[Clinical pathways for the care of multiple sclerosis patients]. / Diseño de una vía clínica para la atención a los pacientes con esclerosis múltiple.

INTRODUCTION: clinical pathways are standard health care methods to coordinate clinical work, reduce inter-clinician variability, improve patient care and increase staff and patient satisfaction. The aim of this study is to develop a clinical pathway capable of organising and developing standard procedures for diagnosis, treatment and care in patients with multiple sclerosis and to coordinate all medical specialists involved in this disease. METHODS: a multidisciplinary unit for the care of MS patients was developed. All of them and quality specialists analysed some international evidence-based studies, clinical guides, international guidelines and other clinical neurological pathways in several meetings and designed several documents for the clinical pathways. RESULTS: a clinical pathway was created consisting of a scientific-technical framework, which arranges the care in relation to the diagnosis and reatment. The framework is accompanied by various patient-information documents on the disease, an information sheet on diagnostic procedures and a map of the process. Quality standards were established to achieve continuous improvement in patient care. CONCLUSIONS: a clinical pathway for the care of MS patients in a multidisciplinary unit homogenises and organises the care which the MSpatient should receive from the initial symptoms to the progressive stages. This clinical pathway improves the quality of patient care, reduces the variability in work protocols and rationalises the use of the available health care resources.

[Development of an acute stroke care pathway in a hospital with stroke unit]. / Implantación de una vía clínica para la atención del ictus agudo en un hospital con unidad de ictus.

INTRODUCTION: Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU). METHODS: Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides. RESULTS: The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document. CONCLUSIONS: A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

Diseño de una vía clínica para la atención a los pacientes con esclerosis múltiple / Clinical pathways for the care of multiple sclerosis patients

Introducción: Las vías clínicas (VC) son herramientas para coordinar el trabajo asistencial, reducir la variabilidad entre el personal sanitario y mejorar la atención y el cuidado del paciente. La esclerosis múltiple (EM) es una enfermedad neurológica crónica que afecta a pacientes jóvenes y es incapacitante. El objetivo es desarrollar una vía clínica para mejorar el diagnóstico, el tratamiento y la atención de los pacientes con EM y, asimismo, facilitar la coordinación de todos los especialistas implicados en este proceso. Método: Siguiendo el modelo FOCUS-PDCA se organiza un equipo de trabajo integrado por diferentes profesionales implicados en la atención del paciente con EM. Se realiza una revisión bibliográfica exhaustiva y se llega a consenso; así, se diseñan los documentos de la VC con base en la evidencia científica. Resultados: Se crea una vía clínica compuesta por los siguientes elementos: una matriz temporal con una serie de anexos para ordenar el proceso diagnóstico y el tratamiento, un impreso de información a los pacientes sobre las pruebas diagnósticas, una hoja de información sobre la enfermedad y un mapa de procesos, una encuesta de evaluación de la calidad percibida y un documento con indicadores de calidad para evaluar la VC. Conclusiones: El desarrollo de una VC de EM facilita la atención multidisciplinaria y mejora la calidad asistencial. Esta propuesta es novedosa al enfocar la atención integral de la EM desde su inicio, tanto en aspectos diagnósticos como terapéuticos, incluyendo el ámbito ambulatorio (AU)

Introduction: Clinical pathways are standard health care methods to coordinate clinical work, reduce inter-clinician variability, improve patient care and increase staff and patient satisfaction. The aim of this study is to develop a clinical pathway capable of organising and developing standard procedures for diagnosis, treatment and care in patients with multiple sclerosis and to coordinate all medical specialists involved in this disease. Methods: A multidisciplinary unit for the care of MS patients was developed. All of them and quality specialists analysed some international evidence-based studies, clinical guides, international guidelines and other clinical neurological pathways in several meetings and designed several documents for the clinical pathways. Results: A clinical pathway was created consisting of a scientific-technical framework, which arranges the care in relation to the diagnosis and reatment. The framework is accompanied by various patient-information documents on the disease, an information sheet on diagnostic procedures and a map of the process. Quality standards were established to achieve continuous improvement in patient care. Conclusions: A clinical pathway for the care of MS patients in a multidisciplinary unit homogenises and organises the care which the MSpatient should receive from the initial symptoms to the progressive stages. This clinical pathway improves the quality of patient care, reduces the variability in work protocols and rationalises the use of the available health care resources (AU)

La gestión por procesos en el tratamiento del dolor / Process managetnent in pain treatment

El tratamiento del dolor constituye una oportunidad de mejora. Los principios de la gestión por procesos pueden facilitar el diseño,desarrollo y funcionamiento de las Unidades del Dolor. El requisito fundamental es la orientación al paciente, buscando la satisfacciónde sus necesidades y demandas. La identificación de los distintos procesos -de gestión, clave y de apoyo- que se integran en la Unidaddel Dolor permite la elaboración del mapa de procesos de la Unidad, con sus correspondientes fichas de procesos y diagramas de flujoo flujogramas. Esta metodología, que supone una ruptura con las formas de gestión tradicional, puede contribuir a dar personalidad eidentidad a la Unidad asistencial, facilitando eventualmente su certificación en calidad(AU)

The management of pain still needs to be improved. The principles of process management can be applied to the design, development and daily function of a Pain Unit. The main request is its orientation to meet the needs and demands of patients. The identification of the different processes within the Unit allow for the design of its process mapping and the development of process files and flowcharts. This methodology of work may break away with traditional management schemes, but can contribute to better define the identity of the Pain Unit and eventually facilitate its certification in quality (AU)

[Impact of cataract surgery on visual acuity and quality of life]. / Impacto de la cirugía de catarata: agudeza visual y calidad de vida.

OBJECTIVE: To evaluate visual acuity and quality of life improvement after cataract surgery. METHODS: Visual acuity and quality of life were assessed in patients undergoing phaco-emulsification. They were of both genders, ranged from forty-six to ninety-two years of age, and were able to understand the SF-36 quality of life questionnaire which explores the differences in quality of life before and after surgery. The questionnaire was completed before cataract surgery and again 6 and 18 months later. Visual acuity was measured with Snellen optotype. RESULTS: The answers of 150 patients were evaluated in this study. The average age was 74.32 years. After the surgery the body pain results increased, with this shown to be statistically significant. The social function, general health, perception, role limitation due to physical problems and physical function significantly improved between the first and third consultations. There were no significant differences in role limitation due to emotional problems, nor in vitality. The mental health dimension became worse between consultations although there was no statistically significant difference found. The average values for Visual Acuity were 18.39, 66.01 and 69.02 at the three timed assessments made. CONCLUSIONS: Cataract surgery performed by phacoemulsification has been proven to be effective in improving quality of life, especially in physical aspects, according to the improvement in role limitation due to physical problems. Visual acuity also improves after surgery. Disease specific instruments, such as the SF-36, should be used as the outcome measure in clinical practice after cataract surgery.

Impacto de la cirugía de catarata: agudeza visual y calidad de vida / Impact of cataract surgery on visual acuity and quality of life

Objetivo: Medir el impacto de la cirugía de catarata sobre la calidad de vida y agudeza visual. Métodos: Se mide la calidad de vida en pacientes intervenidos de Catarata de cuarenta y seis a noventa y dos años de edad, de ambos géneros y con un nivel intelectual que les permitiera comprender el cuestionario (SF-36). Se completó el cuestionario antes del acto quirúrgico seis y dieciocho meses después. La agudeza visual se mide con el optotipo de Snellen. Resultados: Se realizaron 150 cuestionarios. La edad media fue de 74,32 años (DE 6,44). El dolor corporal fue mejorando de forma significativa. La función social, salud general, evolución declarada de la salud, rol físico y función física tienen una evolución similar, manteniendo una mejoría significativa entre la primera y tercera consulta. No existieron diferencias significativas en el rol emocional ni en la vitalidad. La salud mental ha ido empeorando en las sucesivas consultas con diferencias significativas entre ellas. Los valores medios de agudeza visual son 18,39%, 66,01% y 69,02%. Conclusiones: La facoemulsificación es un método efectivo y seguro para mejorar la calidad de vida, sobre todo en los aspectos físicos. La disminución de la limitación de roles debido a problemas de salud físicos tras la cirugía es concordante con la mejora física. La agudeza visual aumenta claramente tras la cirugía. Los cuestionarios genéricos de calidad de vida como el SF-36 se pueden utilizar como medida de resultado de la cirugía de catarata

Objective: To evaluate visual acuity and quality of life improvement after cataract surgery. Methods: Visual acuity and quality of life were assessed in patients undergoing phaco-emulsification. They were of both genders, ranged from forty-six to ninety-two years of age, and were able to understand the SF-36 quality of life questionnaire which explores the differences in quality of life before and after surgery. The questionnaire was completed before cataract surgery and again 6 and 18 months later. Visual acuity was measured with Snellen optotype. Results: The answers of 150 patients were evaluated in this study. The average age was 74.32 years. After the surgery the body pain results increased, with this shown to be statistically significant. The social function, general health, perception, role limitation due to physical problems and physical function significantly improved between the first and third consultations. There were no significant differences in role limitation due to emotional problems, nor in vitality. The mental health dimension became worse between consultations although there was no statistically significant difference found. The average values for Visual Acuity were 18.39, 66.01 and 69.02 at the three timed assessments made. Conclusions: Cataract surgery performed by phacoemulsification has been proven to be effective in improving quality of life, especially in physical aspects, according to the improvement in role limitation due to physical problems. Visual acuity also improves after surgery. Disease specific instruments, such as the SF-36, should be used as the outcome measure in clinical practice after cataract surgery (Arch Soc Esp Oftalmol 2008; 83: 237-248)

[Evaluation of a clinical pathway for septic arthritis]. / Evaluación de una vía clínica de artritis séptica.

INTRODUCTION: Clinical pathways are tools that coordinate clinical work, reducing interclinican variability and improving patient care and management. The use of clinical pathways in septic arthritis is appropriate, as this disease has a predictable course and there is considerable variation in its management. The aim of this study was to evaluate a septic arthritis clinical pathway 2 years after its introduction and to describe the characteristics of the patients included. MATERIAL AND METHODS: Clinical pathway documents: pathway matrix sheet, variance form, parent information sheet, satisfaction survey and evaluation indicators sheet. RESULTS: Thirty-five patients were included, seven with a definitive diagnosis of septic arthritis and 28 with probable septic arthritis. No differences were found between the two groups, with good outcomes in both. Laboratory analyses were performed at admission in all patients, at discharge in 51 %, and at the end of treatment in 97 %. The indicators that best met the standard were clinical pathway coverage, performance of arthrocentesis/arthrotomy, and satisfaction with dealings with staff and the information received. The indicators furthest from the standard were admission shorter than 7 days (77 % vs > 95 %) and obtaining articular fluid prior to antibiotic therapy (76 % vs > 90 %). CONCLUSIONS: The clinical pathway is useful for standardizing the process of septic arthritis diagnosis and treatment. With adequate clinical support, application of this pathway allows decisions to be made on hospital discharge following the clinical criteria of improvement without worsening prognosis. Our immediate challenges are to reduce inpatient stay and to obtain synovial fluid before starting antibiotic therapy.

Desarrollo de una vía clínica para la atención a pacientes con esclerosis lateral amiotrófica en un ámbito regional. Red de Atención de ELA-Comunidad de Madrid / Development of a clinical pathway for the attention of patients with amyotrophic lateral sclerosis in a regional network. ALS Assistance Network-Comunidad de Madrid

Introducción. La esclerosis lateral amiotrófica (ELA) precisa una atención multidisciplinaria compleja. Las vías clínicas son planes asistenciales para determinadas enfermedades con curso predecible establecidas en centros aislados, no en regiones multicéntricas. El objetivo es desarrollar una vía clínica capaz de organizar y homogeneizar la atención en la Red de Atención de ELA-Comunidad de Madrid constituida por cinco hospitales, desde el inicio hasta el fin de la enfermedad.Métodos. Neurólogos de estos hospitales y miembros del Servicio Madrileño de Salud en sucesivas reuniones revisaron las guías terapéuticas publicadas y otros documentos utilizados en la atención de la ELA y desarrollaron una vía clínica adaptando la información a la realidad sociosanitaria de la Comunidad de Madrid siguiendo el modelo FOCUSPDCA para el desarrollo de la misma.Resultados. Se crea una vía clínica compuesta por una matriz cientificotécnica que ordena la atención a los pacientes en relación al diagnóstico y tratamiento según el grado de afectación y un cronograma. Se acompaña de unos documentos de información a los pacientes sobre la enfermedad y las pruebas a realizar y evaluación de la atención recibida. Se establecen los estándares a alcanzar en la atención para promover la mejora continua asistencial.Conclusiones. La vía clínica para la atención de la ELA en una red regional organiza la atención y cuidados que deben recibir los pacientes desde el inicio de los síntomas hasta el fin de la enfermedad. Esta ordenación y homogenización mejora la calidad asistencial, disminuye la variabilidad y racionaliza el uso de los recursos sanitarios

Introduction. Amyotrophic lateral sclerosis (ALS) requires complex multidisciplinary attention. Clinical pathways are assistance plans for certain diseases with a predictable course. These plans are established in isolated centers, not in multicenter regions. The aim is to develop a clinical pathway capable of organizing and homogenizing assistance given in ALS Assistance Network-Comunidad de Madrid which is made up of five hospitals, from the beginning until the end of the disease.Methods. In successive meetings, neurologists of these hospitals and members of the Madrid Health Service evaluated published therapeutic guidelines and other documents used in ALS assistance. A clinical pathway was developed adapting this information to social-health care conditions in the Comunidad de Madrid following the FOCUS-PDCA model.Results. A clinical pathway was created consisting of a scientist-technical framework which arranges the attention in relationship to the diagnosis and treatment, according to the degree of disease progression and a chronogram. This is accompanied by several patient information documents on the disease and the tests that are required, and a patient assistance evaluation form. The standards are established to reach and to promote 354 constant improvement in patient care.Conclusions. Clinical pathway for the ALS assistance in a regional network organizes the attention and cares that the patients must receive from the beginning to the end of the disease. This arrangement and homogenization of the attention improves the quality of patient care, diminishes variability and rationalizes the use of the health care resources

[Development of a clinical pathway for the attention of patients with amyotrophic lateral sclerosis in a regional network. ALS Assistance Network-Comunidad de Madrid]. / Desarrollo de una vía clínica para la atención a pacientes con esclerosis lateral amiotrófica en un ámbito regional. Red de Atención de ELA-Comunidad de Madrid.

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) requires complex multidisciplinary attention. Clinical pathways are assistance plans for certain diseases with a predictable course. These plans are established in isolated centers, not in multicenter regions. The aim is to develop a clinical pathway capable of organizing and homogenizing assistance given in ALS Assistance Network-Comunidad de Madrid which is made up of five hospitals, from the beginning until the end of the disease. METHODS: In successive meetings, neurologists of these hospitals and members of the Madrid Health Service evaluated published therapeutic guidelines and other documents used in ALS assistance. A clinical pathway was developed adapting this information to social-health care conditions in the Comunidad de Madrid following the FOCUS-PDCA model. RESULTS: A clinical pathway was created consisting of a scientist-technical framework which arranges the attention in relationship to the diagnosis and treatment, according to the degree of disease progression and a chronogram. This is accompanied by several patient information documents on the disease and the tests that are required, and a patient assistance evaluation form. The standards are established to reach and to promote 354 constant improvement in patient care. CONCLUSIONS: Clinical pathway for the ALS assistance in a regional network organizes the attention and cares that the patients must receive from the beginning to the end of the disease. This arrangement and homogenization of the attention improves the quality of patient care, diminishes variability and rationalizes the use of the health care resources.

Evaluación de una vía clínica de artritis séptica / Evaluation of a clinical pathway for septic arthritis

Introducción. Una vía clínica es una herramienta que coordina la labor asistencial, disminuyendo la variabilidad entre profesionales, al tiempo que mejora la atención a los pacientes y la gestión. La artritis séptica es candidata a ser abordada mediante una vía clínica porque su evolución es predecible y existe gran diversidad en el manejo. El objetivo del trabajo es evaluar una vía clínica tras 2 años de implantación y describir las características de los pacientes que fueron incluidos. Material y métodos. Documentación de la vía: matriz, hoja de variaciones, hoja informativa, encuesta de satisfacción e indicadores de evaluación. Resultados. Se incluyeron 35 pacientes, siete artritis sépticas seguras y 28 probables. No hubo diferencias entre los 2 grupos, siendo su evolución favorable. Se practicó analítica al ingreso a todos los pacientes, al alta hospitalaria al 51 % y al alta definitiva al 97 %. Los mejores indicadores de evaluación fueron la cobertura de la vía, la realización de artrocentesis/artrotomía y la satisfacción en el trato o información recibidos y los indicadores más alejados del estándar fueron la hospitalización menor de 7 días (77 % frente a > 95 %) y la obtención de líquido articular sin antibióticos (76 % frente a > 90 %). Conclusiones. La vía clínica resulta útil para estandarizar el proceso de diagnóstico y tratamiento de la artritis séptica. Su aplicación con un soporte clínico adecuado permite decidir el alta hospitalaria siguiendo los criterios clínicos de mejoría, sin que por ello empeore el pronóstico. Optimizar el tiempo de hospitalización y conseguir líquido articular antes de iniciar el tratamiento antibiótico son nuestros retos inmediatos

Introduction. Clinical pathways are tools that coordinate clinical work, reducing interclinican variability and improving patient care and management. The use of clinical pathways in septic arthritis is appropriate, as this disease has a predictable course and there is considerable variation in its management. The aim of this study was to evaluate a septic arthritis clinical pathway 2 years after its introduction and to describe the characteristics of the patients included. Material and methods. Clinical pathway documents: pathway matrix sheet, variance form, parent information sheet, satisfaction survey and evaluation indicators sheet. Results. Thirty-five patients were included, seven with a definitive diagnosis of septic arthritis and 28 with probable septic arthritis. No differences were found between the two groups, with good outcomes in both. Laboratory analyses were performed at admission in all patients, at discharge in 51 %, and at the end of treatment in 97 %. The indicators that best met the standard were clinical pathway coverage, performance of arthrocentesis/arthrotomy, and satisfaction with dealings with staff and the information received. The indicators furthest from the standard were admission shorter than 7 days (77 % vs > 95 %) and obtaining articular fluid prior to antibiotic therapy (76 % vs > 90 %). Conclusions. The clinical pathway is useful for standardizing the process of septic arthritis diagnosis and treatment. With adequate clinical support, application of this pathway allows decisions to be made on hospital discharge following the clinical criteria of improvement without worsening prognosis. Our immediate challenges are to reduce inpatient stay and to obtain synovial fluid before starting antibiotic therapy

Etiología y Resistencias a los antibióticos en las infecciones de la localización quirúrgica tras cirugía abdominal / Etiology and antimicrobial resistance of surgical site infections after abdominal surgery

Las infecciones de la localización quirúrgica (ILQ) tras cirugía abdominal son una complicación frecuente. La resistencia de los microorganismos a los antimicrobianos ha aumentado progresivamente en los últimos años. El objetivo es describir la etiología de las ILQ, la frecuencia de resistencias de los microorganismos, y caracterizar los factores que se asocian a las ILQ por microorganismos resistentes (MR). MÉTODOS. Encuestas anuales de prevalencia de infecciones en los pacientes hospitalizados durante el periodo 1999-2005. Se seleccionaron todas las ILQ presentes en los pacientes que habían recibido cirugía abdominal. Se recogieron características demográficas de los pacientes, datos microbiológicos, y de potenciales factores de riesgo. RESULTADOS. Se identificaron un total de 3.564 ILQ en las que se aislaron 3.590 microorganismos. Los más frecuentes fueron: Escherichia coli (25,9%), Enterococcus faecalis (9,4%), Pseudomonas aeruginosa (7,0%) y Staphylococcus aureus (6,5%). Las resistencias a cefalosporinas de tercera generación oscilan entre el 2,5% para K. pneumoniae y el 30% para Enterobacter sp., y para las fluorquinolonas entre el 3,8% de K. pneumoniae y el 16,1% para E. coli (25% en el año 2005). S aureus es resistente a la oxacilina en el 38,2% de los aislados. Los principales factores asociados a infecciones por MR son el año de la encuesta, el tamaño del hospital, y el número de factores de riesgo intrínseco del paciente. CONCLUSIONES. Los microorganismos implicados en las ILQ han aumentado progresivamente sus resistencias antimicrobianas durante el periodo 1999 a 2005. El grado de resistencia a los antimicrobianos está condicionado por el nivel de riesgo intrínseco de los pacientes y el tamaño del hospital (AU)

Surgical site infection (SSI) is a common complication after abdominal surgery. Microorganism resistance to antimicrobials has been increasing progressively during the last years. The objective is to describe the aetiology of SSI, the frequency of antimicrobial resistance and to characterize the factors associated to SSI caused by resistant microorganims (RM).METHODS. A series of yearly prevalence surveys of hospitalized patients during the period 1999-2005 in Spain. Selection of all SSI developed by patients operated on by abdominal procedures. Information recorded included demographic characteristic of patients, microbiological data, and potential risk factors. RESULTS. A total 3,590 microorganisms corresponding to a 3,564 SSI were identified. The most frequent microorganisms isolated were Escherichia coli (25.9%), Enterococcus faecalis (9.4%), Pseudomonas aeruginosa (7.0%) and Staphylococcus aureus (6.5 %). Third generation cephalosporin resistance ranged from 2.5% (K. pneumoniae) and 30% (Enterobacter sp.). Fluorquinolone resistance ranged from 3.8% (K. pneumoniae) and 16.1% (E. coli) (25% for the year 2005). Methicillin resistant S. aureus reached 38% of isolates. The main factors associated to MR infections were year of the survey, size of the hospital and the number of intrinsic risk factors of the patients. CONCLUSIONS Microorganisms involved in SSI have been progressively increasing antimicrobial resistance during the period 1999 through 2005. Patient intrinsic risk and the size of the hospital condition the level of antimicrobial resistance (AU)

[Nosocomial outbreak of epidemic keratoconjunctivitis in a neonatal intensive care unit]. / Brote nosocomial de queratoconjuntivitis epidémica en una unidad de cuidados intensivos neonatal.

OBJECTIVE: To describe an epidemic nosocomial outbreak of keratoconjunctivitis affecting at least 43 people in a Neonatal Intensive Care Unit in Madrid, between May and October 2002, perform epidemiologic research and determine preventive measures to prevent new outbreaks. METHODS: Description of the outbreak, clinical case definition, microbiologic and epidemiologic research through the use of questionnaires. Analysis of the incidence of subepithelial infiltrates 1 year after infection and the use of topical corticosteroid therapy. RESULTS: The epidemic began in the Neonatal Service, with a pair of twins being found as the initial focus. Dissemination occurred to about 24 workers of the unit, and 19 workers from other services. The microbiologic diagnosis confirmed adenovirus in 10 conjunctival smears and one serologically, with the remainder obeying clinical and epidemiological criteria of such infection. Infected patients using topical corticosteroids had a higher incidence of infiltrates 12 months later than those not using such agents (p=0.003 in Fisher test). CONCLUSIONS: Epidemic keratoconjunctivitis occurs frequently, is highly contagious and has possible long-term sequelae, necessitating the use of preventive measures to avoid spread and new outbreaks.

Brote nosocomial de queratoconjuntivitis epidémica en una unidad de cuidados intensivos neonatal / Nosocomial outbreak of epidemic keratoconjunctivitis in a neonatal intensive care unit

Objetivos: Descripción de un brote nosocomial epidémico de queratoconjuntivitis ocurrido en Madrid (Unidad de Cuidados Intensivos Neonatal) entre los meses de mayo y octubre de 2002 y que afectó al menos a 43 trabajadores del centro; investigación del posible origen y valoración de secuelas. Medidas preventivas para evitar nuevos brotes. Material y métodos: Estudio descriptivo del brote, definición de caso clínico, investigación microbiológica y epidemiológica mediante encuesta. Análisis de la relación entre la tasa de infiltrados subepiteliales 1 año después de la infección y la tasa de uso de corticoide tópico. Resultados: El brote epidémico empezó en el Servicio de Neonatología, encontrándose como focos iniciales unos gemelos prematuros ingresados en dicha unidad. La diseminación se produjo en 24 trabajadores de la unidad, y otros 19 trabajadores de otros Servicios. El diagnóstico microbiológico contrafirma infección por adenovirus en 10 exudados conjuntivales y una serología, el resto cumple criterios clínicos y epidemiológicos. Aunque es una muestra pequeña y no concluyente, en este estudio los pacientes que usaron corticoide tópico tienen mayor tasa de infiltrados que los que no usaron (p = 0,003 en test exacto de Fisher). Conclusiones: La queratoconjuntivitis epidémica es una enfermedad frecuente y en la mayoría banal, pero su alta tasa de contagiosidad y sus posibles secuelas requieren que se preste mayor atención a las medidas preventivas para evitar nuevos brotes

Objective: To describe an epidemic nosocomial outbreak of keratoconjunctivitis affecting at least 43 people in a Neonatal Intensive Care Unit in Madrid, between May and October 2002, perform epidemiologic research and determine preventive measures to prevent new outbreaks. Methods: Description of the outbreak, clinical case definition, microbiologic and epidemiologic research through the use of questionnaires. Analysis of the incidence of subepithelial infiltrates 1 year after infection and the use of topical corticosteroid therapy. Results: The epidemic began in the Neonatal Service, with a pair of twins being found as the initial focus. Dissemination occurred to about 24 workers of the unit, and 19 workers from other services. The microbiologic diagnosis confirmed adenovirus in 10 conjunctival smears and one serologically, with the remainder obeying clinical and epidemiological criteria of such infection. Infected patients using topical corticosteroids had a higher incidence of infiltrates 12 months later than those not using such agents (p=0.003 in Fisher test). Conclusions: Epidemic keratoconjunctivitis occurs frequently, is highly contagious and has possible long-term sequelae, necessitating the use of preventive measures to avoid spread and new outbreaks

Exposición laboral al óxido nitroso y sevoflurano durante la anestesia en pediatría: evaluación de un dispositivo de extracción de gases anestésicos / Occupational exposure to nitrous oxide and sevoflurane during pediatric anesthesia: evaluation of an anesthetic gas extractor

OBJETIVOS: Determinar el grado de exposición laboral alos gases anestésicos en ausencia de extracción de gases y evaluarla efectividad de un sistema extractor, original y diseñadoal efecto, durante la anestesia inhalatoria en pediatría.MÉTODOS: Veinticuatro niños sometidos a adenoamigdalectomía.En grupo ASP se aplicó extracción de gasesanestésicos (n=12) y grupo No ASP no se aplicó (n=12).Se hizo inducción inhalatoria mediante circuito MaplesonC con sevoflurano 8%, N2O 60%, oxígeno 40% y flujode gas 8 l.min-1. El mantenimiento se hizo con sevoflurano2% con el mismo flujo y mezcla anestésica, enventilación espontánea con tubo endotraqueal y circuitoMapleson D. Los circuitos disponen de válvula APL (airwaypressure-limiting) que permite la conexión al extractorde gases anestésicos. Se midieron niveles ambientalesde sevoflurano y N2O en la zona respiratoria del anestesiólogo.Se realizó encuesta a cirujano y enfermera sobresíntomas relacionados con la exposición laboral.RESULTADOS: Durante el periodo anestésico el promediode exposición al N2O y sevoflurano fue en No ASP:423±290 y 12±10,9 ppm respectivamente; disminuyendoun 94% y 91% en ASP: 24,7±26 y 1,1±1 ppm; p<0,001.Se detectó más incidencia de “olor a gas” en NoASP:87% frente ASP:11% (p=0,003), malestar general:62% versus 11% (p=0,05), náuseas: 62% versus 0%(p=0,009) y cefalea: 62% versus 0% (p=0,009).CONCLUSIONES: La extracción de gases disminuyó hastaun 94% el nivel de exposición, consiguiendo nivelesinferiores a los límites recomendados y reduciendo intensamentelos riesgos para la salud de los trabajadores

OBJETIVES: To determine the level of occupationalexposure to anesthetic gases in the absence of anextractor during pediatric anesthesia and to assess theefficacy of a purpose-built extraction system.METHODS: The patients were 24 children undergoingtonsillectomy and adenoidectomy. Gases were extractedfrom the room for 1 group and were not extracted forthe other group (n=12 in each group). Induction waswith 8% sevoflurane, 60% nitrous oxide (N2O), 40%oxygen at a flow rate of 8 L·min–1 through a Mapleson Ccircuit. Maintenance was with 2% sevoflurane at thesame flow rate and gas mixture under spontaneousventilation with an endotracheal tube and a Mapleson Dcircuit. The circuits were equipped with an airwaypressure-limiting valve to allow connection to ananesthetic gas extractor. Ambient levels of sevofluraneand N2O were measured in the breathing area aroundthe anesthesiologist. The surgeon and the nurse wereasked about symptoms related to occupational exposure.RESULTS: The mean (SD) exposure to N2O andsevoflurane in the group without an extractor was 423(290) and 12 (10.9) parts per million (ppm), respectively.In the group working with the extractor, exposure was94% and 91% lower: 24.7 (26) and 1.1 (1) ppm (P<.001).A higher incidence of noticing a "smell of gas" wasregistered for the group without an extractor (87% vs11% in the extractor group, P=.003). Higher rates werealso found for general discomfort (62% vs 11%, P=.05),nausea (62% vs 0%, P=.009), and headache (62% vs0%, P=.009) in the absence of the extractor.CONCLUSIONS: Gas extraction decreased the level ofexposure by up to 94%, achieving levels that were belowthe recommended limits and greatly reducing occupationalrisk

Revisión de calidad en dolor agudo postoperatorio / Quality revision in acute postoperative pain

La mejora continua de la calidad en el tratamiento del dolor nos indica los pasos a seguir para instaurar una Unidad de Dolor Agudo (UDA) Postoperatorio. El primer paso es saber el punto de partida mediante la realización de una auditoría para poder plantear unos objetivos y unos valores estándares a alcanzar. El siguiente paso después de realizar la auditoría es la organización y el desarrollo de los procesos asistenciales siguiendo el esquema de las vías clínicas para introducir innovaciones o modificaciones de la actividad asistencial y evitar la variabilidad en los tratamientos, instaurando con ello la Unidad de Dolor Agudo Postoperatorio. El tercer paso consiste en valorar el impacto de su instauración mediante: por una parte la evaluación de los resultados asistenciales obtenidos del cumplimiento de la vía clínica, aplicando los indicadores de calidad, y por otra parte a través del conocimiento del punto de vista del paciente (la calidad percibida) mediante la realización de encuestas de satisfacción donde además puedan expresar sus sugerencias. Se emplea un modelo de encuesta donde se recogen aspectos demográficos y se aplican indicadores de calidad percibida: el conocimiento del nombre del médico y de la enfermera de la UDA, la calidad de la información recibida sobre el tratamiento del dolor y sobre sus posibles efectos secundarios, la máxima y la mínima intensidad percibida de dolor, la importancia dada al alivio del dolor, el trato recibido por parte de médicos y enfermeras, la satisfacción global con la UDA y un apartado para sugerencias

The continuous quality improvement in pain treatment shows us the steps to follow in order to create a Postoperative Acute Pain Unit. It is necessary to carry out an Auditorship so as to know the situation and establish a number of aims and standards values to attain. When the Auditorship is done, the next step is to create Guidelines to quantify the pain intensity and to avoid thetreatment variability. Then we can establish the Postoperative Acute Pain Unit. The third step is to measure the impact of creating the Unit. It is necessary to know the evaluation of the clinical results from the Guidelines application through Quality Indicators, and to know the quality perceptions of the patients and the suggestions given in the satisfaction questionnaires. We use a satisfaction questionnaire model with demografic factors and Quality Indicators: the nurses and doctors’ names of the APU, the quality of the information about the pain treatment and its possible secondary effects, the maximum and minimum pain intensity, the importance given to the pain relief, the quality of the doctors and nurses’ behaviour towards the patients, the global satisfaction with the Acute Pain Unit, and a patients suggestion section

[Postoperative pain management in a tertiary care hospital: initial situation prior to starting a quality assurance program]. / Atención del dolor postoperatorio en un hospital de tercer nivel: situación inicial previa a la implantación de un programa de calidad.

OBJECTIVE: To characterize the initial situation in postoperative pain management among the services General and Vascular surgery as the first step in developing a program to improve postoperative analgesia. METHODS: An anonymous questionnaire with 14 items covered the characteristics of postoperative pain, information received about analgesic treatments and requesting medication, and degree of satisfaction. The questionnaire was filled in during an early postoperative interview with all patients undergoing surgery in the aforementioned departments. RESULTS: A total of 158 patients were interviewed; 89% were from the general surgery department and 11% from vascular surgery. At 24 hours after surgery, 18% were free of pain, 35% had mild pain, and 47% had moderate or intense pain. Nonsteroidal anti-inflammatory drugs were the most frequently used postoperative analgesics, in 94% of patients, and the dosage and timing had been prescribed for 74%. Thirty-six percent of the patients asked for an analgesic to be administered. The correlation between degree of greatest pain and request for an analgesic was statistically significant (P < 0.001). CONCLUSIONS: Postoperative pain is an area in which improvements can be implemented to provide better care and treatment of surgical patients, particularly since there are efficacious analgesic treatments for pain control that are presently not being used. The custom of prescribing pain medication on demand should be avoided in all surgical procedures that are known to produce postoperative pain.

Atención del dolor postoperatorio en un hospital de tercer nivel: situación inicial previa a la implantación de un programa de calidad / Postoperative pain management in a tertiary care hospital: initial situation prior to starting a quality assurance program

OBJETIVOS: Conocer la situación inicial de la atención ytratamiento del dolor postoperatorio en los pacientes intervenidosen los servicios de Cirugía General y Cirugía Vascularcomo fase inicial para el desarrollo de un programade mejora de la calidad de la analgesia postoperatoria.METODOLOGÍA: Se elaboró una encuesta anónima queconsta de 14 preguntas que recogen las características dedolor postoperatorio, la información recibida sobre el tratamientodel dolor, la solicitud de medicación, y el gradode satisfacción. La encuesta se llevó a cabo medianteentrevista en el postoperatorio inmediato a todos lospacientes intervenidos en los servicios citados.RESULTADOS: Fueron entrevistados 158 pacientes, un89% de Cirugía General y un 11% de Vascular. El dolorpostoperatorio a las 24 horas muestra un 18% de lospacientes sin dolor, un 35% de los pacientes con dolor levey un 47% de los mismos con dolor moderado-intenso. Laanalgesia postoperatoria más empleada fueron los AINEen un 94%, un 74% con prescripción pautada. Un 36%de los pacientes solicitaron la administración de un analgésico.Existe una relación estadísticamente significativaentre la solicitud de analgesia y el grado de dolor máximo(p<0,001).CONCLUSIONES: El dolor postoperatorio constituye unaoportunidad para el establecimiento de mejoras en la atencióny tratamiento de los pacientes intervenidos, máximecuando existen tratamientos analgésicos eficaces para elcontrol del dolor que no se están utilizando, debiendo acabarcon la modalidad de prescripción a demanda en todasaquellas intervenciones que de antemano se sabe que vana experimentar dolor postoperatorio

OBJETIVE: To characterize the initial situation inpostoperative pain management among the servicesGeneral and Vascular surgery as the first step in developinga program to improve postoperative analgesia.METHODS: An anonymous questionnaire with 14items covered the characteristics of postoperativepain, information received about analgesic treatmentsand requesting medication, and degree of satisfaction.The questionnaire was filled in during an early postoperativeinterview with all patients undergoing surgeryin the aforementioned departments.RESULTS: A total of 158 patients were interviewed;89% were from the general surgery department and11% from vascular surgery. At 24 hours after surgery,18% were free of pain, 35% had mild pain, and 47%had moderate or intense pain. Nonsteroidal anti-inflammatorydrugs were the most frequently used postoperativeanalgesics, in 94% of patients, and the dosage andtiming had been prescribed for 74%. Thirty-six percentof the patients asked for an analgesic to be administered.The correlation between degree of greatest pain andrequest for an analgesic was statistically significant(P<0.001).CONCLUSIONS: Postoperative pain is an area in whichimprovements can be implemented to provide bettercare and treatment of surgical patients, particularlysince there are efficacious analgesic treatments for paincontrol that are presently not being used. The customof prescribing pain medication on demand should beavoided in all surgical procedures that are known toproduce postoperative pain

Nosocomial and community-acquired meticillin-resistant Staphylococcus aureus infections in hospitalized patients (Spain, 1993-2003).

A series of annual surveys on the prevalence of infections in hospitalized patients in Spain was undertaken from 1993 to 2003 to describe clinical and demographic characteristics, trends and geographical variations in the proportion of meticillin-resistant Staphylococcus aureus (MRSA). A total of 8312 S. aureus infections in patients from 296 acute care hospitals pertaining to 17 regions in Spain were observed during the study period. Overall, 23.8% of these organisms were reported as meticillin resistant. The proportion of MRSA varied widely across regions and during the study period. Patients with nosocomial infections (NIs) had a two-fold higher prevalence of MRSA (31%) than patients with community-acquired infections (CAIs) (14%; P<0.001). Nevertheless, there was an increasing trend in the prevalence of MRSA isolates, both in patients with NI (from 22% to 41%; P<0.001) and with CAI (from 7% to 28%; P<0.001) throughout the 11-year period. Geographical variations over the last three years (2001-2003) show a centripetal gradient, with the lowest MRSA prevalence in south-west Spain and the highest MRSA prevalence in the central regions. Almost five-fold differences in MRSA proportions were seen between regions (range 10.3-54.5%). Compared with bloodstream infections, infections in other sites were more likely to be caused by MRSA (adjusted odds ratios for surgical site, urinary tract, skin and respiratory infections of 1.2, 1.2, 1.5 and 2.1, respectively).

[Application of European Model of Quality in Oncology]. / Aplicación del Modelo Europeo de Calidad en Oncología.

OBJECTIVES: To assess a Medical Oncology Service using a healthcare setting version of the European Foundation for Quality Management (EFQM). To use this tool as training, an opportunity for participation and the base for checking the strategic planning. MATERIAL AND METHODS: We use the EFQM Model adapted to healthcare centers EFQM as the evaluation instrument. It maintains scores and weights, only modifying vocabulary and simplifying that not relevant to the healthcare setting. Exercise was done with the "proform" system. Its advantage is that it uses standard formulas combined with open areas for discussion and presentation of ideas. It uses group sessions for agreement. STUDY PERIOD: 2001 Management. Evaluation was performed in the second term of 2002. RESULTS: 58 strengths and 37 areas of improvement were identified. These elements were used to create a strategic document, which served as the basis for future improvement. The score reached was used as an internal reference to monitor service quality evolution. CONCLUSIONS: The EFQM model is applicable in a Medical Oncology Service, although it would be desirable to have standardized quality indicators that permit a more objective and specific evaluation.

Aplicación del Modelo Europeo de Calidad en Oncología / Application of European Model of Quality in Oncology

Objetivos. Evaluar un servicio de Oncología Médica mediante el Modelo Europeo de Gestión de la Calidad de la European Foundation for Quality Management (EFQM) adaptado al ámbito sanitario. Utilizar dicha herramienta como aprendizaje, oportunidad para la participación y base para revisar la planificación estratégica. Material y métodos. Se utilizó como instrumento de evaluación el Modelo EFQM adaptado a centros sanitarios, que mantiene las puntuaciones y ponderaciones, modificando únicamente el vocabulario y simplificando aquello que no se estima relevante para dicho ámbito. El ejercicio se realiza mediante el sistema «proforma», cuya ventaja es que utiliza formularios estandarizados combinados con áreas abiertas para la discusión y exposición de ideas. Se utilizan sesiones grupales para la puesta en común y consenso. Período de estudio: gestión del año 2001. Evaluación realizada en el segundo trimestre del año 2002. Resultados. Se identificaron 58 puntos fuertes y 37 oportunidades de mejora, a partir de los cuales se elabora un documento estratégico que sirve de base para discutir las acciones de mejora a implantar. La puntuación alcanzada se toma como referencia interna para monitorizar la evolución de la calidad del servicio. Conclusiones. El modelo EFQM es aplicable a un servicio de Oncología Médica, aunque sería deseable disponer de indicadores de calidad estandarizados que permitan realizar una evaluación más objetiva y específica

Objectives. To assess a Medical Oncology Service using a healthcare setting version of the European Foundation for Quality Management (EFQM). To use this tool as training, an opportunity for participation and the base for checking the strategic planning. Material and methods. We use the EFQM Model adapted to healthcare centers EFQM as the evaluation instrument. It maintains scores and weights, only modifying vocabulary and simplifying that not relevant to the healthcare setting. Exercise was done with the «proform» system. Its advantage is that it uses standard formulas combined with open areas for discussion and presentation of ideas. It uses group sessions for agreement. Study period: 2001 Management. Evaluation was performed in the second term of 2002. Results. 58 strengths and 37 areas of improvement were identified. These elements were used to create a strategic document, which served as the basis for future improvement. The score reached was used as an internal reference to monitor service quality evolution. Conclusions. The EFQM model is applicable in a Medical Oncology Service, although it would be desirable to have standardized quality indicators that permit a more objective and specific evaluation