, are at increased risk for morbidity and mortality when these services are disrupted during a disaster. Past experiences have identified significant challenges in restoring necessary care services to these patients following major environmental events. This article describes the impact of disasters on special populations, provides a framework for future disaster preparation and planning, and identifies areas in need of further research. Gravid patients, who are often overlooked in disaster planning and preparation, are also discussed.


Asunto(s)
Enfermedad Crónica/terapia , Cuidados Críticos , Planificación en Desastres , Obesidad Mórbida/terapia , Complicaciones del Embarazo/terapia , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Desastres , Femenino , Humanos , Embarazo
12.
Crit Care Clin ; 35(4): 697-710, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445614

RESUMEN

Outbreaks of Ebola virus disease and high-risk transmissible infections are increasing and pose threats to health care workers and global health systems. Previous outbreaks offer lessons for health system preparedness and response, including establishment of hospital-based high-risk pathogen treatment units. Their creation demands early preparation and interprofessional coordination; infection prevention and control; case management training; prepositioning of supplies; conversion of existing structures to treatment units; and strengthening communication and research platforms. Hospital-based Ebola and high-risk pathogen treatment units may improve case detection, interrupt transmission, and improve staff safety and patient care.


Asunto(s)
Planificación en Desastres , Fiebre Hemorrágica Ebola/terapia , Unidades de Cuidados Intensivos/organización & administración , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Brotes de Enfermedades , Fiebre Hemorrágica Ebola/diagnóstico , Fiebre Hemorrágica Ebola/epidemiología , Humanos
13.
Crit Care Clin ; 35(4): 711-715, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31445615

RESUMEN

In preparation for Superstorm Sandy, the emergency control center at Lenox Hill Hospital (LHH) was activated. Patients were evacuated safely to increase hospital capacity, including increased critical care beds, hospital equipment and supplies, including ventilators. A triage center was established in the emergency department at LHH. Efforts were coordinated between LHH and New York University (NYU) Langone Medical Center. NYU medical staff was granted Disaster Emergency privileges, credentialed at LHH, and oriented to LHH. NYU residents and fellows were added by the Office of Graduate Medical Education.


Asunto(s)
Tormentas Ciclónicas , Desastres , Centros de Atención Terciaria , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Humanos , Ciudad de Nueva York , Centros de Atención Terciaria/organización & administración
15.
Pediatrics ; 144(2)2019 08.
Artículo en Inglés | MEDLINE | ID: mdl-31366685

RESUMEN

Integration of pediatric palliative care (PPC) into management of children with serious illness and their families is endorsed as the standard of care. Despite this, timely referral to and integration of PPC into the traditionally cure-oriented cardiac ICU (CICU) remains variable. Despite dramatic declines in mortality in pediatric cardiac disease, key challenges confront the CICU community. Given increasing comorbidities, technological dependence, lengthy recurrent hospitalizations, and interventions risking significant morbidity, many patients in the CICU would benefit from PPC involvement across the illness trajectory. Current PPC delivery models have inherent disadvantages, insufficiently address the unique aspects of the CICU setting, place significant burden on subspecialty PPC teams, and fail to use CICU clinician skill sets. We therefore propose a novel conceptual framework for PPC-CICU integration based on literature review and expert interdisciplinary, multi-institutional consensus-building. This model uses interdisciplinary CICU-based champions who receive additional PPC training through courses and subspecialty rotations. PPC champions strengthen CICU PPC provision by (1) leading PPC-specific educational training of CICU staff; (2) liaising between CICU and PPC, improving use of support staff and encouraging earlier subspecialty PPC involvement in complex patients' management; and (3) developing and implementing quality improvement initiatives and CICU-specific PPC protocols. Our PPC-CICU integration model is designed for adaptability within institutional, cultural, financial, and logistic constraints, with potential applications in other pediatric settings, including ICUs. Although the PPC champion framework offers several unique advantages, barriers to implementation are anticipated and additional research is needed to investigate the model's feasibility, acceptability, and efficacy.


Asunto(s)
Cardiopatías/terapia , Unidades de Cuidados Intensivos/organización & administración , Cuidados Paliativos/métodos , Cuidados Paliativos/organización & administración , Niño , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Cardiopatías/diagnóstico , Cardiopatías/epidemiología , Humanos , Lactante
17.
Rev Esc Enferm USP ; 53: e03475, 2019 Jul 04.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-31291395

RESUMEN

OBJECTIVE: To describe the Intensive Care Unit nurse's role in the management of continuous hemodialysis within the scope of the collaborative model, analyzing it regarding the links with patient safety. METHOD: A descriptive, qualitative, exploratory study based on the Reason safety model performed at the Intensive Care Unit of a specialized hospital, with nurses working in the direct management of continuous hemodialysis, who were interviewed using a script with its contents being thematically analyzed. RESULTS: 23 nurses participated. The role of the intensive care nurse in continuous hemodialysis involves performing preparation/planning and monitoring/follow-up activities, based on interaction with technology and the application of specialized knowledge. The adopted collaborative model reflects on its qualification and availability in relation to the activities that need to be performed, with repercussions on patient safety. CONCLUSION: There are weaknesses in the participation by intensive care nurses in this continuous hemodialysis model which require elaboration of defensive barriers for the safety of the system.


Asunto(s)
Cuidados Críticos/organización & administración , Rol de la Enfermera , Personal de Enfermería en Hospital/organización & administración , Diálisis Renal/métodos , Conducta Cooperativa , Humanos , Unidades de Cuidados Intensivos , Seguridad del Paciente
18.
J Clin Nurs ; 28(21-22): 4044-4052, 2019 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-31264747

RESUMEN

AIMS AND OBJECTIVES: To qualitatively evaluate an early mobilisation quality improvement project implemented on a general medicine unit. BACKGROUND: Early mobility quality improvement projects show promising quantitative results yet have failed to collect data from patient and staff experience associated with physical activity during illness and the impact of this change in clinical practice. DESIGN: A mixed methods case study was used to evaluate a mobility quality improvement project. Quantitative results will be published separately. The qualitative evaluation used a phenomenological lens to explore the patient and staff experience. METHODS: Semi-structured interviews with twelve participants (four patients and eight staff) were performed during the project. Data were analysed using open coding, direct interpretation and then categorised into an overarching and four supporting themes. Findings are reported per the Standards for Reporting Qualitative Research. RESULTS: Participants reported that early mobilisation bridged a gap in care. Staff understood the benefits of early mobility. Patients expressed how mobility aligned with personal preferences and their need to prepare for hospital discharge. Greater functional independence and higher mobility levels in patients on the unit reduced staff level of care. When patients were consistently presented with opportunities to be mobile and active, they expected mobility to be a part of their daily care plan. CONCLUSIONS: Findings suggest that early mobility quality improvement projects have the potential to transform clinical practice and improve the quality of care for patients in acute care. RELEVANCE TO CLINICAL PRACTICE: All members of the healthcare team, including the patient, recognise the importance of maintaining mobility and function during hospitalisation yet focus on these needs are often delayed or missed. Early mobility quality improvement projects help to set patient expectations and build a culture that promotes patient mobility and function during acute illness.


Asunto(s)
Cuidados Críticos/métodos , Ambulación Precoz/psicología , Grupo de Atención al Paciente/organización & administración , Anciano , Cuidados Críticos/organización & administración , Ambulación Precoz/enfermería , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prioridad del Paciente , Evaluación de Programas y Proyectos de Salud , Investigación Cualitativa , Mejoramiento de la Calidad
19.
Am J Health Syst Pharm ; 76(12): 861-868, 2019 Jun 03.
Artículo en Inglés | MEDLINE | ID: mdl-31361849

RESUMEN

PURPOSE: The purpose of this study was to improve antimicrobial management and outcomes of critically ill patients with community-acquired pneumonia (CAP) through implementation of a pharmacist-driven bundle for ordering evidence-based diagnostic tests in a medical intensive care unit (MICU). METHODS: An inpatient collaborative practice agreement (CPA) was established for MICU pharmacists to order criteria-driven diagnostic testing for CAP from November 2017-March 2018. Adults admitted to the MICU and started on empiric antibiotics for CAP were included. The intervention arm was compared with a standard of care (SOC) group from November 2016-March 2017. RESULTS: Ninety-one patients were included in each group. There was no difference in the median antibiotic duration between SOC and CPA, at 7 days (interquartile range [IQR], 6-10) versus 7 days (IQR, 6-8), respectively. The overall use of evidence-based diagnostic tests increased in the CPA group. Patients in the CPA group had more frequent pathogen identification (SOC and CPA, respectively: 31 [34%] versus 46 [51%], p = 0.035) and antimicrobial deescalation (24 [26%] versus 53 [58%], p < 0.001). There was no significant difference in length of intensive care unit stay, at 4 days for SOC (IQR, 2-10) versus 6 days for CPA (IQR, 3-10), and no significant difference in inpatient all-cause mortality (13 [14%] versus 7 [8%]), retreatment 14 [15%] versus 11 [12%]), or 30-day readmission 16 ([18%] versus 13 [14%]) for SOC and CPA, respectively. The CPA was the only variable that was independently associated with antimicrobial deescalation (odds ratio, 4.030; 95% confidence interval, 2.101-7.731) in a multiple logistic regression. CONCLUSION: Implementation of a pharmacy-driven pneumonia diagnostic stewardship bundle improved the use of evidence-based diagnostics and increased the frequency of pathogen identification. This intervention was associated with increased antimicrobial deescalation without a negative impact on patient safety outcomes.


Asunto(s)
Antibacterianos/uso terapéutico , Programas de Optimización del Uso de los Antimicrobianos/organización & administración , Infecciones Comunitarias Adquiridas/tratamiento farmacológico , Cuidados Críticos/métodos , Neumonía/tratamiento farmacológico , Anciano , Cultivo de Sangre , Infecciones Comunitarias Adquiridas/microbiología , Infecciones Comunitarias Adquiridas/mortalidad , Cuidados Críticos/organización & administración , Enfermedad Crítica , Femenino , Mortalidad Hospitalaria , Humanos , Unidades de Cuidados Intensivos/organización & administración , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Grupo de Atención al Paciente/organización & administración , Readmisión del Paciente/estadística & datos numéricos , Seguridad del Paciente , Servicio de Farmacia en Hospital/organización & administración , Neumonía/microbiología , Neumonía/mortalidad , Mejoramiento de la Calidad , Nivel de Atención , Factores de Tiempo , Resultado del Tratamiento
20.
BMJ ; 365: l1927, 2019 06 04.
Artículo en Inglés | MEDLINE | ID: mdl-31164326

RESUMEN

OBJECTIVE: To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI). DESIGN: Retrospective cohort study. SETTING: 1727 acute care hospitals in the United States. PARTICIPANTS: Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015. MAIN OUTCOME MEASURE: 30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI. RESULTS: The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points). CONCLUSIONS: ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.


Asunto(s)
Cuidados Críticos , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos/estadística & datos numéricos , Infarto del Miocardio con Elevación del ST , Anciano , Cuidados Críticos/métodos , Cuidados Críticos/organización & administración , Femenino , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Medicare/estadística & datos numéricos , Mortalidad , Evaluación de Necesidades , Infarto del Miocardio con Elevación del ST/economía , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Estados Unidos/epidemiología
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