Tonic immobility triggered by COVID-19-related trauma is associated with long-term PTSD symptoms.

During the COVID-19 pandemic healthcare workers were repeatedly exposed to traumatic experiences. Facing life-threatening events and repeated exposure to traumatic duty-related situations may cause posttraumatic stress disorder (PTSD). While tonic immobility has been considered a key vulnerability factor for PTSD, little is known about this relationship in the long term. In this study, we aimed to determine whether peritraumatic tonic immobility triggered by COVID-19-related trauma predicts PTSD symptom severity six to twelve months later. We conducted an online longitudinal survey using the PTSD Checklist for the DSM-5 (PCL-5) and the Tonic Immobility Scale to assess PTSD symptoms and the tonic immobility response, respectively. Multivariate regression models revealed a significant association between tonic immobility and PTSD symptoms. Each one-unit increase in the tonic immobility score was associated with a 1.5 % increase in the average PTSD symptom score six to twelve months after the traumatic event that triggered the tonic immobility. Furthermore, participants who showed significant or extreme levels of tonic immobility were 3.5 times or 7.3 times more likely to have a probable PTSD diagnosis, respectively. Hence, peritraumatic tonic immobility seems to have a lasting deleterious effect on mental health. Psychological treatment for health care professionals is urgent, and psychoeducation about the involuntary, biological nature of tonic immobility is essential to reduce suffering.

The different impacts of COVID-19 on the mental health of distinct health care worker categories.

The present study sought to explore the factors associated with the odds of having probable depression and posttraumatic stress disorder (PTSD) related to traumatic COVID-19 experiences and their impact on health care workers in distinct categories. In this cross-sectional study, 1843 health care workers (nurses, nurse technicians, physicians, physical therapists, and other healthcare workers) were recruited via convenience sampling. A survey was administered to obtain information regarding sociodemographic, occupational, and mental health status. Descriptive statistics and multivariable logistic regression were used for the analyses. Being a nurse technician was associated with an odds ratio of 1.76 for probable PTSD. No relation was observed between health care worker categories and the odds of probable depression. Additionally, being female and not receiving adequate PPE were related to greater odds of having probable PTSD and depression.

The COVID-19 pandemic and its impact on mental health of healthcare workers / A pandemia de COVID-19 e seu impacto na saúde mental dos profissionais de saúde

ABSTRACT The COVID-19 pandemic has imposed a health crisis around the world. Health professionals are frequently exposed to stressors that put them at high risk for the development or progression of disabling mental disorders, including posttraumatic stress disorder (PTSD). To understand how pandemic stressors have affected the mental health of healthcare workers, our group conducted a longitudinal and nationwide survey. We investigated the occurrence of traumatic events related to the COVID-19 pandemic and the association between exposure to these events and PTSD symptomatology. Importantly, we also investigated factors that might increase or decrease the risk for PTSD. Depression symptoms were also investigated. The results of the first wave of the project were published in a series of three articles, each focused on different risk or protective factors. The results showed that female sex, young age, a lack of adequate personal protective equipment, social isolation and a previous history of mental illness were consistent predictors of PTSD symptoms. Healthcare workers who reported high levels of peritraumatic tonic immobility, a defensive response that is involuntary, reflexive, and evoked by an intense and inescapable threat, also exhibited an increase in the probability of being diagnosed with PTSD. On the other hand, professional recognition had a negative relationship with PTSD and depression symptoms, emerging as a significant protective factor for psychological health. The identification of protective and risk factors in these situations is crucial to guide the adoption of long-term measures in work environments that will enhance the psychological health of these professionals.

RESUMO A pandemia de COVID-19 impôs uma crise de saúde no mundo. Profissionais de saúde foram frequentemente expostos a estressores que os colocam em alto risco para o desenvolvimento ou progressão de transtornos mentais incapacitantes, incluindo o transtorno de estresse pós-traumático (TEPT). Para entender como esses estressores afetaram a saúde mental desses profissionais, nosso grupo realizou um estudo longitudinal nacional. Investigamos a ocorrência de eventos traumáticos especificamente relacionados à pandemia e a associação entre a exposição a esses eventos traumáticos e a sintomatologia do TEPT. É importante ressaltar que também investigamos fatores que podem aumentar ou diminuir o risco de TEPT. Sintomas de depressão também foram investigados. Os resultados da primeira onda do projeto foram publicados em uma série de três artigos, cada um focado em diferentes fatores de risco ou proteção. Os resultados mostraram que sexo feminino, idade jovem, falta de equipamento de proteção individual adequado, isolamento social e história prévia de doença mental foram preditores consistentes de sintomas de TEPT. Os profissionais de saúde que relataram altos níveis de imobilidade tônica, uma resposta peritraumática involuntária e reflexa evocada em situações de ameaça intensa e inescapável, exibiram aumento na probabilidade de um provável diagnóstico de TEPT. Por outro lado, reconhecimento profissional teve relação negativa com sintomas de TEPT e depressão, emergindo como importante fator de proteção para a saúde mental. Identificar fatores protetores ou de risco nessas situações é fundamental para orientar a adoção de medidas de longo prazo nos ambientes de trabalho que melhorem a saúde mental desses profissionais.

Tonic immobility is associated with posttraumatic stress symptoms in healthcare professionals exposed to COVID-19-related trauma.

The Coronavirus Disease 2019 (COVID-19) pandemic has exposed healthcare workers (HCW) to traumatic situations that might lead to the development of posttraumatic stress disorder (PTSD). An important vulnerability factor for PTSD is the peritraumatic tonic immobility (TI) reaction, an involuntary and reflexive defensive response evoked by an intense and inescapable threat. TI is largely understudied in humans and has not been investigated during trauma related to COVID-19. For HCW, the pandemic context might be experienced as an intense and potentially inescapable threat, i.e., an overwhelming situation. Here, we investigated if TI response occurred during traumatic events related to the pandemic and its association with posttraumatic stress symptoms (PTSS). An online survey of 1001 HCW investigated COVID-19-related traumatic experiences, TI and PTSS. TI was reported for all types of traumatic events, and multivariate regression models revealed that TI was significantly associated with PTSS severity. HCW who reported high TI scores exhibited an increase of 9.08 times the probability of having a probable diagnosis of PTSD. Thus, TI was evoked by pandemic-related traumatic situations and associated with PTSS severity and higher odds of a PTSD diagnosis. Tonic immobility occurrence should be screened, and psychoeducation about its reflexive biological nature should be introduced.

Impact of surgical checklist and its completion on complications and mortality in urgent colorectal procedures.

OBJECTIVE: to assess the impact of using a surgical checklist and its completion on complications such as surgical site infection (SSI), reoperation, readmission, and mortality in patients subjected to urgent colorectal procedures, as well as the reasons for non adherence to this instrument in this scenario, in a university hospital in Ottawa, Canada. METHODS: this is a retrospective, epidemiological study. We collected data from an electronic database containing information on patients undergoing urgent colorectal operations, and analyzed the occurrence of SSI, reoperation, readmission, and death in a 30 day period, as well as the completion of the checklist. We conducted a descriptive statistical analysis and logistic regression. RESULTS: we included 5,145 records, of which 5,083 (98.8%) had complete checklists. As for the outcomes evaluated, cases with complete checklists displayed higher SSI rate, 9.1% vs. 6.5% (p=0.466), lower reoperation rate, 5% vs.11.3% (p=0.023), lower readmission rates, 7.2% vs. 11.3% (p=0.209), and lower mortality, 3.0% vs. 6.5% (p=0.108) than cases with incomplete ones. CONCLUSION: there was a high level of checklist completion and a larger number of the outcomes in the reduced percentage of incomplete checklists found, demonstrating the impact of its utilization on the safety of patients undergoing urgent operations.

Impact of surgical checklist and its completion on complications and mortality in urgent colorectal procedures / Impacto do uso do checklist cirúrgico e completude em complicações e mortalidade em cirurgias colorretais de urgência

ABSTRACT Objective: to assess the impact of using a surgical checklist and its completion on complications such as surgical site infection (SSI), reoperation, readmission, and mortality in patients subjected to urgent colorectal procedures, as well as the reasons for non adherence to this instrument in this scenario, in a university hospital in Ottawa, Canada. Methods: this is a retrospective, epidemiological study. We collected data from an electronic database containing information on patients undergoing urgent colorectal operations, and analyzed the occurrence of SSI, reoperation, readmission, and death in a 30 day period, as well as the completion of the checklist. We conducted a descriptive statistical analysis and logistic regression. Results: we included 5,145 records, of which 5,083 (98.8%) had complete checklists. As for the outcomes evaluated, cases with complete checklists displayed higher SSI rate, 9.1% vs. 6.5% (p=0.466), lower reoperation rate, 5% vs.11.3% (p=0.023), lower readmission rates, 7.2% vs. 11.3% (p=0.209), and lower mortality, 3.0% vs. 6.5% (p=0.108) than cases with incomplete ones. Conclusion: there was a high level of checklist completion and a larger number of the outcomes in the reduced percentage of incomplete checklists found, demonstrating the impact of its utilization on the safety of patients undergoing urgent operations.

RESUMO Objetivo: verificar o impacto do uso do checklist cirúrgico e a completude em complicações como infecção do sítio cirúrgico (ISC), reoperação, readmissão e mortalidade em pacientes submetidos a procedimentos colorretais de urgência, bem como os motivos para a não adesão a esse instrumento nesse cenário, em hospital universitário de Ottawa, Canadá. Métodos: trata-se de estudo epidemiológico retrospectivo. Os dados foram coletados em base de dados eletrônica contendo informações de pacientes submetidos a cirurgias colorretais de urgência, sendo analisada a ocorrência de ISC, reoperação, readmissão e óbito em período de 30 dias, bem como a completude do checklist. Realizou-se análise estatística descritiva e regressão logística. Resultados: incluíram-se 5.145 registros, dos quais 5.083 (98,8%) possuíam checklists completos. No que se refere aos desfechos avaliados, identificou-se nos checklists completos comparados aos incompletos, respectivamente, maior taxa das ISC de 9,1% contra 6,5% (p=0,466); menor taxa em reoperações de 5% contra 11,3% (p=0,023); em readmissões de 7,2% contra 11,3% (p=0,209); e também em mortalidade de 3,0% contra 6,5% (p=0,108). Conclusão: verificou-se alto nível de completude do checklist e maior número de desfechos no reduzido percentual de checklists incompletos encontrados, demonstrando o impacto da utilização para a segurança do paciente submetido a cirurgias de urgência.

Impact of surgical checklist and its completion on complications and mortality in urgent colorectal procedures.

OBJECTIVE: to assess the impact of using a surgical checklist and its completion on complications such as surgical site infection (SSI), reoperation, readmission, and mortality in patients subjected to urgent colorectal procedures, as well as the reasons for non adherence to this instrument in this scenario, in a university hospital in Ottawa, Canada. METHODS: this is a retrospective, epidemiological study. We collected data from an electronic database containing information on patients undergoing urgent colorectal operations, and analyzed the occurrence of SSI, reoperation, readmission, and death in a 30 day period, as well as the completion of the checklist. We conducted a descriptive statistical analysis and logistic regression. RESULTS: we included 5,145 records, of which 5,083 (98.8%) had complete checklists. As for the outcomes evaluated, cases with complete checklists displayed higher SSI rate, 9.1% vs. 6.5% (p=0.466), lower reoperation rate, 5% vs.11.3% (p=0.023), lower readmission rates, 7.2% vs. 11.3% (p=0.209), and lower mortality, 3.0% vs. 6.5% (p=0.108) than cases with incomplete ones. CONCLUSION: there was a high level of checklist completion and a larger number of the outcomes in the reduced percentage of incomplete checklists found, demonstrating the impact of its utilization on the safety of patients undergoing urgent operations.

Tonic Immobility is Associated with PTSD Symptoms in Traumatized Adolescents.

PURPOSE: Growing evidence suggests that peritraumatic tonic immobility, an involuntary defensive response that involves extreme physical immobility and the perceived inability to escape, is a significant predictor of post-traumatic stress disorder (PTSD) symptomatology. However, this issue has not been specifically addressed in adolescents. Here, we investigated whether tonic immobility response experienced during the worst childhood or adolescent trauma is associated with PTSD symptom severity in a non-clinical student sample. METHODS: The sample was composed of students in 9th grade who were attending public and private schools. Symptoms of post-traumatic stress and tonic immobility were assessed using questionnaires. We performed bivariate and multivariate negative binomial regressions to examine whether tonic immobility was associated with PTSD symptomatology after controlling for confounders (peritraumatic dissociation, peritraumatic panic reactions, gender, age and time since trauma). RESULTS: We found an association between tonic immobility and PTSD symptom severity, even after controlling for confounders. Therefore, tonic immobility is associated with PTSD symptoms in trauma-exposed adolescents. CONCLUSION: These findings highlight tonic immobility as a possible risk factor that could be used to provide direction for more targeted trauma interventions for individuals, particularly those at risk for developing PTSD. Therefore, it contributes to preventing and reducing the psychiatric burden in adolescence and later in life.

The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment.

BACKGROUND: Childhood maltreatment (CM) is unfortunately widespread globally and has been linked with an increased risk of a variety of psychiatric disorders in adults, including posttraumatic stress disorder (PTSD). These associations are well established in the literature for some maltreatment forms, such as sexual and physical abuse. However, the effects of emotional maltreatment are much less explored, even though this type figures among the most common forms of childhood maltreatment. Thus, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on revictimization and PTSD symptom severity using a nonclinical college student sample. METHODS: Five hundred and two graduate and undergraduate students participated in the study by completing questionnaires assessing lifetime traumatic experiences in general, maltreatment during childhood and PTSD symptoms. Bivariate and multivariate negative binomial regressions were applied to examine the associations among childhood maltreatment, revictimization, and PTSD symptom severity. RESULTS: Our results showed that using bivariate models, all types of CM were significantly associated with revictimization and PTSD symptom severity. Multivariate models showed that emotional abuse was the type of maltreatment associated with the highest incidence rates of revictimization and PTSD symptom severity. CONCLUSIONS: These data provide additional evidence of the harmful effects of childhood maltreatment and its long-term consequences for individuals' mental health. Notably, the findings highlight the importance of studying the impacts of emotional abuse, which seems to be a highly prevalent, understudied, and chronic form of maltreatment that is as toxic as other maltreatment forms.

Vulnerability and Protective Factors for PTSD and Depression Symptoms Among Healthcare Workers During COVID-19: A Machine Learning Approach.

Background: Healthcare workers are at high risk for developing mental health problems during the COVID-19 pandemic. There is an urgent need to identify vulnerability and protective factors related to the severity of psychiatric symptoms among healthcare workers to implement targeted prevention and intervention programs to reduce the mental health burden worldwide during COVID-19. Objective: The present study aimed to apply a machine learning approach to predict depression and PTSD symptoms based on psychometric questions that assessed: (1) the level of stress due to being isolated from one's family; (2) professional recognition before and during the pandemic; and (3) altruistic acceptance of risk during the COVID-19 pandemic among healthcare workers. Methods: A total of 437 healthcare workers who experienced some level of isolation at the time of the pandemic participated in the study. Data were collected using a web survey conducted between June 12, 2020, and September 19, 2020. We trained two regression models to predict PTSD and depression symptoms. Pattern regression analyses consisted of a linear epsilon-insensitive support vector machine (ε-SVM). Predicted and actual clinical scores were compared using Pearson's correlation coefficient (r), the coefficient of determination (r2), and the normalized mean squared error (NMSE) to evaluate the model performance. A permutation test was applied to estimate significance levels. Results: Results were significant using two different cross-validation strategies to significantly decode both PTSD and depression symptoms. For all of the models, the stress due to social isolation and professional recognition were the variables with the greatest contributions to the predictive function. Interestingly, professional recognition had a negative predictive value, indicating an inverse relationship with PTSD and depression symptoms. Conclusions: Our findings emphasize the protective role of professional recognition and the vulnerability role of the level of stress due to social isolation in the severity of posttraumatic stress and depression symptoms. The insights gleaned from the current study will advance efforts in terms of intervention programs and public health messaging.

Hidden wounds of violence: Abnormal motor oscillatory brain activity is related to posttraumatic stress symptoms.

Victims of urban violence are at risk of developing Posttraumatic Stress Disorder (PTSD), one of the most debilitating consequences of violence. Considering that PTSD may be associated with inefficient selection of defensive responses, it is important to understand the relation between motor processing and PTSD. The present study aims to investigate the extent to which the severity of posttraumatic stress symptoms (PTSS) is related to motor preparation against visual threat cues in victims of urban violence. Participants performed a choice reaction time task while ignoring a picture that could be threating or neutral. The EEG indices extracted were the motor-related amplitude asymmetry (MRAA) in the alpha frequency range, and the lateralized readiness potential (LRP). We observed a linear relation between longer LRP latency and a slower reaction time, selectively during threat processing (compared to neutral) in low PTSS, but not in high PTSS participants. Alpha MRAA suppression and the PTSS were also linearly related: the smaller the alpha MRAA suppression in the threat condition relative to neutral, the greater the PTSS. These results provide evidence that threatening cues affect motor processing that is modulated by the severity of PTSS in victims of urban violence.

Avaliação da adesáo ao checklist cirúrgico

RESUMO Objetivo: Verificar a adesão ao checklist cirúrgico obtida por meio de diferentes ferramentas: completude, auditoria de processo e a avaliação da taxa de complicações e mortalidade, em um hospital universitário. Material e Método: Tratou-se de um estudo transversal realizado em um centro cirúrgico de um hospital universitário de Belo Horizonte, Brasil. A coleta de dados se deu em dois momentos: primeiro, auditoria da aplicação verbal do checklist e comparação com o preenchimento do formulário; e o segundo, de forma paralela, por revisão de prontuários de pacientes de cirurgias colorretais para avaliação da completude, taxas de infecção do sítio cirúrgico, reoperação, reinternação e óbito. Foi realizada análise descritiva dos dados, estatística inferencial e teste qui-quadrado. Resultados: No primeiro momento, 100 procedimentos aleatórios foram acompanhados para auditoria da aplicação verbal e nenhum deles foi totalmente seguido pela equipe cirúrgica, porém os formulários de 65% foram completamente preenchidos. No segundo momento, dos 353 prontuários analisados, 63,7% dos checklists estavam completos, a taxa de infecção do sítio cirúrgico foi maior naqueles incompletos e não foram observados impactos da sua completude nos demais desfechos. Conclusão: A completude do checklist não retratou a adesão ao mesmo, devendo ser usada com cautela como indicador, associando-a ferramentas complementares como a auditoria periódica e o monitoramento dos desfechos clínicos.

ABSTRACT Objective: To verify surgical checklist compliance obtained through different tools: checklist completion, process auditing and evaluation of complication and mortality rates in a university hospital. Materials and Methods: Cross-sectional study carried out in a surgical center of a university hospital in Belo Horizonte, Brazil. Data collection occurred in two stages: firstly, by auditing the oral application of the checklist and comparing it with the checklist completion level; and secondly, by reviewing medical records of colorectal surgery patients to evaluate compliance, surgical site infection, reoperation, readmission and mortality rates. Descriptive data analysis, inferential statistics and chi-square test were performed. Results: In the first stage, 100 random procedures were monitored for oral application auditing and none of them were totally applied by the surgical team, however, 65% of the checklists were fully completed. In the second stage, from 353 analyzed records, 63.7% of the checklists were complete, surgical site infection rate was higher in cases with incomplete checklists and no impact of their compliance level on the other outcomes was observed. Conclusion: Checklist completion does not portray its compliance level and should be used with caution as an indicator, associating it with complementary tools such as regular auditing and monitoring of clinical outcomes.

RESUMEN Objetivo: Verificar el cumplimiento de la lista de verificación quirúrgica obtenida por diferentes herramientas en un hospital universitario: completación, auditoría de procesos y evaluación de la tasa de complicaciones y mortalidad. Material y Método: Se realizó un estudio transversal en un centro quirúrgico en un hospital universitario en Belo Horizonte, Brasil. La recolección de datos se realizó en dos momentos: primero, la auditoría de la aplicación oral de la lista de verificación y la comparación con el formulario de la lista de verificación; y segundo, en paralelo, mediante la revisión de los registros médicos de pacientes sometidos a cirugías colorrectales para la evaluación del cumplimiento, tasas de infección del sitio quirúrgico, reoperación, readmisión y mortalidad. Se realizó un análisis descriptivo de los datos, estadística inferencial y prueba de chi-cuadrado. Resultados: En el primer momento se siguieron 100 procedimientos aleatorios para la auditoría de la aplicación oral de la lista y ninguno de ellos fue totalmente aplicado por el equipo quirúrgico, sin embargo, 65% de los formularios estaban completamente llenos. En el segundo momento, de los 353 registros analizados, 63,7% de las listas de verificación estaban completas, la tasa de infección del sitio quirúrgico fue mayor en las listas incompletas y no hubo impactos de su cumplimiento en los otros resultados. Conclusión: La completación de la lista de verificación no fue un retrato de su adhesión y debe usarse con precaución como un indicador, asociándolo con herramientas complementarias, como la auditoría periódica y el seguimiento de los resultados clínicos.

Impact of surgical checklist and its completion on complications and mortality in urgent colorectal procedures / Impacto do uso do checklist cirúrgico e completude em complicações e mortalidade em cirurgias colorretais de urgência

ABSTRACT Objective: to assess the impact of using a surgical checklist and its completion on complications such as surgical site infection (SSI), reoperation, readmission, and mortality in patients subjected to urgent colorectal procedures, as well as the reasons for non adherence to this instrument in this scenario, in a university hospital in Ottawa, Canada. Methods: this is a retrospective, epidemiological study. We collected data from an electronic database containing information on patients undergoing urgent colorectal operations, and analyzed the occurrence of SSI, reoperation, readmission, and death in a 30 day period, as well as the completion of the checklist. We conducted a descriptive statistical analysis and logistic regression. Results: we included 5,145 records, of which 5,083 (98.8%) had complete checklists. As for the outcomes evaluated, cases with complete checklists displayed higher SSI rate, 9.1% vs. 6.5% (p=0.466), lower reoperation rate, 5% vs.11.3% (p=0.023), lower readmission rates, 7.2% vs. 11.3% (p=0.209), and lower mortality, 3.0% vs. 6.5% (p=0.108) than cases with incomplete ones. Conclusion: there was a high level of checklist completion and a larger number of the outcomes in the reduced percentage of incomplete checklists found, demonstrating the impact of its utilization on the safety of patients undergoing urgent operations.

RESUMO Objetivo: verificar o impacto do uso do checklist cirúrgico e a completude em complicações como infecção do sítio cirúrgico (ISC), reoperação, readmissão e mortalidade em pacientes submetidos a procedimentos colorretais de urgência, bem como os motivos para a não adesão a esse instrumento nesse cenário, em hospital universitário de Ottawa, Canadá. Métodos: trata-se de estudo epidemiológico retrospectivo. Os dados foram coletados em base de dados eletrônica contendo informações de pacientes submetidos a cirurgias colorretais de urgência, sendo analisada a ocorrência de ISC, reoperação, readmissão e óbito em período de 30 dias, bem como a completude do checklist. Realizou-se análise estatística descritiva e regressão logística. Resultados: incluíram-se 5.145 registros, dos quais 5.083 (98,8%) possuíam checklists completos. No que se refere aos desfechos avaliados, identificou-se nos checklists completos comparados aos incompletos, respectivamente, maior taxa das ISC de 9,1% contra 6,5% (p=0,466); menor taxa em reoperações de 5% contra 11,3% (p=0,023); em readmissões de 7,2% contra 11,3% (p=0,209); e também em mortalidade de 3,0% contra 6,5% (p=0,108). Conclusão: verificou-se alto nível de completude do checklist e maior número de desfechos no reduzido percentual de checklists incompletos encontrados, demonstrando o impacto da utilização para a segurança do paciente submetido a cirurgias de urgência.

Impact of Surgical Checklist on Mortality, Reoperation, and Readmission Rates in Brazil, a Developing Country, and Canada, a Developed Country.

PURPOSE: To compare the mortality, reoperation, and readmission rates before and after the implementation of a surgical checklist in Brazil and Canada. DESIGN: An epidemiological, retrospective study was conducted. METHODS: Preimplementation and postimplementation data were collected via patient chart reviews to determine mortality, reoperation, and readmission rates. FINDINGS: In Brazil, a decrease in readmission rate from 2.9% to 1.7% (P = .518) was observed after the implementation of the checklist. In Canada, reoperation rate decreased from 5.6% to 4.8% (P = .649) and mortality from 1.7% to 0.9% (P = .407) after implementation. In the Brazilian institution, patients with incomplete checklists had increased rates of readmission, from 1.4% to 2.4% (P = .671), and reoperation, from 6.8% to 10.4% (P = .232). CONCLUSIONS: The use of surgical checklist did not translate into improvements in the outcomes studied after its implementation in any of the scenarios evaluated. This result is possibly justified by the socioeconomic structure of each of these settings.

Effect of surgical safety checklist on colorectal surgical site infection rates in 2 countries: Brazil and Canada.

BACKGROUND: The effectiveness of the surgical safety checklist (SSC) in countries with different socioeconomic backgrounds is uncertain. To evaluate the effect of the SSC in 2 different socioeconomic settings, we compared surgical site infection (SSI) rates before and after its implementation in colorectal procedures. METHODS: An epidemiological retrospective study was conducted in the university hospitals in Ottawa, Canada, and Belo Horizonte, Brazil. Data were collected through chart review from the period before and after the SSC implementation. RESULTS: The SSI rate decreased from 27.7%-25.9% (P = .625) and from 17.0%-14.4% in Canada and Brazil, respectively (P = .448) after the SSC implementation. In Canada, there was no SSI in incomplete SSC, and in Brazil, SSI was 20.0% (P = .026). DISCUSSION: Despite high and regular completion of the SSC in the Canadian and Brazilian hospitals, respectively, there was no significant reduction of SSI after the SSC implementation in any setting. However, in Brazil, the association between incomplete SSC and higher SSI rates demonstrated the potential impact of the SSC in developing countries. CONCLUSIONS: The effect of the SSC on SSI may be greater in developing countries due to minor investment and consolidation of policies in SSI prevention.

Uso do Checklist de cirurgia segura da Organização Mundial da Saúde como estratégia de redução de complicações e mortalidade em cirurgias colorretais: uma análise de duas realidades, Brasil X Canadá / Using the World Health Organization Safe Surgery Checklist as a strategy for reducing complications and mortality in colorectal surgery: a two-reality analysis, Brazil vs. Canada

Introdução: Os eventos adversos são responsáveis por um grande número de complicações, invalidez e morte em pacientes cirúrgicos. Estima-se que, anualmente, ocorram sete milhões de complicações em pacientes cirúrgicos e cerca de um milhão de mortes durante ou imediatamente após a cirurgia. Assim, a fim de minimizar a sua ocorrência, em 2008, a Organização Mundial da Saúde (OMS) lançou o desafio global "Cirurgias Seguras Salvam Vidas", visando promover a melhoria da qualidade do cuidado prestado a esses pacientes. O desafio propõe a aplicação de um checklist cirúrgico que contribui para despertar a equipe multiprofissional para ações simples, porém fundamentais dentro da complexidade do procedimento cirúrgico. Diante da proposta de implementação do checklist na melhoria da segurança do paciente cirúrgico, o presente estudo teve como questão norteadora: Qual é o impacto do checklist cirúrgico nas infecções do sítio cirúrgico (ISC), reinternação, reoperação e mortalidade no período de 30 dias em duas instituições de realidades distintas: Brasil e Canadá? Objetivo: Analisar o impacto da adoção do checklist cirúrgico nas infecções do sítio cirúrgico, reinternação, reoperação e mortalidade em cirurgias colorretais de duas instituições de realidades distintas: Brasil e Canadá. Métodos: Tratou-se de um estudo retrospectivo realizado em um hospital de Belo Horizonte, Minas Gerais, Brasil e um hospital em Ottawa, Ontário, Canadá, ambos de grande porte, públicos e universitários. Este estudo respeitou a Resolução 466 de 2012 do Conselho Nacional de Saúde e foi parte de um projeto maior, tendo sido submetido e aprovado pelo Comitê de Ética em Pesquisa no Brasil (037048/2017) e Canadá (REB # 20170449-01H). A coleta de dados foi feita por meio da revisão de prontuários acerca do preenchimento do checklist e registros de complicações como retorno não planejado à sala de cirurgia, reinternação, ISC e mortalidade até o trigésimo dia no pós-operatório de cirurgias colorretais, no período de janeiro de 2015 a julho 2017, em ambas as instituições hospitalares. Para avaliação do impacto da implementação do checklist cirúrgico foram também analisados os mesmos dados de pacientes no ano anterior à implementação do checklist, sendo estes pareados por sexo, idade, classificação ASA (American Society of Anesthesiologists), potencial de contaminação da ferida operatória, tipo de cirurgia (eletiva ou urgência) e tempo de duração. Os resultados foram avaliados por instituição e comparados entre si. Os dados foram analisados estatisticamente no programa Statistical Package for the Social Sciences (SPSS) para Windows (versão 21.0), onde foram realizadas medidas de tendência central e dispersão; análise inferencial, teste paramétrico, Qui-Quadrado ou Exato de Fisher, para variáveis categóricas e t Student simples ou Mann-Whitney, para as variáveis numéricas contínuas. Resultados: Foram incluídos 518 prontuários no Brasil, sendo 171 (33%) no período anterior à implementação do checklist cirúrgico e 347 (67%) posterior à sua implementação; e 842 prontuários no Canadá, dos quais 177 (21%) corresponderam ao período anterior à implementação do checklist cirúrgico e 665 (79%) posterior a sua implementação. No que se refere à completude do checklist no Brasil, dos 347 checklists, 222 (64%) estavam completos e 125 (36%) incompletos. No Canadá, dos 665 prontuários avaliados com a presença do checklist, observou-se que 657 (98,8%) estavam completos e 8 (1,2%) incompletos. Quanto aos desfechos, no hospital do Brasil a taxa de ISC reduziu após a implementação do checklist de 17% para 14,4%, o número de reinternação também teve uma queda de 2,9% para 1,7%, enquanto o quantitativo de reoperações aumentou de 5,3% para 8,1% e os óbitos de 1,8% para 3,5%. No hospital canadense a taxa de ISC reduziu após a implementação do checklist de 27,7% para 25,9%, a reinternação aumentou de 6,8% para 8,1%, a reoperação reduziu de 5,6% para 4,8% e os óbitos de 1,7% para 0,9%. Mas em nenhuma das realidades esses desfechos foram estatisticamente significativos. Observou-se uma relação direta entre o aumento da incompletude do checklist e desenvolvimento de ISC no Brasil (p = 0,026). Conclusão: O presente estudo verificou que embora o checklist seja adotado com adaptações em diferentes cenários, a sua implementação não foi capaz de reduzir complicações e mortalidade cirúrgicas em cirurgias colorretais nas distintas realidades estudadas, conforme evidenciado pela OMS. Contudo, a associação significativa entre aumento de checklists incompletos e o desenvolvimento de ISC no Brasil e a ausência dessa relação no Canadá, permite inferir que o impacto do checklist pode ser maior em países em desenvolvimento, onde políticas para a segurança do paciente são frágeis e as estratégias multimodais de prevenção e controle de ISC são escassas, divergindo da realidade de países desenvolvidos. Entretanto, ainda é passível de questionamento se o potencial impacto dessa ferramenta nesses cenários seria permanente ou pontual, uma vez que apenas o checklist, sem o auxílio de outras medidas, pode não ter um efeito sustentado em longo prazo.(AU)

Introduction: Adverse events are responsible for a huge number of complications, disability, and death in surgical patients. It is estimated that, annually, happens seven million complications and that around one million dies during or immediately after surgery. In this sense, in order to minimize its occurrence, in 2008, the World Health Organization (WHO) launched a global challenge "Safe Surgery Saves Lives", aiming to improve quality of care given to these patients. The challenge proposed an application of a surgical checklist that contributes to awakening the multiprofessional team to simple actions, but essentials considering the complexity of the surgical procedure. Considering the proposal of checklist implementation in patient safety improvement, this study had the following guiding questions: What is the impact of adoption of surgical checklist on Surgical Site Infection (SSI), readmission, reoperation, and mortality in 30 days follow up in two facilities from different settings: Brazil and Canada? Aim: To analyze the impact of adoption of surgical safety checklist on the occurrence of SSI, readmission, reoperation, and mortality in colorectal surgeries of two institutions of different settings: Brazil and Canada. Methods: A retrospective study was conducted in one hospital in Belo Horizonte, Minas Gerais, Brazil and one hospital in Ottawa, Ontario, Canada, both large, public, and university hospitals. This study respected 466 Resolution 2012 of Brazilian National Health Council and it was part of a broader project, which was approved by the Brazilian Research Ethics Board (037048/2017) and Canadian Research Ethics Board (#20170449-01H). Data collection was done through chart review where checklist completion and complications as an unplanned return to the operating room, readmission, SSI and mortality up to thirtieth day in postoperative colorectal procedures were analyzed, from January 2015 to July 2017 in both institutions. To evaluate the impact of surgical checklist implementation also was analyzed the same data from patients in the year before checklists implementation, being these matched by sex, age, ASA (American Society of Anesthesiologists) score, wound classification, type of surgery (elective or urgency), and duration of operation. The results were evaluated by institution and compared between them. Data was statistically analyzed in the Statistical Package for the Social Sciences (SPSS) for Windows (version 21.0) where it was carried out measures of central tendency and dispersion; inferential analysis, nonparametric test, chi-square or Fisher exact test, for categorical variables, simple t Student or Mann-Whitney test, for continuous variables. Results: A total of 518 medical records were included in Brazil, of which 171 (33%) were in the period before the implementation of the surgical checklist and 347 (67%) after the implementation of the checklist; and 842 medical records in Canada, of which 177 (21%) corresponded to the period before the implementation of the surgical checklist and 665 (79%) after the implementation of the checklist. Regarding the completion of the checklist in Brazil, 222 (64%) were complete and 125 (36%) were incomplete. In Canada, of the 665 records evaluated with the presence of the checklist, it was observed that 657 (98.8%) were complete and 8 (1.2%) were incomplete. Regarding the outcomes, in Brazilian hospital the SSI rate decreased after the implementation of the checklist from 17% to 14.4%, and readmission also fell from 2.9% to 1.7%, the number of reoperations increased from 5.3 % to 8.1%, and deaths from 1.8% to 3.5%. In Canadian hospital the SSI rate reduced after the implementation of the checklist from 27.7% to 25.9%, readmission increased from 6.8% to 8.1%, reoperation decreased from 5.6% to 4.8%, and deaths from 1.7% to 0.9%. But in no setting the outcomes were statistically significant. It was observed a direct association between a high number of incomplete checklists and development of SSI in Brazil (p = 0.026). Conclusion: The present study verified that although the checklist has been adopted with adaptations in different scenarios, its implementation was not able to reduce surgical complications and mortality in colorectal surgeries in the distinct settings studied, as evidenced by the WHO. However, the significant association between the increase in incomplete checklists and the development of SSI in Brazil and the absence of such relationship in Canada suggests that the impact of the checklist may be greater in developing countries, where patient safety policies are fragile and multimodal strategies for SSI control and prevention are scarce, diverging from the reality of developed countries. However, it is still questionable whether the potential impact of this tool on these scenarios would be permanent or punctual, since the checklist only, without the aid of other measures, may not have a sustained long-term effect.(AU)

O que usar no preparo cirúrgico da pele: povidona-iodo ou clorexidina? / What to use in preoperative skin preparation: povidone-iodine or chlorhexidine? / ¿Qué usar en la preparación quirúrgica de la piel: povidona-iodo o clorhexidina?

Objetivo: Discorrer sobre a eficácia do gluconato de clorexidina e do povidona-iodo em soluções aquosas ou alcoólicas na redução de infecções do sítio cirúrgico e na contagem bacteriana da pele, no preparo pré-operatório do paciente. Método: Estudo de reflexão acerca do melhor antisséptico a ser usado no preparo cirúrgico da pele. Resultados: Verificou-se que tanto a clorexidina quanto o povidona-iodo são igualmente seguros e efetivos e que os manuais de boas práticas internacionais têm recomendado a sua utilização em soluções alcoólicas. Observou-se uma tendência na indicação da clorexidina alcoólica e a emergência de estudos que têm avaliado o uso sequencial ou concomitante da clorexidina e do povidona-iodo com resultados favoráveis a essa prática. Conclusão: Há uma tendência mundial mais favorável ao uso da clorexidina alcoólica em detrimento ao povidona-iodo. Contudo, a decisão pelo melhor agente antisséptico deve considerar cada caso clínico, (contra) indicações e situação

Objective: To discuss the efficacy of chlorhexidine gluconate and povidone-iodine in aqueous or alcoholic solutions in reducing surgical site infections and skin bacterial counts in the preoperative preparation of the patient. Method: Reflective study about the best antiseptic to use in preoperative skin preparation. Results: We found that chlorhexidine and povidone-iodine are equally safe and effective and that international guidelines for good practices have recommended their use in alcoholic solutions. We observed a trend in recommending alcoholic chlorhexidine and an emergence of studies that have evaluated the sequential or concurrent use of chlorhexidine and povidone-iodine with favorable results for this practice. Conclusion: There is a global trend that favors the use of alcoholic chlorhexidine over povidone-iodine. However, the decision about the best antiseptic agent to useshould be based on each clinical case, (contra)indications, and situation

Objetivo: Discutir sobre la eficacia del gluconato de clorhexidina y del povidona-yodo en soluciones acuosas o alcohólicas en la reducción de infecciones del sitio quirúrgico y en el recuento bacteriano de la piel en la preparación preoperatoria del paciente. Método: Estudio de reflexión acerca del mejor antiséptico a utilizarse en la preparación quirúrgica de la piel. Resultados: Se ha comprobado que tanto la clorhexidina como el povidona yodo son igualmente seguros y efectivos y que los manuales de buenas prácticas internacionales han recomendado su utilización en soluciones alcohólicas. Se observó una tendencia en la indicación de la clorhexidina alcohólica y la emergencia de estudios que han evaluado el uso secuencial o concomitante de la clorhexidina y del povidona-yodo con resultados favorables a esa práctica. Conclusión: Hay una tendencia mundial más favorable al uso de la clorhexidina alcohólica en detrimento del povidona-yodo. Sin embargo, la decisión por el mejor agente antiséptico debe considerar cada caso clínico, (contra) indicaciones y situación.

Control de la higiene de manos: observación directa versus tasa autorreportada / Monitorização da higienização das mãos: observação direta versus taxa autorreportada / Monitoring hand hygiene: direct observation versus self-report rates

La higiene de las manos es una de las principales medidas de control de las infecciones. Este estudio tuvo como objetivo comparar las tasas de adherencia a la higiene de las manos obtenidos por métodos de observación directa y la tasa autorreportada en una unidad de cuidados intensivos. Estudio transversal realizado en un hospital universitario, entre septiembre y diciembre de 2013. Los datos fueron recolectados a través de la observación directa del personal médico y de enfermería, y la aplicación de un cuestionario estructurado para identificación de las tasas de adhesión autorreportadas. Se realizaron análisis descriptivos y univariantes. El proyecto fue aprobado por el Comité de Ética. Se obtuvo un total de 1935 oportunidades para la higiene de las manos. La tasa de adhesión autorreportada fue de 87,9%, mientras que la tasa observada fue del 19,0% (p <0,001). La higiene de las manos simple fue referido como preferido por 70,2% de los profesionales de la salud, seguido de 12,3% de fricción con solución alcohólica antiséptica y 17,5% por ambos (higiene de las manos simple seguida de fricción con solución alcohólica antiséptica), y dichas tasas fueron similares en la adhesión autorreportadas y la observación directa. Las tasas de adhesión autorreportadas a la higiene de manos fueron sobreestimadas y las tasas obtenidas por observación directa fueron bajas, aunque no distinta de la escena mundial, reafirmando la necesidad de estrategias de implementación continua para la mejora de estas (AU)

A higienização das mãos (HM) constitui uma das principais medidas de controle das infecções. Objetivou-se comparar as taxas de adesão à HM obtidas por métodos de observação direta e taxa autorreportada em uma unidade de terapia intensiva. Tratou-se de um estudo transversal, realizado em um hospital universitário entre setembro e dezembro de 2013. Os dados foram coletados por meio da observação direta dos médicos e equipe de enfermagem e aplicação de um questionário estruturado para identificar a taxa de adesão autorreportada e sua percepção sobre tal procedimento. Foram realizadas análises descritiva e univariada. Foram acompanhadas 1.935 oportunidades para HM. A taxa de adesão autorreportada foi de 87,9% e a taxa observada 19,0% (p<0,001). A HM simples foi referida como preferida por 70,2% dos profissionais de saúde, seguido de 12,3% para fricção antisséptica e 17,5% para ambas (HM simples seguida de fricção antisséptica), sendo tais taxas semelhantes para a taxa autorreportada e observação direta. As taxas de adesão à HM autorreportadas foram superestimadas e as taxas obtidas pela observação direta foram baixas, embora não distintas do panorama mundial, reafirmando a necessidade de implementação de estratégias contínuas para melhoria destas (AU)

Hand hygiene is one of the main measure to control infections. This study aimed to compare hand hygiene adherence rates in an intensive care unit obtained through direct observation and self-reported compliance. This cross-sectional study was conducted in a university hospital between September and December of 2013. Data were collected through direct observation of healthcare workers from medical and nursing staff and the application of a structured questionnaire to identify self-reported compliance rates. Descriptive and univariate analysis were performed. A total of 1,935 opportunities for practicing hand hygiene was obtained. The self-reported hand hygiene adherence rate was 87.9% and observed adherence was 19.0% (p<0.001). Simple hand hygiene was reported as preferred by 70.2% of healthcare workers, followed by 12.3% for hand rubbing with alcohol and 17.5% for both (simple hand hygiene followed by hand rubbing with alcohol), such rates being similar for self-reported and observed rates. The self-reported hand hygiene rates were overestimated and the rates obtained through direct observation were low, although not distinct from the world scenario, reaffirming the need to implement continuous strategies to improve these (AU)

Adherence and factors related to acceptance of alcohol for antiseptic hand rubbing among nursing professionals.

OBJECTIVE: Identify rates of adhesion and related factors to acceptance of an alcohol based preparation to hands antiseptic friction among nursing professionals in a unit of intensive therapy. METHOD: A cross-sectional study, which involved direct observation of hand hygiene opportunities and nursing professionals' completion of questionnaires, was conducted at a university hospital between January and July 2015. Descriptive and univariate analyses were performed, with a 5% significance level. RESULTS: It was observed 956 opportunities of hand hygiene among 46 nursing professionals. The rate of adhesion to alcohol-based handrub (ABH) was 34.8% and about 87.0% preferred handwashing. Nurses used ABH more frequently than nursing technicians (p <0.001), and the report of feeling of clean hands after using the alcohol product was directly related to higher rates of adherence to antiseptic friction through observation (P <0.05). CONCLUSION: The finding indicating low ABH usage highlights the need for greater institutional investment in strategies that help health professionals to recognize the advantages of this type of HH with respect to time spent, ease of access to dispensers, effectiveness in eliminating microorganisms, and maintaining skin moisturization.

Surgical site infection prevention: An analysis of compliance with good practice in a teaching hospital.

BACKGROUND: Surgical teams play a critical role in reducing surgery-related risks during preoperative and intraoperative phases. AIM: To analyse the preoperative and intraoperative practices adopted by surgical teams in surgical site infections prevention. METHODS: This was a cross-sectional study conducted during April-September 2013 in a large university hospital in Belo Horizonte, Minas Gerais, Brazil. It was conducted through observation of the surgical practice during preoperative and intraoperative phases of procedures used by a gastroenterological, cardiovascular and paediatric surgical team. RESULTS: A total of 100 surgeries were monitored. Hair removal was performed for 20% of the patients inside the operating room by professionals using clippers in 65% of operations. The antimicrobial agent of choice was appropriate/satisfactory in 62% of the operations and administered up to 60 min before surgical incision in 90.3% of the cases. The operating room door was kept closed in 4% of these procedures. DISCUSSION: Some preoperative measures for surgical site infection prevention were not adhered to by the professionals who were monitored in this study. It is recommended that surgical teams undergo professional surveillance and training to highlight the necessity and importance of implementing measures to improve the quality of care provided to surgical patients.