Desarrollo de un sistema de monitorización clínica para hemodiálisis: propuesta de indicadores del Grupo de Gestión de Calidad de la SEN / Developing a clinical performance measures system for hemodialysis, quality group, Spanish Society of Nephrology

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[Functional dependency evaluation of hemodialysis patients: a multicentric study]. / Valoración del grado de dependencia funcional de los pacientes en hemodiálisis (HD): estudio multicéntrico.

BACKGROUND: There has been a change in the hemodialysis population characteristics over the last years with a progressive increase in patient,s age and associated comorbility and mortality. This older hemodialysis population are more functionally and medically dependent increasing the time taken to perform nursing work. The objective of this study was to evaluate the degree of functional dependency on hemodialysis patients and the need of care by nursing workload. METHODS: A transversal descriptive study was done during 1 month (april 2005) on 586 patients from 10 HD Units in Spain. No exclusion criteria were used. The Delta Test, who was used to evaluate the patients dependency needs, is a workload measure instrument base on three subscales: dependency, Physical Deficiency and mental deficiency. The indicators are measure on a scale of one to three with each level representing an increasing demand on nursing time. The results obtained from the Delta Test were analyzed taking into account the following variables: age, average time in dialysis, Charlson comorbidity Index, geographic location and HD unit. RESULTS: 46% of the patients show some degree of dependency, of these 12.8% were moderated and 8.1% severe; the subscale analysis showed that 19.6% and 6.7% had, respectively, a moderate to severe physical and mental health deficiency. The dependency degree varied significantly between HD Units and geographic location with a range of 0% to 59.8%. The degree of dependency were statistically associated with age and CCI. The higher CCI (r: 0,21; p < 0.001) and age (r: 0,26; p < 0.001) the higher was the Delta Test Score for dependency level. Patients times of initiation on dialysis were not associated with an increase in the degree of dependency. The aspects evaluated by the Delta Test that showed a higher score were those related to patients mobility. The patients assistance requirements during the HD session are basically related to a lack of mobility due to musculoskeletal disease and to a lesser extent to behavior alterations. CONCLUSIONS: HD units are attending patients with an important degree of dependency which impose and added workload to the healthcare personnel. In occasions, it is very difficult to attend and give proper care with the current legally established nurse to patient ratio which. This suggests the need to implement a better staffing policy. The Delta Test provides an objective, adaptable and standardized instrument for measuring degree of dependency of HD patients.

Valoración del grado de dependencia funcional de los pacientes en hemodiálisis (HD): estudio multicéntrico / Functional dependency evaluation of hemofialysis patients. A multicentric study

Introducción: Las características de los pacientes que se incluyen en hemodiálisis (HD) han cambiado en los últimos años, habiendo aumentado la edad y la comorbilidad, lo que tiene implicaciones sobre aspectos funcionales, dada la necesidad de ayuda que requieren estos pacientes. El objetivo de este estudio ha sido analizar el grado de dependencia funcional del paciente en HD. Métodos: Estudio transversal y descriptivo en 586 pacientes dializados en abril de 2005 en 10 unidades de HD ubicadas en la Comunidad Valenciana, Andalucía y Castilla-León. Para valorar el grado de dependencia se utilizó el «Test Delta», que consta de tres subescalas que miden: Dependencia: (puntuación máxima 30), Deficiencia física: (puntuación máxima 15) y Deficiencia psíquica: (puntuación máxima 15). Los ítems se puntúan de 0 a 3, de menor a mayor severidad. Se analizaron los resultados obtenidos de acuerdo con las siguientes variables: Edad, tiempo medio en hemodiálisis, Índice de Comorbilidad de Charlson (ICC), Provincias y Unidades. Resultados: El 45,6% de los pacientes presentaba algún tipo de dependencia (un 12,8% en grado moderado y un 8,1% en grado severo). El análisis por sub-escalas mostró una Deficiencia física moderada-severa en el 19,6%, y en el 6,7% una Deficiencia psíquica. Este grado de dependencia variaba significativamente de unas unidades a otras (0%- 59,8%), y según áreas geográficas. La edad y el ICC mostraron asociación estadísticamente significativa con el grado de dependencia, de modo que a mayor edad (r: 0,26; p < 0,001) y mayor puntuación en el ICC (r: 0,21; p < 0,001) mayor grado de dependencia, sin embargo el tiempo de permanencia en hemodiálisis no mostró asociación. Los aspectos evaluados en el Test Delta que mostraron mayor puntuación fueron los relacionados con la movilidad del paciente. Los requerimientos de ayuda se deben fundamentalmente a falta de autonomía en la movilidad por alteraciones del aparato locomotor y, en menor medida, a trastornos de conducta. En conclusión, los centros de hemodiálisis están atendiendo a pacientes con un importante grado de dependencia, lo que supone una mayor carga de trabajo para el personal sanitario y muy especialmente el de enfermería. En ocasiones es imposible atender a este tipo de pacientes con el ratio de personal asignado actualmente por los conciertos vigentes, y se requiere una mayor dotación de enfermería. La existencia de parámetros que de manera objetiva permitan valorar tales circunstancias, hacen aconsejable aprobar un instrumento de valoración común, que sea sencillo, universal y rápido en la valoración y que, además, pueda adaptarse a las necesidades cambiantes de la población a la que va destinado

Background: There has been a change in the hemodialysis population characteristics over the last years with a progressive increase in patient,s age and associated comorbility and mortality. This older hemodialysis population are more functionally and medically dependent increasing the time taken to perform nursing work. The objective of this study was to evaluate the degree of functional dependency on hemodialysis patients and the need of care by nursing workload. Methods: A transversal descriptive study was done during 1 month (april 2005) on 586 patients from 10 HD Units in Spain. No exclusion criteria were used. The Delta Test, who was used to evaluate the patients dependency needs, is a workload measure instrument base on three subscales: dependency, Physical Deficiency and mental deficiency. The indicators are measure on a scale of one to three with each level representing an increasing demand on nursing time. The results obtained from the Delta Test were analyzed taking into account the following variables: age, average time in dialysis, Charlson comorbidity Index, geographic location and HD unit. Results: 46% of the patients show some degree of dependency, of these 12.8% were moderated and 8.1% severe; the subscale analysis showed that 19.6% and 6.7% had, respectively, a moderate to severe physical and mental health deficiency. The dependency degree varied significantly between HD Units and geographic location with a range of 0% to 59.8%. The degree of dependency were statistically associated with age and CCI. The higher CCI (r: 0,21; p < 0.001) and age (r: 0,26; p < 0.001) the higher was the Delta Test Score for dependency level. Patients times of initiation on dialysis were not associated with an increase in the degree of dependency. The aspects evaluated by the Delta Test that showed a higher score were those related to patients mobility. The patients assistance requirements during the HD session are basically related to a lack of mobility due to musculoskeletal disease and to a lesser extent to behavior alterations. Conclusions: HD units are attending patients with an important degree of dependency which impose and added workload to the healthcare personnel. In occasions, it is very difficult to attend and give proper care with the current legally established nurse to patient ratio which. This suggests the need to implement a better staffing policy. The Delta Test provides an objective, adaptable and standardized instrument for measuring degree of dependency of HD patients

[Quality control systems implementation in the Spanish Dialysis Units]. / Implantación de sistemas de gestión de calidad en las unidades de nefrología españolas.

OBJECTIVE: The aim of this study was to evaluate and analyze the implementation of a Quality Management Systems (QMS) and the use of Clinical Performance measures by the Nephrology Services and Hemodialysis Units in Spain. METHOD: The Quality Management Work Group of the Spanish Society of Nephrology (SEN) realized a survey that was directed to all the Spanish Nephrology Services and Hemodialysis Units. No exclusion criteria were defined for the study. The survey was based on a multichotomous self completing "Ad Hoc" questionnaire. RESULTS: The survey was answered by 46.7% of the polled centers (44.5% were public hospitals and 55.5% private centers). Of those replying the survey 70 % had a QMS, with a higher implementation in the area of Hemodialysis (HD). The ISO 9001-2000 was the prefer QMS model chosen by 76.4% of the centers. 68.6% of the centers with a QMS were certified by an external Auditing Group. 91.7% of the Nephrology Services and Hemodialysis units were using some clinical practice guideline. A high percentage of the centers had medical protocols and nursing plans (> 90%). A significantly higher implementation of QMS was observed in Private Hospitals and Hemodialysis Units (88.8 %) when compared to public Hospitals (46.1%) (X2: 31.5; p < 0.001). The ISO 9000 Standard certification was selected by 78,3% of the private centers and by 21,7% of the public centers (X2: 37.3; p < 0.001). The certification or accreditation were done by an external auditing group in 68. 1% of the private centers compared to 31.9% for the public Hospitals (X2: 24.8; p < 0.001). Although the rate of answers prevents from extracting definitive conclusions, the result seems to indicate that in the Spanish Nephrology Community a clear trend exists towards the use QMS. This tendency suggests, that in the near future, there will be a progressive implementation and routine use of QMS in the Nephrology Community in Spain.

Implantación de sistemas de gestión de calidad en las unidades de nefrología españolas / Quality control systems implementation in the spanish dialysis units

Objetivo. Evaluar la situación actual en los servicios de Nefrología y las unidadesde hemodiálisis de ámbito nacional, con respecto a la utilización de sistemasde gestión de calidad y al seguimiento de indicadores, y conocer la opinión delos nefrólogos respecto a este tema.Material y método. El Grupo de trabajo sobre Gestión de Calidad de la SENha realizado una encuesta dirigida a todos los servicios y centros de nefrologíaespañoles. No se consideró ningún criterio de exclusión. El cuestionario, estructuradopara autocumplimentación, fue elaborado ad hoc.Resultados: Un 46,7% de los centros encuestados respondió la encuesta (44,5%eran hospitales públicos y 55,5% centros privados). El 70% de los centros disponíade Sistemas de gestión de Calidad (SGC). La mayor implantación de SGCse observó en el área de hemodiálisis (HD). Los sistemas de gestión de calidadestán basados en su mayoría (76,4%) en las Normas ISO 9001-2000. El 68,6%de los centros con SGC estaba acreditado o certificado por una entidad externa.El 91,7% de los servicios y unidades de Nefrología refería utilizar alguna guía depráctica clínica en su rutina diaria. Un alto porcentaje de los centros disponía deprotocolos médicos y planes de cuidados de enfermería (> 90%). La implantaciónde SGC en los hospitales que respondieron la encuesta, fue significativamentesuperior en los centros privados (88,8%) que en los centros públicos (46,1%)(X2: 31.5; p < 0,001). Los centros privados optaron mayoritariamente por los SGCbasados en la normas ISO 9000 (78,3%), comparados con los centros públicos(21,7%) (X2: 37,3; p < 0,001). La certificación o acreditación por un organismoexterno reconocido fue significativamente superior en los centros privados (68,1%)que en los públicos (31,9%)(X2: 24,8; p < 0,001).Aunque la tasa de respuestas impide extraer conclusiones definitivas, el resultadoparece indicar que en la nefrología española existe una clara tendencia haciael uso de sistemas de acreditación y certificación, lo que permite suponer queésta será la forma habitual de trabajar en un futuro no muy lejano

Objective: The aim of this study was to evaluate and analyze the implementationof a Quality Management Systems (QMS) and the use of Clinical Performancemeasures by the Nephrology Services and Hemodialysis Units in Spain. Method: The Quality Management Work Group of the Spanish Society of Nephrology(SEN) realized a survey that was directed to all the Spanish Nephrology Servicesand Hemodialysis Units. No exclusion criteria were defined for the study. Thesurvey was based on a multichotomous self completing «Ad Hoc» questionnaire.Results: The survey was answered by 46.7% of the polled centers (44.5% werepublic hospitals and 55.5% private centers). Of those replying the survey 70 %had a QMS, with a higher implementation in the area of Hemodialysis (HD). TheISO 9001-2000 was the prefer QMS model chosen by 76.4% of the centers. 68.6%of the centers with a QMS were certified by an external Auditing Group. 91.7%of the Nephrology Services and Hemodialysis units were using some clinical practiceguideline. A high percentage of the centers had medical protocols and nursingplans (> 90%). A significantly higher implementation of QMS was observedin Private Hospitals and Hemodialysis Units (88.8 %) when compared to publicHospitals (46.1%) (X2: 31.5; p < 0.001). The ISO 9000 Standard certification wasselected by 78,3% of the private centers and by 21,7% of the public centers (X2:37.3; p < 0.001). The certification or accreditation were done by an external auditinggroup in 68.1% of the private centers compared to 31.9% for the publicHospitals (X2: 24.8; p < 0.001). Although the rate of answers prevents from extractingdefinitive conclusions, the result seems to indicate that in the SpanishNephrology Community a clear trend exists towards the use QMS. This tendencysuggests, that in the near future, there will be a progressive implementation androutine use of QMS in the Nephrology Community in Spain

Implantación de sistemas de gestión de calidad en las unidades de nefrología españolas / Implementation of quality management systems in spanish nephrology units

Objetivo. Evaluar la situación actual en los servicios de Nefrología y las unidades de hemodiálisis de ámbito nacional, con respecto a la utilización de sistemas de gestión de calidad y al seguimiento de indicadores, y conocer la opinión de los nefrólogos respecto a este tema. Material y método. El Grupo de trabajo sobre Gestión de Calidad de la SEN ha realizado una encuesta dirigida a todos los servicios y centros de nefrología españoles. No se consideró ningún criterio de exclusión. El cuestionario, estructurado para autocumplimentación, fue elaborado ad hoc. Resultados: Un 46,7% de los centros encuestados respondió la encuesta (44,5% eran hospitales públicos y 55,5% centros privados). El 70% de los centros disponía de Sistemas de gestión de Calidad (SGC). La mayor implantación de SGC se observó en el área de hemodiálisis (HD). Los sistemas de gestión de calidad están basados en su mayoría (76,4%) en las Normas ISO 9001-2000. El 68,6% de los centros con SGC estaba acreditado o certificado por una entidad externa. El 91,7% de los servicios y unidades de Nefrología refería utilizar alguna guía de práctica clínica en su rutina diaria. Un alto porcentaje de los centros disponía de protocolos médicos y planes de cuidados de enfermería (> 90%). La implantación de SGC en los hospitales que respondieron la encuesta, fue significativamente superior en los centros privados (88,8%) que en los centros públicos (46,1%) (X2: 31.5; p < 0,001). Los centros privados optaron mayoritariamente por los SGC basados en la normas ISO 9000 (78,3%), comparados con los centros públicos (21,7%) (X2: 37,3; p < 0,001). La certificación o acreditación por un organismo externo reconocido fue significativamente superior en los centros privados (68,1%) que en los públicos (31,9%)(X2: 24,8; p < 0,001). Aunque la tasa de respuestas impide extraer conclusiones definitivas, el resultado parece indicar que en la nefrología española existe una clara tendencia hacia el uso de sistemas de acreditación y certificación, lo que permite suponer que ésta será la forma habitual de trabajar en un futuro no muy lejano

Objective: The aim of this study was to evaluate and analyze the implementation of a Quality Management Systems (QMS) and the use of Clinical Performance measures by the Nephrology Services and Hemodialysis Units in Spain Method: The Quality Management Work Group of the Spanish Society of Nephrology (SEN) realized a survey that was directed to all the Spanish Nephrology Services and Hemodialysis Units. No exclusion criteria were defined for the study. The survey was based on a multichotomous self completing «Ad Hoc» questionnaire. Results: The survey was answered by 46.7% of the polled centers (44.5% were public hospitals and 55.5% private centers). Of those replying the survey 70 % had a QMS, with a higher implementation in the area of Hemodialysis (HD). The ISO 9001-2000 was the prefer QMS model chosen by 76.4% of the centers. 68.6% of the centers with a QMS were certified by an external Auditing Group. 91.7% of the Nephrology Services and Hemodialysis units were using some clinical practice guideline. A high percentage of the centers had medical protocols and nursing plans (> 90%). A significantly higher implementation of QMS was observed in Private Hospitals and Hemodialysis Units (88.8 %) when compared to public Hospitals (46.1%) (X2: 31.5; p < 0.001). The ISO 9000 Standard certification was selected by 78,3% of the private centers and by 21,7% of the public centers (X2: 37.3; p < 0.001). The certification or accreditation were done by an external auditing group in 68.1% of the private centers compared to 31.9% for the public Hospitals (X2: 24.8; p < 0.001). Although the rate of answers prevents from extracting definitive conclusions, the result seems to indicate that in the Spanish Nephrology Community a clear trend exists towards the use QMS. This tendency suggests, that in the near future, there will be a progressive implementation and routine use of QMS in the Nephrology Community in Spain

Increases in the size, number and proliferation rate of VIP-immunoreactive pituitary cells induced in vitro by TRH are associated with increases in VIP release / Los aumentos del tamaño, número y proliferación de las células hipofisarias inmunorreactivas a VIP, inducidos in vitro por TRH, están asociados con incrementos de la liberación de VIP

Pituitary VIP levels and pituitary VIP-expressing cell numbers are increased in hypothyroidism, but the regulating role of TRH as regards morphological changes remains obscure. In order to determine whether TRH is involved in regulating the maintenance of pituitary VIP-expressing cells and its cellular proliferation a double immunocytochemical study for VIP and proliferating cell nuclear antigen (PCNA) was carried out in pituitary monolayer cultures treated with TRH. TRH induced a significant in vitro increase in the numerical density (p<0.01) and percentage (p<0.001) of VIP-expressing cells. These changes were accompanied by increases in VIP release (p<0.01) and in the size (p<0.01) of VIP-expressing cells. Our results suggest that TRH could regulate the maintenance of the percentage of pituitary VIP-expressing cells, their activity and their proliferation in a similar way to the way in which it regulates the release of VIP (AU)

Los niveles hipofisarios de VIP y el número de células que expresan VIP están aumentados en el hipotiroidismo, pero el papel regulador de TRH respecto a los cambios morfológicos permanece inaclarado. Con el fin de determinar si la TRH está implicada en la regulación del mantenimiento de las células hipofisarias que expresan VIP y su proliferación celular, se llevó a cabo un estudio inmunocitoquímico doble para VIP y el antígeno nuclear de proliferación celular (PCNA) en cultivos hipofisarios monocapa tratados con TRH. TRH indujo un aumento significativo in vitro de la densidad numérica (p<0.01) y el porcentaje (p<0.001) de las células que expresan VIP. Estos cambios estuvieron acompañados por aumentos de la liberación de VIP (p<0.01) y del tamaño (p<0.01) de las células VIP-positivas. Nuestros resultados sugieren que la TRH podría regular el mantenimiento del porcentaje, actividad y proliferación de las células que expresan VIP, de forma similar al modo en que regula la liberación de VIP (AU)