[Prognostic implications of myocardial injury in patients with and without COVID-19 infection treated in a university hospital]. / Implicaciones pronósticas del daño miocárdico en pacientes con y sin diagnóstico confirmado de COVID-19 atendidos en un hospital universitario.

INTRODUCTION AND OBJECTIVES: Cardiac troponin, a marker of myocardial injury, is frequently observed in patients with COVID-19 infection. Our objective was to analyze myocardial injury and its prognostic implications in patients with and without COVID-19 infection treated in the same period of time. METHODS: The present study included patients treated in a university hospital with cardiac troponin I measurements and with suspected COVID-19 infection, confirmed or ruled out by polymerase chain reaction analysis. The impact was analyzed of cardiac troponin I positivity on 30-day mortality. RESULTS: In total, 433 patients were distributed among the following groups: confirmed COVID-19 (n = 186), 22% with myocardial injury (n = 41); and ruled out COVID-19 (n = 247), 21.5% with myocardial injury (n = 52). The confirmed and ruled out COVID-19 groups had a similar age, sex, and cardiovascular history. Mortality was significantly higher in the confirmed COVID-19 group than in the ruled out group (19.9% vs 5.3%, P < .001). In Cox multivariate regression analysis, cardiac troponin I was a predictor of mortality in both groups (confirmed COVID-19 group: HR, 3.54; 95%CI, 1.70-7.34; P = .001; ruled out COVID-19 group: HR, 5.57; 95%CI, 1.70-18.20; P = .004). The predictive model analyzed by ROC curves was similar in the 2 groups (P = .701), with AUCs of 0.808 in the confirmed COVID-19 group (0.750-0.865) and 0.812 in the ruled out COVID-19 group (0.760-0.864). CONCLUSIONS: Myocardial injury is detected in 1 in every 5 patients with confirmed or ruled out COVID-19 and predicts 30-day mortality to a similar extent in both circumstances.

Prognostic implications of myocardial injury in patients with and without COVID-19 infection treated in a university hospital.

INTRODUCTION AND OBJECTIVES: Cardiac troponin, a marker of myocardial injury, is frequently observed in patients with COVID-19 infection. Our objective was to analyze myocardial injury and its prognostic implications in patients with and without COVID-19 infection treated in the same period of time. METHODS: The present study included patients treated in a university hospital with cardiac troponin I measurements and with suspected COVID-19 infection, confirmed or ruled out by polymerase chain reaction analysis. The impact was analyzed of cardiac troponin I positivity on 30-day mortality. RESULTS: In total, 433 patients were distributed among the following groups: confirmed COVID-19 (n=186), 22% with myocardial injury (n=41); and ruled out COVID-19 (n=247), 21.5% with myocardial injury (n=52). The confirmed and ruled out COVID-19 groups had a similar age, sex, and cardiovascular history. Mortality was significantly higher in the confirmed COVID-19 group than in the ruled out group (19.9% vs 5.3%, P <.001). In Cox multivariate regression analysis, cardiac troponin I was a predictor of mortality in both groups (confirmed COVID-19 group: HR, 3.54; 95%CI, 1.70-7.34; P=.001; ruled out COVID-19 group: HR, 5.57; 95%CI, 1.70-18.20; P=.004). The predictive model analyzed by ROC curves was similar in the 2 groups (P=.701), with AUCs of 0.808 in the confirmed COVID-19 group (0.750-0.865) and 0.812 in the ruled out COVID-19 group (0.760-0.864). CONCLUSIONS: Myocardial injury is detected in 1 in every 5 patients with confirmed or ruled out COVID-19 and predicts 30-day mortality to a similar extent in both circumstances.

Registro MORCAT: descripción de la sedación paliativa y la mortalidad en los servicios de urgencias / Palliative sedation and mortality in emergency departments: descriptive study of cases in the MORCAT registry

Objetivo: Describir las características y manejo de los pacientes con sedación paliativa (SP) en 11 servicios de urgencias hospitalarios (SUH) catalanes. Método: Estudio prospectivo descriptivo de pacientes que recibieron SP entre abril y julio de 2018. Se recogieron variables demográficas, enfermedades del paciente, índice de Charlson (IC), procedencia, tiempos en urgencias y fármacos utilizados. Resultados: Se incluyeron 323 pacientes (48,9% varones) con una edad media de 84 (DE 12) años. El IC fue significativamente mayor en hospitales de primer nivel. La SP se consideró primera opción de tratamiento en el 27% y se inició en una media de 18 (DE 28) horas tras su llegada, significativamente diferente en hospitales de segundo nivel. Fallecieron mayoritariamente en el SUH (74,2%). Conclusiones: Los pacientes que reciben SP en los SUH son ancianos con comorbilidad grave, y en su mayoría reciben tratamiento con intención curativa como primera opción terapéutica. Existen diferencias significativas del tiempo transcurrido hasta el inicio de la SP según la complejidad del centro

Objective: To describe the clinical management of palliative sedation and the characteristics of sedated patients in 11 Catalan hospital emergency departments. Methods: Prospective descriptive study of a cohort of patients given palliative sedation between April and July 2018. We registered patient demographic and disease data, the Charlson comorbidity index (CCI), patient’s point of origin before emergency department arrival, times related to emergency care, and medications used. Results: We included 323 patients (48.9% men) with a mean (SD) age of 84 (12) years. The CCIs were significantly higher in patients attended in level-I hospitals. Palliative sedation was the first option in 27% and was initiated within 18 (28) hours of arrival on average, an interval that was significantly shorter in level-II hospitals. Most patients (74.2%) died in the emergency department. Conclusions: Patients treated with palliative sedation in hospital emergency departments are older and have serious concomitant conditions. Most patients are first treated with intention to cure. Time until the start of palliative sedation differs significantly according to hospital level

Palliative sedation and mortality in emergency departments: descriptive study of cases in the MORCAT registry. / Registro MORCAT: descripción de la sedación paliativa y la mortalidad en los servicios de urgencias.

OBJECTIVES: To describe the clinical management of palliative sedation and the characteristics of sedated patients in 11 Catalan hospital emergency departments. MATERIAL AND METHODS: Prospective descriptive study of a cohort of patients given palliative sedation between April and July 2018. We registered patient demographic and disease data, the Charlson comorbidity index (CCI), patient's point of origin before emergency department arrival, times related to emergency care, and medications used. RESULTS: We included 323 patients (48.9% men) with a mean (SD) age of 84 (12) years. The CCIs were significantly higher in patients attended in level-I hospitals. Palliative sedation was the first option in 27% and was initiated within 18 (28) hours of arrival on average, an interval that was significantly shorter in level-II hospitals. Most patients (74.2%) died in the emergency department. CONCLUSION: Patients treated with palliative sedation in hospital emergency departments are older and have serious concomitant conditions. Most patients are first treated with intention to cure. Time until the start of palliative sedation differs significantly according to hospital level.

OBJETIVO: Describir las características y manejo de los pacientes con sedación paliativa (SP) en 11 servicios de urgencias hospitalarios (SUH) catalanes. METODO: Estudio prospectivo descriptivo de pacientes que recibieron SP entre abril y julio de 2018. Se recogieron variables demográficas, enfermedades del paciente, índice de Charlson (IC), procedencia, tiempos en urgencias y fármacos utilizados. RESULTADOS: Se incluyeron 323 pacientes (48,9% varones) con una edad media de 84 (DE 12) años. El IC fue significativamente mayor en hospitales de primer nivel. La SP se consideró primera opción de tratamiento en el 27% y se inició en una media de 18 (DE 28) horas tras su llegada, significativamente diferente en hospitales de segundo nivel. Fallecieron mayoritariamente en el SUH (74,2%). CONCLUSIONES: Los pacientes que reciben SP en los SUH son ancianos con comorbilidad grave, y en su mayoría reciben tratamiento con intención curativa como primera opción terapéutica. Existen diferencias significativas del tiempo transcurrido hasta el inicio de la SP según la complejidad del centro.

Implicaciones pronósticas del daño miocárdico en pacientes con y sin diagnóstico confirmado de COVID-19 atendidos en un hospital universitario / Prognostic implications of myocardial injury in patients with and without COVID-19 infection treated in a university hospital

INTRODUCCIÓN Y OBJETIVOS: La elevación de la troponina cardiaca como marcador de daño miocárdico es un predictor pronóstico en pacientes con COVID-19. Sin embargo, se desconoce su rendimiento en pacientes coetáneos con sospecha de COVID-19 pero con prueba de reacción en cadena de la polimerasa negativa. MÉTODOS: Estudio de cohortes retrospectivo que incluyó a todos los pacientes consecutivos atendidos en un hospital universitario con sospecha de COVID-19, confirmada o descartada mediante prueba de reacción en cadena de la polimerasa, todos ellos con determinaciones de troponina cardiaca I. Se analizó el impacto de la positividad de la troponina cardiaca I en la mortalidad a 30 días. RESULTADOS: Un total de 433 pacientes quedaron distribuidos en los siguientes grupos: COVID-19 confirmada (n=186), el 22% de ellos con daño miocárdico (n=41), y COVID-19 descartada (n=247), el 21,5% de ellos con daño miocárdico (n=52). Los grupos de COVID-19 confirmada y descartada tuvieron similares edad, sexo y antecedentes cardiovasculares. La mortalidad en el grupo de COVID-19 confirmada frente al de descartada fue significativamente superior (el 19,9 frente al 5,3%; p <0,001). En ambos grupos, el daño miocárdico fue predictor de mortalidad en el análisis multivariado de regresión de Cox (grupo de COVID-19 confirmada, HR=3,54; IC95%, 1,70-7,34; p = 0,001; grupo de COVID-19 descartada, HR=5,57; IC95%, 1,70-18,20; p = 0,004). El modelo predictivo analizado por curvas ROC fue similar en ambos grupos: COVID-19 confirmada, AUC=0,808 (0,750-0,865); COVID-19 descartada, AUC=0,812 (0,760-0,864) (p = 0,701). CONCLUSIONES: Se detecta daño miocárdico en 1 de cada 5 pacientes con infección por COVID-19 confirmada o descartada. En ambas circunstancias, el daño miocárdico es predictor de mortalidad a 30 días en similar grado

INTRODUCTION AND OBJECTIVES: Cardiac troponin, a marker of myocardial injury, is frequently observed in patients with COVID-19 infection. Our objective was to analyze myocardial injury and its prognostic implications in patients with and without COVID-19 infection treated in the same period of time. METHODS: The present study included patients treated in a university hospital with cardiac troponin I measurements and with suspected COVID-19 infection, confirmed or ruled out by polymerase chain reaction analysis. The impact was analyzed of cardiac troponin I positivity on 30-day mortality. RESULTS: In total, 433 patients were distributed among the following groups: confirmed COVID-19 (n=186), 22% with myocardial injury (n=41); and ruled out COVID-19 (n=247), 21.5% with myocardial injury (n=52). The confirmed and ruled out COVID-19 groups had a similar age, sex, and cardiovascular history. Mortality was significantly higher in the confirmed COVID-19 group than in the ruled out group (19.9% vs 5.3%, P <.001). In Cox multivariate regression analysis, cardiac troponin I was a predictor of mortality in both groups (confirmed COVID-19 group: HR, 3.54; 95%CI, 1.70-7.34; P=.001; ruled out COVID-19 group: HR, 5.57; 95%CI, 1.70-18.20; P=.004). The predictive model analyzed by ROC curves was similar in the 2 groups (P=.701), with AUCs of 0.808 in the confirmed COVID-19 group (0.750-0.865) and 0.812 in the ruled out COVID-19 group (0.760-0.864). CONCLUSIONS: Myocardial injury is detected in 1 in every 5 patients with confirmed or ruled out COVID-19 and predicts 30-day mortality to a similar extent in both circumstances

Aceptación clínica de la definición universal del infarto de miocardio / Clinical acceptance of the universal definition of myocardial infarction

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Prognostic implications of troponin I elevation in emergency department patients with tachyarrhythmia.

BACKGROUND: Tachyarrhythmias are very common in emergency medicine, and little is known about the long-term prognostic implications of troponin I levels in these patients. HYPOTHESIS: This study aimed to investigate the correlation of cardiac troponin I (cTnI) levels and long-term prognosis in patients admitted to the emergency department (ED) with a primary diagnosis of tachyarrhythmia. METHODS: A retrospective cohort study was conducted between January 2012 and December 2013, enrolling patients admitted to the ED with a primary diagnosis of tachyarrhythmia and having documented cTnI measurements. Clinical characteristics and 5-year all-cause mortality were analyzed. RESULTS: Of a total of 222 subjects with a primary diagnosis of tachyarrhythmia, 73 patients had elevated levels of cTnI (32.9%). Patients with elevated cTnI levels were older and presented significantly more cardiovascular risk factors. At the 5-year follow-up, mortality was higher among patients with elevated cTnI levels (log-rank test P < 0.001). In the multivariable Cox regression analysis, elevated cTnI was an independent predictor of all-cause death (hazard ratio, 1.95, 95% confidence interval: 1.08-3.50, P = 0.026), in addition to age and prior heart failure. CONCLUSION: Patients admitted to the ED with a primary diagnosis of tachyarrhythmia and high cTnI levels have higher long-term mortality rates than patients with low cTnI levels. cTnI is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of this population.

Risk Estimation in Type 2 Myocardial Infarction and Myocardial Injury: The TARRACO Risk Score.

BACKGROUND: Despite adverse prognoses of type 2 myocardial infarction and myocardial injury, an effective, practical risk stratification method remains an unmet clinical need. We sought to develop an efficient clinical bedside tool for estimating the risk of major adverse cardiovascular events at 180 days for this patient population. METHODS: The derivation cohort included patients with type 2 myocardial infarction or myocardial injury admitted to a tertiary hospital between 2012 and 2013 (n = 611). The primary outcome was a major adverse cardiovascular event (death or readmission for heart failure or myocardial infarction). The score included clinical variables significantly associated with the outcome. External validation was conducted using the UTROPIA cohort (n = 401). RESULTS: The TARRACO Score included cardiac troponin (cTn) concentrations and 5 independent clinical predictors of adverse cardiovascular events: age, hypertension, absence of chest pain, dyspnea, and anemia. The score exhibited good discriminative accuracy (area under the curve = 0.74; 95% CI, 0.70-0.79). Patients were classified into low-risk (score 0-6) and high-risk (score ≥7) categories. Major adverse cardiovascular events rates were 5 times more likely in high-risk patients compared with those at low risk (78.9 vs 15.4 events/100 patient-years, respectively; logrank P < .001). The external validation showed equivalent prognostic capacity (area under the curve=0.71, 0.65-0.78). CONCLUSION: A novel risk score based on bedside clinical variables and cTn concentrations allows risk stratification for death and cardiac-related rehospitalizations in patients with type 2 myocardial infarctions and myocardial injury. This score identifies patients at the highest risk of adverse events, a subset of patients who may benefit from close observation, medical intensification, or both.

Clinical Features and Prognosis of Patients with Acute and Chronic Myocardial Injury Admitted to the Emergency Department.

BACKGROUND: This study aimed to investigate the clinical features and prognosis of acute and chronic myocardial injury without clinical evidence of myocardial infarction in patients admitted to the emergency department. METHODS: We analyzed the clinical data of all consecutive patients admitted to the emergency department during the years 2012 and 2013 who had at least 2 determinations of troponin I (TnI Ultra Siemens, Advia Centaur) and without a diagnosis of myocardial infarction. Clinical events were evaluated in a 3-year follow-up. RESULTS: A total of 1201 patients met the study's inclusion criteria and were included in the analysis (833 with cTnI below the 99th percentile, 261 with acute myocardial injury, and 107 with chronic myocardial injury). During a median follow-up of more than 36 months, mortality and rehospitalization for heart failure were significantly higher in patients with acute or chronic myocardial injury compared with patients without myocardial injury. No differences were observed in overall mortality between patients with acute and chronic myocardial injury, or in the rate of readmission due to acute coronary syndrome. However, the risk of readmission due to heart failure (adjusted HR 2.17; 95% confidence interval, 1.26-3.75; P = .005) was higher in patients with chronic myocardial injury. CONCLUSIONS: Mortality in long-term follow-up is high and similar in acute and chronic myocardial injury; however, the risk of readmission due to heart failure is higher in patients with chronic myocardial injury compared with patients with acute myocardial injury.

Prognostic implications of detectable cardiac troponin I below the 99th percentile in patients admitted to an emergency department without acute coronary syndrome.

BACKGROUND: Detectable troponin below the 99th percentile may reflect an underlying cardiac abnormality which might entail prognostic consequences. This study aimed to investigate the prognosis of patients admitted to an emergency department (ED) with detectable troponin below the 99th percentile reference limit who did not present with an acute coronary syndrome (ACS). METHODS: We analysed the clinical data of all consecutive patients admitted to the ED during the years 2012 and 2013 in whom cardiac troponin was requested by the attending clinician (cTnI Ultra Siemens, Advia Centaur). Patients with troponin below the 99th percentile of the reference population (40 ng/L) and who did not have a diagnosis of ACS were selected, and their mortality was evaluated in a 2-year follow-up. RESULTS: A total of 2501 patients had a troponin level below the reference limit, with 43.9% of those showing detectable levels (>6 ng/L and <40 ng/L). Patients with detectable levels were elderly and had a higher prevalence of cardiovascular history and more comorbidities. The total mortality in the 2-year follow-up was 12.4% in patients with detectable troponin and 4.5% in patients with undetectable troponin (p<0.001). In the Cox multivariate regression analysis, the detectable troponin was an independent marker of mortality at 2 years (HR 1.62, 95% CI 1.07-2.45, p=0.021). CONCLUSIONS: Detectable troponin I below the 99th percentile is associated with higher mortality risk at 2-year follow-up in patients admitted to the ED who did not present with ACS.

Outcomes with type 2 myocardial infarction compared with non-ischaemic myocardial injury.

OBJECTIVE: To identify patients with type 2 myocardial infarction (MI) and patients with non-ischaemic myocardial injury (NIMI) and to compare their prognosis with those of patients with type 1 MI. METHODS: A retrospective observational study was performed in 1010 patients admitted to the emergency department of a university hospital with at least one troponin I test between 2012 and 2013. Participants were identified using laboratory records and divided into three groups: type 1 MI (rupture of atheromatous plaque), type 2 MI (imbalance between myocardial oxygen supply and/or demand) and NIMI (patients who did not meet diagnostic criteria for type 1 or type 2 MI). Clinical characteristics and 2-year outcomes were analysed. RESULTS: Patients with type 2 MI and NIMI were older, with higher proportion of women and more comorbidities than patients with type 1 MI. Absolute mortality and the adjusted risk for all-cause mortality in both groups were significantly higher than that of patients with type 1 MI (39.7%, HR: 1.41 95% CI 1.02 to 1.94, p=0.038 and 40.0%, HR: 1.54 95% CI 1.16 to 2.04, p=0.002, respectively). Patients with type 2 MI and NIMI tended to present more readmissions due to heart failure (16.5%, HR: 1.55 95% CI 0.87 to 2.76, p=0.133 and 12.3%, HR: 1.15 95% CI 0.70 to 1.90, p=0.580) and less readmission rates due to acute coronary syndrome (ACS) than patients with type 1 MI (2.1%, HR: 0.11 95% CI 0.04 to 0.31, p<0.001 and 4.3%, HR: 0.22 95% CI 0.12 to 0.41, p<0.001), CONCLUSIONS: Patients diagnosed with type 2 MI and NIMI have higher rates of mortality and lower readmission rates for ACS compared with patients with type 1 MI.

Pronóstico a un año de la elevación de troponina I en los pacientes dados de alta directamente desde un servicio de urgencias hospitalario / Elevated troponin I level in patients discharged home directly from the emergency department: prognostic value for 1-year mortality

Objetivo: Estudiar el papel pronóstico a un año de la troponina I elevada en los pacientes dados de alta directamente desde un servicio de urgencias hospitalario. Métodos: Estudio observacional de cohortes retrospectivo que incluyó a todos los pacientes atendidos por cualquier causa a los que se les había solicitado al menos una determinación de troponina I y fueron dados de alta directamente desde un servicio de urgencias de un hospital universitario entre enero y diciembre de 2012. Se recogieron datos demográficos, antecedentes personales y clínicos relacionados con el episodio agudo y el diagnóstico al alta. La variable de resultado principal fue la mortalidad por cualquier causa en el primer año tras el alta. Resultados: Se incluyeron 1.381 pacientes dados de alta directamente desde urgencias, de los cuales, 1.192 (86,3%) tenían troponina I negativa y 189 (13,7%) troponina I positiva. Tras un análisis multivariado, la troponina I elevada se mostró como un factor de riesgo independiente para mortalidad a un año (HR = 2,41 IC 95%: 1,40-4,22, p < 0,01). Conclusiones: La troponina I elevada es un marcador independiente de mortalidad al año en los pacientes dados de alta directamente desde urgencias a los que se les solicitó al menos una determinación por parte del urgenciólogo (AU)

Objective: To study the prognostic role of elevated troponin I levels in patients discharged home directly from a hospital emergency department. Methods: Observational study of a retrospective cohort of all patients attended for any emergency for whom troponin I tests were ordered and who were discharged home directly from our hospital emergency department between January and December 2012. We collected demographic information, medical histories, symptoms related to the acute coronary event, and diagnosis on discharge. The main outcome was all-cause mortality in the year following discharge. Results: A total of 1381 patients discharged home directly from the emergency department were studied; 1192 (86.3%) had normal troponin I results and 189 (13.7%) had elevated levels. On multivariate analysis, troponin I elevation emerged as an independent risk factor for death within a year of discharge (hazard ratio, 2.41; 95% CI, 1.40-4.22; P<.01). Conclusions: A raised troponin I level is an independent predictor of 1-year mortality in patients for whom this test is ordered at least once and who are discharged home directly from a hospital emergency service (AU)

[Elevated troponin I level in patients discharged home directly from the emergency department: prognostic value for 1-year mortality]. / Pronóstico a un año de la elevación de troponina I en los pacientes dados de alta directamente desde un servicio de urgencias hospitalario.

OBJECTIVES: To study the prognostic role of elevated troponin I levels in patients discharged home directly from a hospital emergency department. MATERIAL AND METHODS: Observational study of a retrospective cohort of all patients attended for any emergency for whom troponin I tests were ordered and who were discharged home directly from our hospital emergency department between January and December 2012. We collected demographic information, medical histories, symptoms related to the acute coronary event, and diagnosis on discharge. The main outcome was all-cause mortality in the year following discharge. RESULTS: A total of 1381 patients discharged home directly from the emergency department were studied; 1192 (86.3%) had normal troponin I results and 189 (13.7%) had elevated levels. On multivariate analysis, troponin I elevation emerged as an independent risk factor for death within a year of discharge (hazard ratio, 2.41; 95% CI, 1.40-4.22; P<.01). CONCLUSION: A raised troponin I level is an independent predictor of 1-year mortality in patients for whom this test is ordered at least once and who are discharged home directly from a hospital emergency service.

OBJETIVO: Estudiar el papel pronóstico a un año de la troponina I elevada en los pacientes dados de alta directamente desde un servicio de urgencias hospitalario. METODO: Estudio observacional de cohortes retrospectivo que incluyó a todos los pacientes atendidos por cualquier causa a los que se les había solicitado al menos una determinación de troponina I y fueron dados de alta directamente desde un servicio de urgencias de un hospital universitario entre enero y diciembre de 2012. Se recogieron datos demográficos, antecedentes personales y clínicos relacionados con el episodio agudo y el diagnóstico al alta. La variable de resultado principal fue la mortalidad por cualquier causa en el primer año tras el alta. RESULTADOS: Se incluyeron 1.381 pacientes dados de alta directamente desde urgencias, de los cuales, 1.192 (86,3%) tenían troponina I negativa y 189 (13,7%) troponina I positiva. Tras un análisis multivariado, la troponina I elevada se mostró como un factor de riesgo independiente para mortalidad a un año (HR = 2,41 IC 95%: 1,40-4,22, p < 0,01). CONCLUSIONES: La troponina I elevada es un marcador independiente de mortalidad al año en los pacientes dados de alta directamente desde urgencias a los que se les solicitó al menos una determinación por parte del urgenciólogo.

Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias / Catalan hospital emergency department heads’ opinions on the creation of a residency program for specializing in emergency medicine

Objetivo: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). Método: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). Resultados: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). Conclusiones: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico (AU)

Objective: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. Methods: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). Results: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%–97.9%), by their in their departments (88.6%; 95% CI, 79.4%–94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%–59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%–89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%–98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%–71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). Conclusions: The heads of Catalan ED, their staff, and their hospitals’ staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs (AU)

[Catalan hospital emergency department heads' opinions on the creation of a residency program for specializing in emergency medicine]. / Opinión de los responsables de los servicios de urgencias hospitalarios de Cataluña acerca de la creación de la especialidad de Medicina de Urgencias y Emergencias.

OBJECTIVES: To understand the opinions of emergency department (ED) heads in Catalonia on their support for a residency program for specializing in emergency medicine (EM) and on their beliefs about the impact such a program would have. MATERIAL AND METHODS: Heads of ED were asked if there would be support (from them, their staff, and their hospital) for a residency program to train specialists in EM. They were also asked their opinion on the impact that specialization would have on quality of care and costs in their department. Responses were compared by type of hospital and ED and by affiliation or not with the Spanish Society of Emergency Medicine (SEMES). RESULTS: Responses were received from 79 of the 82 heads of hospital EDs in Catalonia (96%). They reported that favorable opinions toward creation of an EM specialization were held by them personally (93.7%; 95% CI, 85.8%-97.9%), by their in their departments (88.6%; 95% CI, 79.4%-94.7%), and by staff in their hospitals (48.7%; 95% CI, 36.7%-59.6%). A majority thought that the impact of specialization would be good in the short term (82.0%; 95% CI, 71.7%-89.8%) and in the medium and long term (94.8%; 95% CI, 87.2%-98.6%). The respondents were neutral about whether there would be an impact on costs (60.3%; 95% CI, 48.6%-71.2%). More heads in mid-sized hospitals, private hospitals, and nonmembers of SEMES thought that creating a specialty would raise ED costs (p<0,05). CONCLUSION: The heads of Catalan ED, their staff, and their hospitals' staffs hold favorable opinions of the proposal to create a residency program allowing specialization in EM. They foresee short-, medium-, and long-term benefits for the EDs and scarce impact on costs.

OBJETIVO: Conocer la opinión de los responsables de los servicios de urgencias hospitalarios (SUH) de Cataluña respecto al soporte e impacto que tendría la creación de la especialidad primaria de Medicina de Urgencias y Emergencias (MUE). METODO: Se solicitó la opinión a los responsables de SUH respecto al respaldo a una futura especialidad primaria de MUE (personal, en su servicio y en su hospital) y la estimación del impacto (cualitativo y económico) que tendría en su SUH. Se compararon las respuestas en función del tipo de hospital y SUH y de su afiliación a la Sociedad Española de Medicina de Urgencias y Emergencias (SEMES). RESULTADOS: Contestaron 79 de los 82 responsables de los SUH de Cataluña (96%), que percibieron una posición favorable a la creación de la especialidad, tanto ellos personalmente (93,7%; IC 95%: 85,8-97,9) como en sus SUH (88,6%; 79,4- 94,7) y hospitales (48,7%; 36,7-59,6). El 82,0% (71,7-89,8) opinó que la especialidad tendría un efecto positivo a corto plazo y el 94,8% (87,2-98,6) que también lo tendría a medio-largo plazo, y respecto al impacto económico, la opinión mayoritaria fue que sería neutro (60,3%; 48,6-71,2). Los responsables de SUH con actividad media, de hospitales privados y no afiliados a SEMES consideraron más frecuentemente que la creación de la especialidad encarecería el SUH (p < 0,05). CONCLUSIONES: Los responsables de los SUH catalanes tienen una opinión favorable y también la perciben en su servicio y su hospital respecto a la creación de la especialidad primaria de MUE y consideran que tendría efectos beneficiosos a corto, medio y largo plazo para el SUH, con un escaso impacto económico.

Estudio SUHCAT (1): mapa físico de los servicios de urgencias hospitalarios de Cataluña / SUHCAT study, part 1: a map of the physical characteristics of hospital emergency services in Catalonia

Objetivo: Describir las características físicas de los servicios de urgencias hospitalarios (SUH) de Cataluña y su relación con diferentes características del SUH y del hospital. Método: Se entrevistó a los jefes de 79 de los 82 SUH de Cataluña (96%) que respondieron un cuestionario de 353 preguntas. Una parte de ellas hacía referencia a las características físicas y estructurales de los SUH. Las respuestas se tabularon globalmente y de forma detallada en función de la actividad del SUH (alta, media o baja), el uso del hospital (privado o público) y la complejidad del hospital público (alta tecnología o alta resolución, de referencia, comarcal). Resultados: En la mitad de SUH, su estructura física fue construida o reformada en los 4 años previos. El 59,5% de los SUH cuenta con un área observación (AO) (más los SUH de alta actividad y los hospitales públicos de mayor complejidad). El 35% tiene unidad de corta estancia en su hospital: en el 68% trabajan urgenciólogos, en el 46% éstos son los únicos facultativos especialistas y el 61% depende del SUH. En 2011, los SUH realizaron 3.949.885 atenciones (0,53 atenciones por habitante y año), el 16% en hospitales privados. La mediana (p25-p75) de ingresos fue del 9% (6-12). Un 34,2% incrementa su actividad por motivos de temporalidad turística, durante los cuales sólo el 37,0% aumenta el personal y el 18,5% la estructura. Los índices de fallecimientos, altas sin atención médica y reconsultas a las 72 horas son de 0,05% (0,00-0,13), 1,1% (0,3-2,5) y 4,5% (3,5-5,6), respectivamente (todos ellos mejores en los SUH de menor actividad, los hospitales privados y los hospitales públicos de menor complejidad). El 77,2% colocan identificativos a los pacientes y el 20,3% a los acompañantes, el 84,8% permite el acompañamiento permanente en el área de primera asistencia (APA) y el 59,5% en el AO. Un 36,7% de SUH no tiene ningún tipo de vigilancia (más frecuente en SUH de baja actividad, en hospitales privados y en hospitales públicos de baja complejidad). La superficie dedicada a actividad asistencial es 364 m2 (230-1200), con 13 boxes (7-26) en APA (2 para pacientes críticos) y 8 (4-13) en AO. Estos espacios se calificaron insuficientes en el 50,7% de SUH (más frecuente en hospitales públicos que privados) y su calidad deficiente el 16,5%. En caso de necesidad, las APA pueden aumentar su capacidad un 11% (0-50%) y las AO un 0% (0-5%). La disponibilidad de pruebas complementarias depende del tipo de SUH y de hospital. El 44,3% y el 13,7% tienen la radiología convencional y el escáner, respectivamente, en el propio SUH. El 49,4% dispone de ecógrafo propio y un 10% (0-30%) de sus urgenciólogos sabe utilizarlo. La informatización de la información asistencial es superior al 90% con la excepción del ECG digitalizado (48,8%) y la receta electrónica (25,5%). El 74,7% de SUH dispone de los tiempos asistenciales, pero sólo un 10% los muestra a los usuarios. Conclusiones: El presente estudio pone de manifiesto la realidad estructural de los SUH catalanes y señala diversas oportunidades de mejora

Objective: To describe the physical characteristics of hospital emergency departments in Catalonia, Spain, with reference to other characteristics of the departments and the hospitals. Methods: The heads of 79 of the 82 hospital emergency departments in Catalonia (96%) responded to a 353-item questionnaire and were personally interviewed. This study analyzes information from items referring to the departments' facilities. Statistics were compiled for the entire dataset and for three levels of emergency department volumen (high, medium, and low), for private and public hospital status, and for complexity of public hospitals (technologically well equipped, comprehensive general, other referral, or local). Results: Half the departments had premises built or remodelled in the last 4 years; 59.5% had an observation area. Such areas were more often available in high-volume hospitals and public health service hospitals with a higher degree of complexity. A short-stay area was available in 35% of the emergency departments: 68% had staff physicians who were specialized in emergency medicine, 46% were staffed exclusively by emergency physicians, and 61% were under the emergency department’s supervision. In 2011, these departments managed 3 949 885 emergencies (0.53 visits/inhabitant/ y); 16% were handled in private hospitals. The median (25th-75th percentile) admission rate was 9% (6%-12%). Volume increased during the high tourist season for 34.2% of the departments; only 37.0% of them hired additional staff at these times and 18.5% increased the available space. Rates for mortality, discharge without care, and revisits within 72 hours were 0.05% (0.00-0.13), 1.1% (0.3-2.5), and 4.5% (3.5-5.6), respectively. All these rates were lower in lower-volume hospitals, private hospitals, and less complex public hospitals. Patient identification bracelets were used in 77.2% of the departments. An accompanying person was allowed at all times in the initial assessment area in 84.8% and in the observation area in 59.5%. Security personnel were not provided in 36.7% of the departments; this rate was higher in lower-volume hospitals, private hospitals, and less complex public hospitals. The departments had a median surface area of 364 (230-1200) m2, 13 (7-26) initial treatment rooms or spaces (2 for critical cases), and 8 (4-13) observation-area beds. A 50,7% of the respondents considered their facilities were inadequate (an opinion expressed more often for public hospitals than for private ones), and 16,5% reported that the quality of available spaces was unsatisfactory. The area designated for initial treatment could be increased at 11% (0%–50%) of the hospitals, but 0% (0%-5%) could increase the number of observation beds. The availability of complementary tests was related to type of emergency department and hospital. Conventional radiography could be performed in 44.3% of the departments and computed tomography in 13.7%. Although 49.4% had ultrasound machines, only 10% (0%-30%) of the emergency physicians knew how to use one. High-quality information systems were in place in 90% of the hospitals, although only 48.8% had digitized electrocardiography and 25.5% could prescribe electronically. Although 74.7% of the departments compiled time statistics, only 10% shared the information with users. Conclusions: This study reveals the physical conditions of Catalan hospital emergency departments and identifies several ways they can be improved

Estudio SUHCAT (2): mapa funcional de los servicios de urgencias hospitalarios de Cataluña / SUHCAT study, part 2: a map of the functional characteristics of hospital emergency services in Catalonia

Objetivo: Describir las características organizativas y funcionales de los servicios de urgencias hospitalarios (SUH) de Cataluña y la de los médicos y enfermeros que trabajan en ellos. Método: Los responsables de 79 de los 82 SUH de Cataluña (96%) respondieron a preguntas referentes a organización y estructura directiva y ejecutiva del SUH, sistema de triaje, relación con los sistemas de emergencias médicas (SEM), volumen y características contractuales y demográficas de los médicos y enfermeros, así como de organización de su trabajo. Se estimaron los puestos de trabajo a tiempo completo para médicos y enfermeros existentes en los SUH en función de las horas totales anuales contratadas. Se analizaron las respuestas según la actividad del SUH (alta, media o baja), el uso del hospital (privado o público) y la complejidad del hospital público (alta tecnología o alta resolución, referencia, comarcal). Resultados: El 69,6% se organiza como servicio y el 53,2% tiene un jefe de servicio. El 68,4% organiza la asistencia en diferentes circuitos, preferentemente basados en un modelo mixto (triaje y especialidad). El 77,2% dispone de un sistema estructurado de triaje, casi siempre funcionando permanentemente, y en el 80,3% enfermería es la encargada. El Modelo Andorrano de Triaje es el más extendido, que clasificó como categorías 1, 2, 3, 4 y 5 al 0,7%, 5,5%, 28,2%, 47,9% y 17,8% de los pacientes, respectivamente. La organización de la jornada de los médicos es predominantemente a turnos (53,2%, preferentemente de 12 horas) y mixta (turnos y guardias, 30,4%). En 2012 se contrataron 4.894.264 horas de trabajo médico y 3.836.579 de trabajo enfermero, que suponen, respectivamente, 2.899 y 2.368 puestos de trabajo teóricos a jornada completa. De las horas de trabajo médico, el 50,4% las desarrollan médicos con contratos directamente vinculados a urgencias (73% fijos y 27% no fijos o interinos), el 19,1% médicos de otros (AU)

Objective: To describe the organization and functional characteristics of hospital emergency departments (ED) in Catalonia, Spain, as well as to describe the how these departments are staffed with physicians and nurses. Methods: The heads of 79 of the 82 hospital EDs in Catalonia (96%) responded to questions about the management structure of their department, their triage systems, relations with out-of-hospital emergency medical services, volume, contractual arrangements with staff, demographic characteristics of physicians and nurses on staff, and how their work is organized. A theoretical estimate of the number of full-time staff positions for physicians and nurses in each department was based on the total number of contracted hours each year. Statistics were compiled for three levels of ED volume (high, medium, and low), for private and public hospital status, and for level of complexity of public hospitals (technologically well equipped, comprehensive general, other referral, or local). Results: ED were organizationally separate in 69.6% of the hospitals, and 53.2% had their own department head. Organization was based on care pathways in 68.4%; the pathways usually followed a mixed model reflecting triage and specialty. A structured triage system was operating in 77.2% and was in use at all times in nearly all those departments; in 80.3%, nurses were in charge of triage. The Andorran Triage Model was the system most widely used. Triage levels 1 through 5 accounted for 0.7%, 5.5%, 28.2%, 47.9%, and 17.8% of the emergency patients, respectively. Physicians' assignments were organized in shifts (preferably 12 hours) in 53.2% of the EDs or in a combination of shifts and on-call schedules (30.4%). A total of 4 894 264 physician hours and 3 836 579 nurse hours were contracted in 2012; that number would correspond to 2899 full-time staff positions for physicians and 2368 for nurses. Physicians contracted directly by the EDs covered 50.4% of the hours (73% of the contracted physicians had permanent contracts and 27% were on temporary or training contracts); 19.1% of the hours were covered by physicians from other departments and 30.6% were covered by residents. Most of the fully trained physicians were specialists in family and community medicine (24%) and internal medicine (16.6%); 11.3% had not done residency training in a specialty. The EDs were staffed by physicians from Spain (62.8%), from other European Union (EU) countries (2.1%), and from non-EU countries (17.7%). Many of these characteristics were significantly different according to hospital category. Conclusions: In Catalonia differ in their organization and functional characteristics and in staffing characteristics. These EDs generate full-time employment for over 5000 physicians and nurses (AU)

Estudio SUHCAT (3): mapa docente e investigador de los servicios de urgencias hospitalarios de Cataluña / SUHCAT study, part 3: a map of educational and research activity in hospital emergency services in Catalonia

Objetivo: Investigar las actividades formativas, docentes e investigadoras realizadas en los servicios de urgencias hospitalarios (SUH) de Cataluña, y compararlas en función de las características de estos SUH y de los hospitales. Método: Se entrevistó a los responsables de 79 de los 82 SUH de Cataluña (96%), que respondieron a preguntas referentes a las actividades formativas en las que participan los profesionales de urgencias, las características y resultados de las actividades docentes e investigadoras llevadas a cabo por ellos y la disponibilidad de tiempos por parte de médicos y enfermeros para realizarlas. Se excluyeron de este análisis los datos referentes a la formación de residentes. Se analizaron las respuestas según la actividad del SUH (alta, media, baja), el uso del hospital (privado, público) y la complejidad del hospital público (alta tecnología o alta resolución, referencia, comarcal). Resultados: El 31,6% de SUH protege parte de la jornada laboral para la formación de sus facultativos y el 23,1% parte de la jornada de sus enfermeros, con unas medianas del 5% (p25-75: 3-10%) y el 2% (1-3%) del tiempo contratado, respectivamente. Existen sesiones propias del servicio para los facultativos y los enfermeros en el 79,7% y 94,2% de los SUH, respectivamente. La presencia de facultativos y enfermeros al congreso catalán y español y en congresos internacionales de la especialidad existió en el 79,5%, 76,9% y 25,6% de los SUH para los primeros, y en el 57,7%, 39,8% y 3,8% para los segundos. Existen estudiantes de pregrado de medicina y de enfermería en el 59,5% y el 81% de SUH, respectivamente; y de postgrado en el 22,8% y 40,5%. El 24,1% y 36,7% de SUH tienen algún profesional de medicina o enfermería, respectivamente, que imparte clases teóricas de pregrado en sus facultades, y el 35,4% y 25,3% respecto a clases de postgrado. La mediana de presentaciones anuales a congresos de los SUH catalanes en 2011 fue 2 (0-6), en tanto que la de ponencias invitadas, publicaciones científicas y profesionales que realizan investigación con continuidad fue 0 para todas ellas. En total, 28 SUH (35,4%) publicaron un total de 115 trabajos durante 2011, 71 (61,7%) en revistas con factor de impacto, y 24 (25%) y 20 (30%) SUH tienen un total de 78 facultativos y 35 enfermeros que investigan con continuidad. Globalmente, 62 facultativos de 28 SUH diferentes tenían el título de doctor, lo que supone el 5,8% de los facultativos de urgencias. En muchos de estos aspectos se produjeron diferencias significativas en función del tipo de SUH y hospital, siempre con un mejor perfil formativo y mayor participación docente e investigadora en los SUH de mayor actividad y en los hospitales públicos y de mayor complejidad. Conclusiones: Los SUH catalanes tienen un elevado papel en la actividad docente de pregrado y postgrado, tanto de medicina como de enfermería, y en cambio la actividad investigadora todavía abarca a un número excesivamente limitado de SUH y de profesionales

Objective: To describe the training, educational, and research activities of hospital emergency department staff in Catalonia, Spain, and to analyze differences in these activities between hospitals of various types. Methods: The heads of 79 of the 82 hospital emergency departments in Catalonia (96%) responded to questions about the training undertaken by emergency department staff and the characteristics and results of educational and research activities carried out by these physicians and nurses. The survey also asked about the number of hours available to staff for these activities. Medical residency training was excluded. Statistics were compiled for three levels of emergency department volume (high, medium, and low), for private and public hospital status, and for level of complexity of public hospitals (technologically well equipped, comprehensive general, other referral, or local). Results: In 31.6% of the departments, a portion of the shift was reserved for training staff physicians; 23.1% reserved time for nurse training. A median (interquartile range) of 5% (3%-10%) of contracted time was reserved for training physicians and 2% (1%-3%) was allotted for nurse training. Departmental sessions were organized for emergency physicians and nurses in 79.7% and 94.2% of the hospitals, respectively. Emergency physicians from 79.5%, 76.9%, and 25.6% of the hospitals attended the conferences of Catalan, Spanish, and international emergency medicine associations, respectively. Nurses from 57.7%, 29.8%, and 3.8% of the departments attended these conferences. Undergraduate medical students were taught in 59.5% of the departments and postgraduate training was given in 22.8%. Undergraduate nurses were taught in 81% and postgraduate training for nurses was given in 40.5%. In 24.1% of the hospitals, a staff physician was also giving classroom instruction in an undergraduate program in medicine; in 36.7% a nurse was teaching in a nursing program. In 35.4%, a physician was involved with postgraduate classroom education; a nurse was teaching such classes in 25.3%. A median of 2 (0-6) staff members gave presentations at the Catalan emergency medicine conference in 2011; with regard to invited talks at that conference, scientific publications, and ongoing research, the median number of staff members involved was 0. Twenty-eight departments (35.4%) published a total of 115 papers in 2011; 71 (61.7%) were in journals with an impact factor. Twenty-four hospitals (25%) employed 78 physicians who undertook research on a regular basis; 20 (30%) employed nurses who researched. Sixty-two physicians from 28 different departments had a PhD (5.8% of the emergency physicians). Many of these statistics differed significantly by hospital category. Departments with higher volumes and in public or complex hospitals were more engaged with training, education, and research. Conclusions: Catalan emergency departments play a strong role in undergraduate and postgraduate teaching in medicine and nursing. In contrast, the staff of these departments do not undertake research in large numbers