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1.
BJOG ; 127(3): 416-423, 2020 02.
Artículo en Inglés | MEDLINE | ID: mdl-31677228

RESUMEN

OBJECTIVE: To develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings. DESIGN: Modified Delphi process. SETTING: Participants from 34 countries. POPULATION: Healthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group. METHODS: We reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in-person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts. MAIN OUTCOME MEASURE: Consensus on bundle items. RESULTS: Consensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher-level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym 'FAST-M'. CONCLUSION: A clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus. TWEETABLE ABSTRACT: A maternal sepsis bundle for low resource settings has been developed by international consensus.


Asunto(s)
Paquetes de Atención al Paciente/métodos , Manejo de Atención al Paciente , Complicaciones Infecciosas del Embarazo , Consenso , Técnica Delfos , Femenino , Humanos , Recién Nacido , Cooperación Internacional , Área sin Atención Médica , Manejo de Atención al Paciente/métodos , Manejo de Atención al Paciente/organización & administración , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/terapia , Organización Mundial de la Salud
2.
Anaesthesia ; 75(1): 63-71, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31549413

RESUMEN

Delirium is a common complication following hip fracture surgery. We introduced a peri-operative care bundle that standardised management in the emergency department, operating theatre and ward. This incorporated: use of fascia iliaca blocks; rationalisation of analgesia; avoidance of drugs known to trigger delirium; a regular education program for staff; and continuous auditing of compliance. The study was conducted between June 2017 and December 2018. We recruited 150 patients before (control group) and 150 patients after (care bundle group) the introduction of the care bundle. In patients having surgery for a hip fracture, there was a lower incidence of delirium on the third postoperative day in the care bundle group compared with the control group (33 patients (22%) vs. 49 patients (33%)), respectively; p = 0.04). Patients in the care bundle group had an adjusted OR of 2.2 (95%CI 1.1-4.4) (p = 0.03) for the avoidance of delirium on the third postoperative day. There was no difference between groups for the secondary outcome measures (measured at 30 days postoperatively) including: all-cause mortality; composite morbidity; institutionalisation; and walking status. During the study period, compliance with elements of the care bundle improved in the emergency department (49 patients (33%) compared with 85 patients (59%); p < 0.001) and anaesthetic department (40 patients (27%) compared with 104 patients (69%); p < 0.001), while orthogeriatrics maintained a high level of compliance (140 patients (93%) compared with 143 patients (95%); p = 0.45). There was a clinically and statistically significant reduction in the incidence of delirium following hip fracture surgery in patients treated with a multidisciplinary care bundle.


Asunto(s)
Delirio/prevención & control , Fracturas de Cadera/cirugía , Paquetes de Atención al Paciente/métodos , Complicaciones Posoperatorias/prevención & control , Mejoramiento de la Calidad , Anciano , Anciano de 80 o más Años , Delirio/inducido químicamente , Femenino , Humanos , Incidencia , Masculino , Complicaciones Posoperatorias/inducido químicamente , Estudios Prospectivos
3.
Orthop Nurs ; 38(4): 262-269, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31343631

RESUMEN

BACKGROUND: Standardized approaches to care and care pathways for patients with joint replacement have been shown to decrease length of stay (LOS), improve patient participation in education, decrease patient anxiety while improving perception of care, and lead to overall efficiency and improved care and outcomes. PURPOSE: The purpose of this study was to determine whether implementation of a standardized bundle approach to care influenced the outcomes after total hip or total knee arthroplasty (THA or TKA). METHODS: A retrospective, quasi-experimental before- and after-design study was used to evaluate the impact of the intervention. Two hospitals implemented a standardized bundle of care for patients undergoing THA or TKA that included preoperative patient education, day of surgery mobilization, and a total joint group physical therapy session (Full Bundle). Data analyses were completed on a convenience sample of 2,200 patients who underwent THA or TKA. Outcomes data measured were LOS, discharge disposition, costs, and readmission rate. RESULTS: Patients receiving the Full Bundle had significant reduction in LOS of roughly 1 day (OR = 1.687, 95% CI [1.578, 1.797]) versus group not receiving all elements (OR = 2.706; 95% CI [2.623, 2.789]). Full Bundle patients were 6 times more likely to be discharged home compared with the Partial Bundle group (OR = 6.01, 95% CI [4.01, 9.03]). Full Bundle group had significantly lower total direct costs, F(1) = 4.06, p = .046, partial η = 0.003. There were no differences in readmission rates between the 2 groups. CONCLUSION: Patients who had all elements of the THA/TKA bundle had the best outcomes. By improving efficiencies of care through the use of the bundle, the 2 hospitals positively impacted the care and outcomes of THA and TKA patients.


Asunto(s)
/normas , Paquetes de Atención al Paciente/normas , Complicaciones Posoperatorias/epidemiología , Resultado del Tratamiento , Anciano , Artroplastia de Reemplazo de Cadera/métodos , Artroplastia de Reemplazo de Cadera/normas , Artroplastia de Reemplazo de Cadera/estadística & datos numéricos , Artroplastia de Reemplazo de Rodilla/métodos , Artroplastia de Reemplazo de Rodilla/normas , Artroplastia de Reemplazo de Rodilla/estadística & datos numéricos , Distribución de Chi-Cuadrado , Procedimientos Quirúrgicos Electivos/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paquetes de Atención al Paciente/instrumentación , Paquetes de Atención al Paciente/métodos , Complicaciones Posoperatorias/etiología , Estudios Retrospectivos , Factores de Riesgo , Sudeste de Estados Unidos/epidemiología
4.
Rev Bras Enferm ; 72(3): 671-679, 2019 Jun 27.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-31269131

RESUMEN

OBJECTIVE: to construct collectively with nursing professionals bundle for best practices of cold chain maintenance of immunobiological agents conservation at the local level. METHOD: a qualitative research of convergent care type. Bundle construction was guided by the Evidence-Based Practice criterion. Data collection was carried out from October to December 2016, through five workshops, with the participation of 21 professionals from 7 vaccination rooms of a municipality of Minas Gerais State. The framework developed by Morse and Field was adopted for data analysis. RESULTS: through bundle, care is taken regarding refrigeration equipment temperature monitoring, contingency plan performance, recyclable ice coil setting and chamber use as refrigeration equipment. FINAL CONSIDERATIONS: the chosen interventions began to guide the practice and promote a care based on safety and quality.


Asunto(s)
Paquetes de Atención al Paciente/métodos , Refrigeración/métodos , Vacunas/uso terapéutico , Adulto , Competencia Clínica/normas , Enfermería Basada en la Evidencia/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Investigación Cualitativa , Refrigeración/normas
5.
J Pediatr Orthop ; 39(7): e514-e519, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31157753

RESUMEN

BACKGROUND: Surgical site infection (SSI) following posterior spinal fusion for idiopathic scoliosis is a difficult complication, with little information published regarding the best preventative comprehensive care plan. The Spine Subgroup of the Quality, Safety, Value Initiative (QSVI) committee of the Pediatric Orthopaedic Society of North America undertook a survey to generate an overview of bundle elements in comprehensive SSI care bundles across institutions in North America. The purpose of this study was to develop a toolkit of SSI care bundle elements that could be used in developing future SSI care bundles. METHODS: A survey email was sent to pediatric orthopaedic surgeons requesting a copy of the SSI prevention care bundle used in their practice. Surgeons were included if they had participated in the 2016 POSNA QSVI challenge, indicated they performed pediatric spine surgery, and had a spine SSI bundle. These bundles were evaluated by the QSVI committee and divided into preoperative, intraoperative, and postoperative elements with the frequency of use of each element recorded. A follow-up qualitative questionnaire was sent assessing the implementation and development of these SSI bundles. RESULTS: In total, 16 care bundles from 15 different institutions were included for review. The response rate for this survey was 44% of individuals (50/113 QSVI challenge participants) and 43% (15/35) of unique institutions. The most common elements included: use of preoperative antibiotics, use of preoperative chlorhexidine wipes, use of wound irrigation intraoperatively, and a standardized prescription for the length of postoperative antibiotic. Each of these elements was included in ≥75% of the SSI bundles evaluated. CONCLUSIONS: SSI care bundles are increasingly being used by pediatric institutions to lower the risk of SSI following pediatric spinal surgery. This study provides an overview of various care elements used in established SSI care bundles across multiple institutions in North America. It is hoped this data will provide institutions interested in developing their own SSI care bundle with useful information for beginning this process. LEVEL OF EVIDENCE: Level V-Decision Analysis.


Asunto(s)
Control de Infecciones/métodos , Paquetes de Atención al Paciente/métodos , Escoliosis/cirugía , Fusión Vertebral/efectos adversos , Infección de la Herida Quirúrgica , Adolescente , Niño , Humanos , Servicios Preventivos de Salud , Mejoramiento de la Calidad , Fusión Vertebral/métodos , Infección de la Herida Quirúrgica/epidemiología , Infección de la Herida Quirúrgica/etiología , Infección de la Herida Quirúrgica/prevención & control , Estados Unidos/epidemiología
7.
Intensive Crit Care Nurs ; 53: 68-72, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31036423

RESUMEN

OBJECTIVE: Determine the incidence and risk factors for pressure ulcers in a paediatric intensive care unit. Use the information gathered to develop preventive pressure ulcer care bundles. RESEARCH METHODOLOGY: Prospective cohort study using Braden Q Scale for Predicting Pressure Sore Risk and European Pressure Ulcer Advisory Panel Pressure Ulcer Staging tool. SETTING: General paediatric intensive care unit in a tertiary level hospital between May and October 2017. RESULTS: Seventy-seven children were recruited. Most children were male (n = 42, 54.5%) and all nine children (11.7%) that developed a pressure ulcer were male. The main risk factor for developing a pressure ulcer was lack of physical activity. None of the children assessed as high or severe risk developed a pressure ulcer. Eight (89%) pressure ulcers were assessed as grade one. Seven pressure ulcers (77.8%) were on the facial and scalp area and all seven children were receiving airway support at the time the pressure ulcers developed. CONCLUSION: Incidence of pressure ulcers was 11.7%, with the facial and scalp area the most common anatomical areas affected. Medical devices appeared to be the prime causative factor. Based on our data we have modified and launched the SSKIN care bundle for the paediatric intensive care unit setting.


Asunto(s)
Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Paquetes de Atención al Paciente/normas , Úlcera por Presión/diagnóstico , Preescolar , Estudios de Cohortes , Femenino , Humanos , Incidencia , Lactante , Unidades de Cuidado Intensivo Pediátrico/organización & administración , Unidades de Cuidado Intensivo Pediátrico/normas , Irlanda/epidemiología , Masculino , Paquetes de Atención al Paciente/métodos , Paquetes de Atención al Paciente/estadística & datos numéricos , Úlcera por Presión/epidemiología , Úlcera por Presión/prevención & control , Estudios Prospectivos , Factores de Riesgo
8.
Rev Bras Enferm ; 72(1): 50-56, 2019.
Artículo en Inglés, Portugués | MEDLINE | ID: mdl-30916267

RESUMEN

OBJECTIVE: To investigate the factors that influence the knowledge and behavior of professionals of neonatal and pediatric units about bundled strategies of insertion of central venous catheter. METHOD: This is a cross-sectional study, conducted in one neonatal and one pediatric intensive care units in a public hospital in Belo Horizonte, Brazil, from April to July, 2016. The sample consisted of 255 professionals who answered a structured instrument. Descriptive and comparative analyses were made using the SPSS software. RESULTS: The category nursing professional (p = 0.010), working hours of 12×36 scale (p < 0.001), training as a form of acquiring knowledge (p < 0.001) and participation in training programs (p < 0.001) are associated to greater knowledge about the bundle. Regarding behavior, no significant associations were observed. CONCLUSION: The study showed that there are factors that influence the knowledge about bundled strategies of insertion of central venous catheter, reflecting the need to consider these practices for making more effective educational practices in health care.


Asunto(s)
Cateterismo Venoso Central/métodos , Conocimientos, Actitudes y Práctica en Salud , Paquetes de Atención al Paciente/normas , Adulto , Anciano , Brasil , Cateterismo Venoso Central/instrumentación , Cateterismo Venoso Central/tendencias , Competencia Clínica/normas , Estudios Transversales , Femenino , Humanos , Unidades de Cuidado Intensivo Pediátrico/organización & administración , Unidades de Cuidado Intensivo Pediátrico/tendencias , Masculino , Persona de Mediana Edad , Paquetes de Atención al Paciente/métodos , Encuestas y Cuestionarios
10.
Infect Control Hosp Epidemiol ; 40(1): 72-78, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30501661

RESUMEN

OBJECTIVE: The aim of this study was to assess the impact of a urinary tract infection (UTI) management bundle to reduce the treatment of asymptomatic bacteriuria (AB) and to improve the management of symptomatic UTIs. DESIGN: Before-and-after intervention study.SettingsTertiary-care hospital.PatientsConsecutive sample of inpatients with positive single or mixed-predominant urine cultures collected and reported while admitted to the hospital. METHODS: The UTI management bundle consisted of nursing and prescriber education, modification of the reporting of positive urine cultures, and pharmacists' prospective audit and feedback. A retrospective chart review of consecutive inpatients with positive urinary cultures was performed before and after implementation of the management bundle. RESULTS: Prior to the implementation of the management bundle, 276 patients were eligible criteria for chart review. Of these 276 patients, 165 (59·8%) were found to have AB; of these 165 patients with AB, 111 (67·3%) were treated with antimicrobials. Moreover, 268 patients met eligibility criteria for postintervention review. Of these 268, 133 patients (49·6%) were found to have AB; of these 133 with AB, 22 (16·5%) were treated with antimicrobials. Thus, a 75·5% reduction of AB treatment was achieved. Educational components of the bundle resulted in a substantial decrease in nonphysician-directed urine sample submission. Adherence to a UTI management algorithm improved substantially in the intervention period, with a notable decrease in fluoroquinolone prescription for empiric UTI treatment. CONCLUSIONS: A UTI management bundle resulted in a dramatic improvement in the management of urinary tract infection, particularly a reduction in the treatment of AB and improved management of symptomatic UTI.


Asunto(s)
Antiinfecciosos/uso terapéutico , Bacteriuria/tratamiento farmacológico , Paquetes de Atención al Paciente/métodos , Infecciones Urinarias/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Enfermedades Asintomáticas , Bacteriuria/diagnóstico , Manejo de la Enfermedad , Femenino , Hospitales de Enseñanza , Humanos , Masculino , Persona de Mediana Edad , Nuevo Brunswick , Estudios Retrospectivos , Centros de Atención Terciaria , Urinálisis , Infecciones Urinarias/diagnóstico
11.
Int Emerg Nurs ; 43: 56-60, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30381143

RESUMEN

INTRODUCTION: Pain management in children is often poorly executed in Emergency Departments and Minor Injury Units. The aim of this study was to assess the impact of a care bundle comprising targeted education on pain score documentation and provision of appropriately dosed analgesia for the paediatric population attending Emergency Departments (EDs) and Minor Injury Units (MIUs). METHODS: A total of 29 centres - 5 EDs and 24 MIUs - participated in an intervention study initiated by Emergency Nurse Practitioners to improve paediatric pain management. In Phase 1, up to 50 consecutive records of children under 18 presenting at each MIU and ED were examined (n = 1201 records); Pain Score (PS), age, whether the child was weighed, and provision of analgesia was recorded. A care bundle consisting of an education programme, paediatric dosage chart and flyers, was then introduced across the 29 centres. Nine months following introduction of the care bundle, the same data set was collected from units (Phase 2, n = 1090 records). RESULTS: The likelihood of children having a pain score documented increased significantly in Phase 2 (OR 6.90, 95% CI 5.72-8.32), The likelihood of children receiving analgesia also increased (OR1.82, 95% CI 1.51-2.19), although there was no increase in the proportion of children with moderate or severe pain receiving analgesia. More children were weighed following the care bundle (OR 2.58 95% CI 1.86-3.57). Infants and children who were not weighed were more likely to receive an incorrect analgesia dose (p < 0.01). CONCLUSIONS: Rates of PS documentation improved and there was greater provision of analgesia overall following introduction of the care bundle. Although weighing of children did improve, the levels remain disappointingly low. EDs generally performed better than MIUs. The results show there were some improvements with this care bundle, but future work is needed to determine why pain management continues to fall below expected standards and how to further improve and sustain the impact of the care bundle.


Asunto(s)
Dolor/enfermería , Paquetes de Atención al Paciente/normas , Pediatría/normas , Adolescente , Niño , Preescolar , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Inglaterra , Femenino , Humanos , Lactante , Masculino , Manejo del Dolor/métodos , Manejo del Dolor/normas , Dimensión del Dolor/métodos , Paquetes de Atención al Paciente/métodos , Pediatría/métodos , Factores de Tiempo
12.
J Pediatr Orthop ; 39(3): e216-e221, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30376495

RESUMEN

BACKGROUND: Distal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost. METHODS: We retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression. RESULTS: We identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs. CONCLUSIONS: Closed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices. LEVEL OF EVIDENCE: Level III-therapeutic.


Asunto(s)
Fijación de Fractura , Paquetes de Atención al Paciente , Fracturas del Radio , Adolescente , Niño , Preescolar , Costos y Análisis de Costo , Servicio de Urgencia en Hospital/estadística & datos numéricos , Episodio de Atención , Femenino , Fijación de Fractura/economía , Fijación de Fractura/métodos , Humanos , Masculino , Paquetes de Atención al Paciente/economía , Paquetes de Atención al Paciente/métodos , Radiografía/economía , Radiografía/métodos , Fracturas del Radio/diagnóstico por imagen , Fracturas del Radio/economía , Fracturas del Radio/cirugía , Estudios Retrospectivos , Estados Unidos
14.
J Microbiol Immunol Infect ; 52(4): 592-597, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-29198953

RESUMEN

BACKGROUND/PURPOSE: This study investigated the impact of implementing ventilator-associated pneumonia (VAP) bundle care on the rates of VAP in intensive care units (ICUs) in Taiwan. METHODS: A total of 10 ICUs (bed number, 170), including surgical (SICUs) (n = 7), cardiovascular/surgical (CV/S-ICUs) (n = 1), and medical ICUs (MICUs) (n = 2) from 10 hospitals (7 medical center hospitals and 3 regional hospitals) were enrolled in this quality-improvement project. This study was divided into the pre-intervention phase (1st January, 2012-31st July, 2013) and the intervention phase (1st August, 2013-31st October, 2014). RESULTS: Among the 10 hospitals, the overall rates (cases per 1000 ventilator-days) of VAP declined significantly (p = 0.005; rate ratio, 0.71) from 1.9 in the pre-intervention period to 1.5 in the intervention period. Significant difference in VAP rates between these periods was found in the regional hospitals (from 1.6 to 0.7; p < 0.001) and the SICUs (from 2.1 to 1.4; p < 0.001), but not in the medical centers (2.0 vs. 1.9; p = 0.0667) or CV/S-ICUs (4.5 vs. 4.5; p = 0.5391). However, VAP rate increased significantly (cases per 1000 ventilator-days) in the MICUs between the two periods (from 0.5 to 1.0; p = 0.0489). For the VAP bundle care elements, the overall compliance rate was 87.7% with 83.6% and 97.9% in the medical centers and regional hospitals, respectively. CONCLUSIONS: Implementing VAP bundle care has effectively reduced VAP in Taiwanese ICUs, but differences in performance and compliance rates of VAP bundle care among the different ICUs and hospital categories did exist.


Asunto(s)
Unidades de Cuidados Intensivos , Paquetes de Atención al Paciente/métodos , Neumonía Asociada al Ventilador/prevención & control , Infección Hospitalaria , Hospitales , Humanos , Control de Infecciones/métodos , Neumonía Asociada al Ventilador/epidemiología , Estudios Prospectivos , Taiwán/epidemiología
15.
Am J Infect Control ; 47(1): 33-37, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30201414

RESUMEN

BACKGROUND: Central line-associated bloodstream infections (CLABSIs) are among the most common hospital-acquired infections and can lead to increased patient morbidity and mortality rates. Implementation of practice guidelines and recommended prevention bundles has historically been suboptimal, suggesting that improvements in implementation methods could further reductions in CLABSI rates. In this article, we describe the agile implementation methodology and present details of how it was successfully used to reduce CLABSI. METHODS: We conducted an observational study of patients with central line catheters at 2 adult tertiary care hospitals in Indianapolis from January 2015 to June 2017. RESULTS: The intervention successfully reduced the CLABSI rate from 1.76 infections per 1,000 central line days to 1.24 (rate ratio = 0.70; P = .011). We also observed reductions in the rates of Clostridium difficile and surgical site infections, whereas catheter-associated urinary tract infections remained stable. CONCLUSIONS: Using the AI model, we were able to successfully implement evidence-based practices to reduce the rate of CLABSIs at our facility.


Asunto(s)
Infecciones Relacionadas con Catéteres/prevención & control , Cateterismo Venoso Central/efectos adversos , Control de Infecciones/métodos , Sepsis/prevención & control , Humanos , Indiana , Paquetes de Atención al Paciente/métodos , Centros de Atención Terciaria
16.
J Trauma Nurs ; 25(6): 348-355, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30395033

RESUMEN

Delirium is a frequent complication of intensive care unit (ICU) admissions, manifesting as acute confusion with inattention and disordered thinking. Patients in the ICU who develop acute delirium are more likely to experience long-term disability and mortality. The Society of Critical Care Medicine published guidelines for the management of pain, agitation, and delirium (PAD) in the ICU in 2013. Based on these PAD guidelines, the ABCDEF bundle was created. Research is lacking on how adherence to the ABCDEF bundle elements impacts specific populations such as trauma patients. This represents a significant gap for patients whose multisystem injuries and comorbidities add a higher level of complexity to their care and outcomes. The medical ICU at a large community hospital participated in a 2-year quality improvement project as part of the Society of Critical Care Medicine's ICU Liberation Collaborative. However the organization's trauma ICU (TICU) was excluded from the study. The purpose of this study was to conduct a baseline assessment of trauma patient records to determine which bundle elements were already being applied in the TICU, and if the resources required for implementing the full ABCDEF bundle would be beneficial to the TICU patient outcomes. Benchmark data from the organization's participation in the ICU Liberation Collaborative quality improvement project served as the primary source of evidence. Analysis revealed strengths and opportunities for improvement. Incidence of delirium remained unchanged and far below national averages, indicating the need for further investigation into practices to verify this finding. An opportunity was identified to expand implementation of certain elements of the ABCDEF bundle in the trauma ICU. There is an opportunity for nurses to take the lead in improving patient outcomes. With improved education, evidence-based assessment tools, and best practice guidelines, nurses can help decrease the incidence of delirium by as much as 30%.


Asunto(s)
Cuidados Críticos/organización & administración , Delirio/etiología , Mortalidad Hospitalaria , Unidades de Cuidados Intensivos , Paquetes de Atención al Paciente/normas , Mejoramiento de la Calidad , Benchmarking , Delirio/fisiopatología , Femenino , Hospitales Comunitarios/organización & administración , Humanos , Masculino , Paquetes de Atención al Paciente/métodos , Guías de Práctica Clínica como Asunto , Análisis de Supervivencia , Centros Traumatológicos/organización & administración , Estados Unidos
17.
J Trauma Nurs ; 25(6): 366-373, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30395037

RESUMEN

Complications from catheter-associated urinary tract infections (CAUTIs) can cause morbidity and mortality. Our institution's Trauma Quality and Improvement Program analysis identified CAUTIs as an outlier complication in our trauma population. This study aimed to determine whether implemented measures would reduce CAUTI rates in trauma population. A 5-S CAUTI bundle was implemented. Its effects were measured on a prospectively collected dataset of adult trauma patients using our Trauma Registry during the 4-year study period. Implemented measures included (1) staff education, (2) bladder catheter stabilization, (3) patient and caregiver education, (4) keeping the collection bag below the bladder and above the floor, and (5) daily evaluations for discontinuation. Chi-squared and t-test analyses were used with significance defined as p < .05. Twelve thousand nine hundred and sixty-two trauma patients were admitted to trauma service during the 4-year study period. Of these, 94 developed CAUTIs, with an average age of 67 years and 56% were females. The average injury severity score was 16 in patients with CAUTIs compared with 9 in non-CAUTI patients (p < .0002). In the index year, CAUTIs occurred in 41 out of 3,054 (1.34%), the following year there were 34 out of 3,455 (0.98%), in 2016 there were 11 out of 3,246 (0.33%), and 8 out of 3,207 (0.25%) in 2017 (p < .001). Results demonstrated an 80% reduction in CAUTI rate. Execution of the 5-S CAUTI bundle resulted in a significant 80% reduction in CAUTI rate in our trauma population.


Asunto(s)
Infecciones Relacionadas con Catéteres/prevención & control , Paquetes de Atención al Paciente/métodos , Cateterismo Urinario/efectos adversos , Infecciones Urinarias/prevención & control , Adulto , Infecciones Relacionadas con Catéteres/diagnóstico , Infecciones Relacionadas con Catéteres/epidemiología , Estudios de Cohortes , Infección Hospitalaria/prevención & control , Bases de Datos Factuales , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Puntaje de Gravedad del Traumatismo , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Medición de Riesgo , Centros Traumatológicos , Cateterismo Urinario/métodos , Infecciones Urinarias/etiología , Heridas y Traumatismos/diagnóstico , Heridas y Traumatismos/terapia
18.
Indian J Med Microbiol ; 36(3): 381-384, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30429391

RESUMEN

Purpose: Clostridium difficile infection (CDI) is a serious healthcare-associated infection (HAI) now being increasingly reported from hospitals across India. However, there is a paucity of data on the incidence of and impact of control measures on CDI in India. Materials and Methods: This is a retrospective study conducted at a tertiary care hospital in Mumbai from January 2016 to December 2017. All patients with healthcare-onset diarrhoea were tested for C. difficile by glutamate dehydrogenase (GDH)/toxin assay or nucleic acid amplification test (NAAT). CDI was defined as either GDH and toxin positive or NAAT positive. The incidence of CDI was calculated per 1000 patient days. Demographic features of patients with CDI including age, sex, duration of hospitalisation before onset of CDI, antibiotic use and treatment administered were summarised. Results: A total of 67 patients had CDI in the study period with a mean incidence of 0.2/1000 patient days. A halving of the CDI incidence was seen after intensification of the CDI prevention bundle. The mean age of affected patients was 64 years and CDI occurred at a median duration of 2 weeks after hospitalisation. Eighty-seven per cent of the patients were on antibiotics at the time of diagnosis of CDI. The crude mortality rate was 22%. Conclusions: CDI is an emerging HAI in India. All hospitals need to set up policies for surveillance, testing, treatment and prevention of CDI based on recent international guidelines and local infrastructure/logistics.


Asunto(s)
Infecciones por Clostridium/epidemiología , Infecciones por Clostridium/prevención & control , Clostridium difficile/aislamiento & purificación , Control de Infecciones/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Toxinas Bacterianas/análisis , Infecciones por Clostridium/tratamiento farmacológico , Infecciones por Clostridium/mortalidad , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/epidemiología , Infección Hospitalaria/mortalidad , Infección Hospitalaria/prevención & control , Demografía , Diarrea/tratamiento farmacológico , Diarrea/epidemiología , Diarrea/mortalidad , Diarrea/prevención & control , Utilización de Medicamentos , Femenino , Glutamato Deshidrogenasa/análisis , Hospitales Privados , Humanos , Incidencia , India , Masculino , Persona de Mediana Edad , Técnicas de Diagnóstico Molecular , Paquetes de Atención al Paciente/métodos , Estudios Retrospectivos , Análisis de Supervivencia , Centros de Atención Terciaria , Adulto Joven
19.
Surg Infect (Larchmt) ; 19(8): 821-830, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-30272529

RESUMEN

Background: With the prospect of antibiotic failure in the post-antibiotic era, strategies that prevent surgical site infection (SSI) are increasingly important. Current literature suggests that incisional Negative Pressure Wound Therapy (iNWPT) is a promising intervention. Methods: Based on published literature regarding iNPWT, its mechanisms of action, and clinical results, a narrative summary was built, including both the experimental as well as the clinical literature. Results: The experimental literature indicates that iNPWT provides a barrier against external contamination before re-epithelialization, increases blood flow and lymphatic clearance, and reduces edema. Meta-analyses of randomized studies indicate that iNWPT is effective in reducing SSI. We did not identify studies that assessed bacterial clearance during iNPWT in contaminated surgical sites, nor did we identify clinical studies that specified they omitted concomitant antibiotic prophylaxis. Conclusions: Moderate quality evidence indicates that iNWPT reduces SSI, although data without the concomitant use of antibiotic prophylaxis are lacking. The iNPWT is likely effective as a result of its barrier function and optimization of the surgical site micro-environment. For now, iNPWT is recommended for incorporation in SSI prevention bundles. The iNPWT as a substitute for antibiotic prophylaxis is not recommended currently. Further reduction of SSI by iNPWT will lessen the need for therapeutic use of antibiotic agents.


Asunto(s)
Terapia de Presión Negativa para Heridas/métodos , Infección de la Herida Quirúrgica/prevención & control , Animales , Humanos , Paquetes de Atención al Paciente/métodos , Resultado del Tratamiento
20.
Paediatr Anaesth ; 28(10): 924-929, 2018 10.
Artículo en Inglés | MEDLINE | ID: mdl-30302885

RESUMEN

BACKGROUND: An electronic review of unplanned day case admission rates in our hospital demonstrated an average annual rate for pediatric circumcision of 2%-3% in recent years with high levels of perioperative strong opiate use. This lay above target unplanned admission rates (<2%) set out by the Royal College of Anaesthetists for day case surgery. A targeted quality improvement initiative was undertaken to improve patient flow through the pediatric day case surgery unit for elective circumcision. Among the reasons for unplanned admission, factors modifiable by the anesthetist (pain, postoperative nausea and vomiting, somnolence) are significant contributors. METHODS: A prospective audit was undertaken over a 3-month period. Our practice was compared with evidence-based analgesic and antiemetic interventions in accordance the Association of Paediatric Anaesthetists of Great Britain and Ireland. Perioperative strong opiate administration rates occurred in 44% of cases. Four strategic interventions were selected based on quality of evidence, ease of implementation, and low cost: selection of higher concentration local anesthetic use for penile blocks, intravenous dexamethasone, and preoperative paracetamol combined with maximum dose nonsteroidal anti-inflammatory. RESULTS: The audit was duplicated a year later demonstrating a significant increase in application of these interventions with a parallel fall in strong opiate use from 44% to 9% and an unprecedented zero unplanned admission rate in our unit for 10 months in a row after implementation. CONCLUSION: Regular scrutiny of patient electronic data helps identify high impact areas for audit and intervention. Unplanned admission in pediatric day case surgery is an area amenable to such targeted intervention.


Asunto(s)
Circuncisión Masculina/estadística & datos numéricos , Centros de Día/estadística & datos numéricos , Admisión del Paciente/estadística & datos numéricos , Paquetes de Atención al Paciente/métodos , Anestesia Local/métodos , Anestesia Local/estadística & datos numéricos , Anestésicos Locales/administración & dosificación , Preescolar , Circuncisión Masculina/efectos adversos , Circuncisión Masculina/métodos , Auditoría Clínica , Centros de Día/organización & administración , Procedimientos Quirúrgicos Electivos/efectos adversos , Procedimientos Quirúrgicos Electivos/métodos , Procedimientos Quirúrgicos Electivos/estadística & datos numéricos , Hospitales Pediátricos/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Irlanda/epidemiología , Masculino , Dolor Postoperatorio/tratamiento farmacológico , Dolor Postoperatorio/epidemiología , Paquetes de Atención al Paciente/estadística & datos numéricos , Mejoramiento de la Calidad/estadística & datos numéricos , Reino Unido/epidemiología
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