Análisis de eventos adversos en los servicios de cirugía general y aparato digestivo. Estudio multicéntrico / Analysis of adverse events in general surgery: A multicenter study

Introducción: El conocimiento de los eventos adversos (EA) en los hospitales de agudos es un aspecto de especial relevancia en la seguridad del paciente. Su incidencia oscila entre un 3-17% y la cirugía se relaciona con la aparición de entre un 46-65% de todos los EA. Material y métodos: Se realiza un estudio observacional, descriptivo, retrospectivo y multicéntrico, con la participación de 31 hospitales de agudos españoles, para la determinación y análisis de los EA en los servicios de cirugía general. Resultados: La prevalencia de EA fue del 31,53%. Los tipos de EA más frecuentes fueron de tipo infeccioso (35%). Los pacientes con mayores grados de ASA, mayor complejidad y un tipo de ingreso urgente son factores asociados a la presencia de EA. A la mayoría de los pacientes se les atribuyó una categoría de daño F (daño temporal al paciente que requiera iniciar o prolongar la hospitalización) (58,42%). El 14,69% de los EA son considerados graves. El 34,22% de los EA se consideraron evitables. Conclusiones: La prevalencia de EA en los pacientes de cirugía general y del aparato digestivo (CGAD) es elevada. La mayor parte de los EA fueron de tipo infeccioso. El EA más frecuente fue la infección de herida o sitio quirúrgico. Los pacientes con mayores grados de ASA, mayor complejidad y un tipo de ingreso urgente son factores asociados a la presencia de EA. La mayoría de los EA detectados han supuesto un daño leve o moderado sobre los pacientes. Alrededor de un tercio de EA fueron evitables.(AU)

Introduction: Knowledge of adverse events (AE) in acute care hospitals is a particularly relevant aspect of patient safety. Its incidence ranges from 3% to 17%, and surgery is related to the occurrence of 46%-65% of all AE. Material and methods: An observational, descriptive, retrospective, multicenter study was conducted with the participation of 31 Spanish acute-care hospitals to determine and analyze AE in general surgery services. Results: The prevalence of AE was 31.53%. The most frequent types of AE were infectious (35%). Higher ASA grades, greater complexity and urgent-type admission are factors associated with the presence of AE. The majority of patients (58.42%) were attributed a category F event (temporary harm to the patient requiring initial or prolonged hospitalization); 14.69% of AE were considered severe, while 34.22% of AE were considered preventable. Conclusions: The prevalence of AE in General and GI Surgery (GGIS) patients is high. Most AE were infectious, and the most frequent AE was surgical site infection. Higher ASA grades, greater complexity and urgent-type admission are factors associated with the presence of AE. Most detected AE resulted in mild or moderate harm to the patients. About one-third of AE were preventable.(AU)

Analysis of adverse events in general surgery. Multicenter study.

INTRODUCTION: Knowledge of adverse events (AE) in acute care hospitals is a particularly relevant aspect of patient safety. Its incidence ranges from 3% to 17%, and surgery is related to the occurrence of 46%-65% of all AE. MATERIAL AND METHODS: An observational, descriptive, retrospective, multicenter study was conducted with the participation of 31 Spanish acute-care hospitals to determine and analyze AE in general surgery services. RESULTS: The prevalence of AE was 31.53%. The most frequent types of AE were infectious (35%). Higher ASA grades, greater complexity and urgent-type admission are factors associated with the presence of AE. The majority of patients (58.42%) were attributed a category F event (temporary harm to the patient requiring initial or prolonged hospitalization); 14.69% of AE were considered severe, while 34.22% of AE were considered preventable. CONCLUSIONS: The prevalence of AE in General and GI Surgery (GGIS) patients is high. Most AE were infectious, and the most frequent AE was surgical site infection. Higher ASA grades, greater complexity and urgent-type admission are factors associated with the presence of AE. Most detected AE resulted in mild or moderate harm to the patients. About one-third of AE were preventable.

Predictive Power of the "Trigger Tool" for the detection of adverse events in general surgery: a multicenter observational validation study.

BACKGROUND: In spite of the global implementation of standardized surgical safety checklists and evidence-based practices, general surgery remains associated with a high residual risk of preventable perioperative complications and adverse events. This study was designed to validate the hypothesis that a new "Trigger Tool" represents a sensitive predictor of adverse events in general surgery. METHODS: An observational multicenter validation study was performed among 31 hospitals in Spain. The previously described "Trigger Tool" based on 40 specific triggers was applied to validate the predictive power of predicting adverse events in the perioperative care of surgical patients. A prediction model was used by means of a binary logistic regression analysis. RESULTS: The prevalence of adverse events among a total of 1,132 surgical cases included in this study was 31.53%. The "Trigger Tool" had a sensitivity and specificity of 86.27% and 79.55% respectively for predicting these adverse events. A total of 12 selected triggers of overall 40 triggers were identified for optimizing the predictive power of the "Trigger Tool". CONCLUSIONS: The "Trigger Tool" has a high predictive capacity for predicting adverse events in surgical procedures. We recommend a revision of the original 40 triggers to 12 selected triggers to optimize the predictive power of this tool, which will have to be validated in future studies.

Value-Based Healthcare Project Implementation in a Hierarchical Tertiary Hospital: Lessons Learned.

An important innovation in healthcare is the value-based healthcare (VBHC) framework, a way to solve health services' sustainability problems and ensure continuous improvement of healthcare quality. The Quality and Safety Unit at the Hospital Universitario 12 de Octubre has been since May 2018 coordinating the implementation of several healthcare innovation projects within the paradigm of VBHC. Implementing innovations in a complex institution, such as a tertiary hospital, is a challenge; we present here the lessons learned in the last 4 years of work. We detail exclusively the aspects related to continuous improvement and value addition to the process. In summary, for any VBHC project implementation, we found that there are five main issues: (1) adequate data quality; (2) development of data recording and visualization tools; (3) minimizing healthcare professional's effort to record data; (4) centralize governance, coordination, and transparency policies; (5) managerial's implication and follow-up. We described six steps key to ensure a successful implementation which are the following: testing the feasibility and complexities of the entry process; establishing leadership and coordination of the project; developing patient-reported outcomes and experience measurements; developing and adapting the data recording and data analysis tools; piloting in one or more medical conditions and evaluating the results and project management. The implementation duration can vary depending on the complexity of the Medical Condition Clinical Process and Patient Pathways. However, we estimate that the implementing phase will last a minimum of 18 and a maximum of 24 months. During this period, the institution should be capable of designing and implementing the proposed innovations. The implementation costs vary as well depending on the complexity, ranging from 90,000 euros to 250,000 euros. Implementation problems included the resistance to change of institutions and professionals. To date, there are few successful, published implementations of value-based healthcare. Our quality of care and patient safety methodological approach to the implementation has provided a particular advantage.

Estimation of the Overuse of Preoperative Chest X-rays According to "Choosing Wisely", "No Hacer", and "Essencial" Initiatives: Are They Equally Applicable and Comparable?

BACKGROUND: Overuse reduces the efficiency of healthcare systems and compromises patient safety. Different institutions have issued recommendations on the indication of preoperative chest X-rays, but the degree of compliance with these recommendations is unknown. This study investigates the frequency and characteristics of the inappropriateness of this practice. METHODS: This is a descriptive observational study with analytical components, performed in a tertiary hospital in the Community of Madrid (Spain) between July 2018 and June 2019. The inappropriateness of preoperative chest X-ray tests was analyzed according to "Choosing Wisely", "No Hacer" and "Essencial" initiatives and the cost associated with this practice was estimated in Relative Value and Monetary Units. RESULTS: A total of 3449 preoperative chest X-ray tests were performed during the period of study. In total, 5.4% of them were unjustified according to the "No Hacer" recommendation and 73.3% according to "Choosing Wisely" and "Essencial" criteria, which would be equivalent to 5.6% and 11.8% of the interventions in which this test was unnecessary, respectively. One or more preoperative chest X-ray(s) were indicated in more than 20% of the interventions in which another chest X-ray had already been performed in the previous 3 months. A higher inappropriateness score was also recorded for interventions with an American Society of Anesthesiologists (ASA) grade ≥ III (16.5%). The Anesthesiology service obtained a lower inappropriateness score than other Petitioning Surgical Services (57.5% according to "Choosing Wisely" and "Essencial"; 4.1% according to "No Hacer"). Inappropriate indication of chest X-rays represents an annual cost of EUR 52,122.69 (170.1 Relative Value Units) according to "No Hacer" and EUR 3895.29 (2276.1 Relative Value Units) according to "Choosing Wisely" or "Essencial" criteria. CONCLUSIONS: There was wide variability between the recommendations that directly affected the degree of inappropriateness found, with the main reasons for inappropriateness being duplication of preoperative chest X-rays and the lack of consideration of the particularities of thoracic interventions. This inappropriateness implies a significant expense according to the applicable recommendations and therefore a high opportunity cost.

Impact of the implementation of electronic health records on the quality of discharge summaries and on the coding of hospitalization episodes.

OBJECTIVE: To determine whether the implementation and use of the electronic health records (EHR) modifies the quality, readability and/or the length of the discharge summaries (DS) and the average number of coded diagnosis and procedures per hospitalization episode. DESIGN: A pre-post-intervention descriptive study conducted between 2010 and 2014. SETTING: The 'Hospital Universitario 12 de Octubre' (H12O) of Madrid (Spain). A tertiary University Hospital of up to 1200 beds. INTERVENTION: Implementation and systematic use of the EHR. MAIN OUTCOME MEASURES: The quality, length and readability of the DS and the number of diagnosis and procedures codes by raw and risk-adjusted data. RESULTS: A total of 200 DS were included in the present work. After the implementation of the EHR the DS had better quality per formal requirements, although were longer and harder to read (P < 0.001). The average number of coded diagnoses and procedures was increased, 9.48 in the PRE-INT and 10.77 in the POST-INT, and the difference was statistically significant (P < 0.001) in both raw and risk-adjusted data. CONCLUSIONS: The implementation of EHR improves the formal quality of DS, although poor use of EHR functionalities might reduce its understandability. Having more clinical information immediately available due to EHR increases the number of diagnosis and procedure codes enhancing their utility for secondary uses.

Rendimiento y optimización de la herramienta trigger en la detección de eventos adversos en pacientes adultos hospitalizados / Performance and optimisation of a trigger tool for the detection of adverse events in hospitalised adult patients

Objetivo: Caracterizar el rendimiento de los triggers utilizados en la detección de eventos adversos (EA) de pacientes adultos hospitalizados y definir un panel de triggers simplificado suficientemente sensible y específico, para la detección de EA. Método: Estudio transversal de altas de pacientes de un servicio de medicina interna para la detección de EA mediante revisión sistemática de la historia clínica y la identificación de 41 triggers (evento clínico relacionado frecuentemente con EA), determinando si hubo EA según el contexto en que apareció el trigger. Una vez identificado el EA, se procedió a la caracterización de los triggers que lo detectaron. Se aplicó regresión logística para la selección de los triggers con mayor capacidad de detección de EA. Resultados: Se revisaron 291 historias clínicas y se detectaron 562 triggers en 103 pacientes, de los cuales 163 estuvieron implicados en la detección de un EA. Los triggers que detectaron más EA fueron «A.1. Úlcera por presión» (9,82%), «B.5. Laxante o enema» (8,59%), «A.8. Agitación» (8,59%), «A.9. Sobresedación» (7,98%), «A.7. Hemorragia» (6,75%) y «B.4. Antipsicótico» (6,75%). Se obtuvo un modelo simplificado de triggers que incluyó la variable «Número de fármacos» y los triggers «Sobresedación», «Sondaje», «Reingreso en 30 días», «Laxante o enema» y «Cese brusco de la medicación». Este modelo obtuvo una probabilidad del 81% de clasificar correctamente las historias con EA y sin EA (p <0,001; intervalo de confianza del 95%: 0,763-0,871). Conclusiones: Un número elevado de triggers estuvieron asociados a EA. El modelo resumido permite detectar una gran cantidad de EA con un mínimo de elementos (AU)

Objective: To characterise the performance of the triggers used in the detection of adverse events (AE) of hospitalised adult patients and to define a simplified panel of triggers to facilitate the detection of AE. Method: Cross-sectional study of charts of patients from a service of internal medicine to detect EA through systematic review of the charts and identification of triggers (clinical event often related to AE), determining if there was AE as the context in which it appeared the trigger. Once the EA was detected, we proceeded to the characterization of the triggers that detected it. Logistic regression was applied to select the triggers with greater AE detection capability. Results: A total of 291 charts were reviewed, with a total of 562 triggers in 103 patients, of which 163 were involved in detecting an AE. The triggers that detected the most AE were 'A.1. Pressure ulcer' (9.82%), 'B.5. Laxative or enema' (8.59%), 'A.8. Agitation' (8.59%), 'A.9. Over-sedation' (7.98%), 'A.7. Haemorrhage' (6.75%) and 'B.4. Antipsychotic' (6.75%). A simplified model was obtained using logistic regression, and included the variable 'Number of drugs' and the triggers 'Over-sedation', 'Urinary catheterisation', 'Readmission in 30 days', 'Laxative or enema' and 'Abrupt medication stop'. This model showed a probability of 81% to correctly classify charts with EA or without EA (p <0.001; 95% confidence interval: 0.763-0.871). Conclusions: A high number of triggers were associated with AE. The summary model is capable of detecting a large amount of AE, with a minimum of elements (AU)

[Performance and optimisation of a trigger tool for the detection of adverse events in hospitalised adult patients]. / Rendimiento y optimización de la herramienta trigger en la detección de eventos adversos en pacientes adultos hospitalizados.

OBJECTIVE: To characterise the performance of the triggers used in the detection of adverse events (AE) of hospitalised adult patients and to define a simplified panel of triggers to facilitate the detection of AE. METHOD: Cross-sectional study of charts of patients from a service of internal medicine to detect EA through systematic review of the charts and identification of triggers (clinical event often related to AE), determining if there was AE as the context in which it appeared the trigger. Once the EA was detected, we proceeded to the characterization of the triggers that detected it. Logistic regression was applied to select the triggers with greater AE detection capability. RESULTS: A total of 291 charts were reviewed, with a total of 562 triggers in 103 patients, of which 163 were involved in detecting an AE. The triggers that detected the most AE were "A.1. Pressure ulcer" (9.82%), "B.5. Laxative or enema" (8.59%), "A.8. Agitation" (8.59%), "A.9. Over-sedation" (7.98%), "A.7. Haemorrhage" (6.75%) and "B.4. Antipsychotic" (6.75%). A simplified model was obtained using logistic regression, and included the variable "Number of drugs" and the triggers "Over-sedation", "Urinary catheterisation", "Readmission in 30 days", "Laxative or enema" and "Abrupt medication stop". This model showed a probability of 81% to correctly classify charts with EA or without EA (p <0.001; 95% confidence interval: 0.763-0.871). CONCLUSIONS: A high number of triggers were associated with AE. The summary model is capable of detecting a large amount of AE, with a minimum of elements.

Detección de efectos adversos en cirugía general mediante la aplicación de la metodología «Trigger Tool» / Detection of adverse events in general surgery using the « Trigger Tool» methodology

INTRODUCCIÓN: La cirugía supone una de las áreas de alto riesgo para la aparición de efectos adversos (EA). El objetivo de este estudio es conocer el porcentaje de EA en hospitalización que se detectan mediante la metodología «Global Trigger Tool» en pacientes de cirugía general, las características de los mismos y la validez de la herramienta. MATERIAL Y MÉTODOS: Estudio retrospectivo, observacional y descriptivo sobre pacientes ingresados en cirugía general de un hospital de tercer nivel, sometidos a intervención quirúrgica durante el año 2012. La identificación de EA se lleva a cabo mediante una revisión de historias clínicas empleando una adaptación de la metodología «Global Trigger Tool» Una vez identificado el EA, se le asignó una categoría de daño y se determinó el grado en el que este podría haber sido evitado así como su relación con el procedimiento quirúrgico. RESULTADOS: La prevalencia de EA fue de 36,8%. Con un número de EA por paciente de 0,5. El 56,2% se consideraron evitables. Y un 69,3% se relacionaron directamente con el procedimiento quirúrgico. La herramienta demostró una sensibilidad del 86% y una especificidad del 93,6%. El valor predictivo positivo fue de 89%, el valor predictivo negativo de 92%. CONCLUSIONES: La prevalencia de EA es más alta de lo estimado en otros estudios. La mayoría de los EA detectados están relacionados con el procedimiento quirúrgico, y más de la mitad son evitables. La metodología «Global Trigger Tool» adaptada ha demostrado ser altamente eficaz y eficiente para la detección de EA en cirugía, identificando todos los EA graves y con pocos falsos negativos

INTRODUCTION: Surgery is one of the high-risk areas for the occurrence of adverse events (AE). The purpose of this study is to know the percentage of hospitalisation-related AE that are detected by the «Global Trigger Tool» methodology in surgical patients, their characteristics and the tool validity. MATERIAL AND METHODS: Retrospective, observational study on patients admitted to a general surgery department, who underwent a surgical operation in a third level hospital during the year 2012. The identification of AE was carried out by patient record review using an adaptation of «Global Trigger Tool» methodology. Once an AE was identified, a harm category was assigned, including the grade in which the AE could have been avoided and its relation with the surgical procedure. RESULTS: The prevalence of AE was 36,8%. There were 0,5 AE per patient. 56,2% were deemed preventable. 69,3% were directly related to the surgical procedure. The tool had a sensitivity of 86% and a specificity of 93,6%. The positive predictive value was 89% and the negative predictive value 92%. CONCLUSIONS: Prevalence of AE is greater than the estimate of other studies. In most cases the AE detected were related to the surgical procedure and more than half were also preventable. The adapted «Global Trigger Tool» methodology has demonstrated to be highly effective and efficient for detecting AE in surgical patients, identifying all the serious AE with few false negative results

Detection of adverse events in general surgery using the " Trigger Tool" methodology.

INTRODUCTION: Surgery is one of the high-risk areas for the occurrence of adverse events (AE). The purpose of this study is to know the percentage of hospitalisation-related AE that are detected by the «Global Trigger Tool¼ methodology in surgical patients, their characteristics and the tool validity. MATERIAL AND METHODS: Retrospective, observational study on patients admitted to a general surgery department, who underwent a surgical operation in a third level hospital during the year 2012. The identification of AE was carried out by patient record review using an adaptation of «Global Trigger Tool¼ methodology. Once an AE was identified, a harm category was assigned, including the grade in which the AE could have been avoided and its relation with the surgical procedure. RESULTS: The prevalence of AE was 36,8%. There were 0,5 AE per patient. 56,2% were deemed preventable. 69,3% were directly related to the surgical procedure. The tool had a sensitivity of 86% and a specificity of 93,6%. The positive predictive value was 89% and the negative predictive value 92%. CONCLUSIONS: Prevalence of AE is greater than the estimate of other studies. In most cases the AE detected were related to the surgical procedure and more than half were also preventable. The adapted «Global Trigger Tool¼ methodology has demonstrated to be highly effective and efficient for detecting AE in surgical patients, identifying all the serious AE with few false negative results.

Análisis de la calidad asistencial en el tratamiento quirúrgico del cáncer colorrectal. Estudio de ámbito nacional. Resultados del seguimiento / Analysis of the quality of care in surgical treatment of colorectal cancer: National study. Follow-up results

OBJETIVOS: Tomando como referencia la casuística del «Estudio sobre la calidad asistencial en el cáncer colorrectal», llevado a cabo por la Asociación Española de Cirujanos en el año 2008, se analiza el seguimiento de los pacientes. MÉTODO: Estudio multicéntrico, descriptivo, prospectivo y longitudinal de pacientes intervenidos de forma programada por cáncer colorrectal (CCR). Han participado 35 hospitales, aportando 334 pacientes. Se han recogido datos del seguimiento: supervivencia, recidivas y complicaciones. RESULTADOS: Seguimiento medio 28,61 ± 11,32 meses. Seguimiento por Cirugía General 69,2%, recidiva tumoral fue del 23,6%, el 83,3% sistémica; el 28,2% fue sometido a cirugía de rescate. La supervivencia global fue del 76,6% y la supervivencia libre de enfermedad del 65,6% (26,49 ± 11,90 meses). La mortalidad relativa fue del 12,6%. El porcentaje de eventraciones fue del 5,8% y la obstrucción intestinal del 3,5%. CONCLUSIONES: El nivel de calidad y los resultados del seguimiento de los pacientes intervenidos por CCR en España son similares a los observados en la literatura internacional. Existen áreas de mejora seguimiento, diagnóstico más temprano, aumentar tratamientos adyuvantes y neoadyuvantes y establecer la escisión total del mesorrecto como cirugía estándar en cáncer de recto

OBJECTIVES: Using the cases included in the study on the quality of care in colorectal cancer conducted by the Spanish Association of Surgeons in 2008, we present follow-up data. METHOD: Multicenter, descriptive, longitudinal and prospective study of patients operated on a scheduled basis for colorectal cancer. 35 hospitals have contributed data on 334 patients. Follow-up data included: survival, recurrence and complications. RESULTS: Mean follow-up was 28.61±11.32 months. Follow-up by the surgeon was 69.2%, tumor recurrence was 23.6%, in 83.3% it was systemic; and 28.2% underwent salvage surgery. Overall survival was 76.6%, disease-free survival 65.6% (26.49 ± 11.90 months). Tumor related mortality was 12.6%. Percentage of ventral hernias was 5.8% and intestinal obstruction was 3.5%. CONCLUSIONS: Quality and results of follow-up of patients operated on for CRC in Spain are similar to those reported in the scientific literature. Areas for improvement included: follow-up, earlier diagnosis, increased adjuvant and neoadjuvant treatments and total mesorectal excision as standard surgery for rectal cancer

Analysis of the quality of care in surgical treatment of colorectal cancer: national study. Follow-up results.

OBJECTIVES: Using the cases included in the Study on the quality of care in colorectal cancer conducted by the Spanish Association of Surgeons in 2008, we present follow-up data. METHOD: Multicenter, descriptive, longitudinal and prospective study of patients operated on a scheduled basis of colorectal cancer. 35 hospitals have contributed data on 334 patients. Follow-up data: survival, recurrence and complications. RESULTS: Mean follow-up was 28.61±11.32 months. Follow-up by surgeon: 69.2%, tumor recurrence 23.6%, in 83.3% it was systemic; 28.2% underwent salvage surgery. Overall survival was 76.6%, disease-free survival 65.6% (26.49±11.90 months). Tumor related mortality was 12,6%. Percentage of ventral hernias was 5.8%, intestinal obstruction 3.5%. CONCLUSIONS: Quality and results of follow-up of patients operated on for CRC in Spain are similar to those reported in the Scientific literature. Areas for improvement: follow-up, earlier diagnosis, increase adjuvant and neoadjuvant treatments and total mesorectal excision as standard surgery for rectal cancer.

Assessment of a rapid referral pathway for suspected colorectal cancer in Madrid.

OBJECTIVE: To assess the results achieved with a rapid referral pathway for suspected colorectal cancer (CRC), comparing with the standard referral pathway. METHODS: Three-year audit of patients suspected of having CRC routed via a rapid referral pathway, and patients with CRC routed via the standard referral pathway of a health care district serving a population of 498,000 in Madrid (Spain). Outcomes included referral criteria met, waiting times, cancer diagnosed and stage of disease. RESULTS: Two hundred and seventy-two patients (mean age 68.8 years, SD 14.0; 51% male) were routed via the rapid referral pathway for colonoscopy. Seventy-nine per cent of referrals fulfilled the criteria for high risk of CRC. Fifty-two cancers were diagnosed: 26% Stage A (Astler-Coller), 36% Stage B, 24% Stage C and 14% Stage D. Average waiting time to colonoscopy for the rapid referral patients was 18.5 days (SD 19.1) and average waiting time to surgery was 28.6 days (SD 23.9). Colonoscopy was performed within 15 days in 65% of CRC rapid referral patients compared to 43% of standard pathway patients (P = 0.004). Overall waiting time for patients with CRC in the rapid referral pathway was 52.7 days (SD 32.9); while for those in the standard pathway, it was 71.5 days (SD 57.4) (P = 0.002). Twenty-six per cent Stage A CRC was diagnosed in the rapid referral pathway compared to 12% in the standard pathway (P < 0.001). CONCLUSION: The rapid referral pathway reduced waiting time to colonoscopy and overall waiting time to final treatment and appears to be an effective strategy for diagnosing CRC in its early stages.

Análisis de la calidad asistencial del tratamiento quirúrgico del cáncer colorrectal en 2008. Estudio de ámbito nacional / Analysis of the quality of surgical treatment of colorectal cancer, in 2008. A national study

Objectivos: Estudio de ámbito nacional realizado por la Asociación Española de Cirujanos con el objetivo de analizar el tratamiento quirúrgico del cáncer colorrectal (CCR) en España y compararlo con la bibliografía. Material y métodos: Estudio multicéntrico descriptivo, prospectivo y longitudinal de pacientes intervenidos quirúrgicamente de forma programada por CCR. Han participado 50 hospitales de 15 comunidades autónomas aportando 496 casos intervenidos en 2008. Se han recogido 88 variables. Resultados: Mediana de edad 72 años, aumento de pacientes ASA III, preoperatorio correcto, en el recto un 4% sin estatificar. Tendencia a no realizar preparación del colon o a hacerlo únicamente un día. Los porcentajes de complicaciones están en rangos de la bibliografía excepto infección de herida quirúrgica (19%). Media de ganglios resecados: 13,2; 4,3% no resección mesorrectal. Anastomosis mecánicas: 80,8%, 65,9% de las intervenciones realizadas por cirujano colorrectal, Radioterapia preoperatoria en cáncer de recto 43,5%. Quimioterapia 32,9%. Laparoscopia: 35,1% de los casos, índice de conversión 13,8%. Uso de antibióticos: 37,1%, transfusión sanguínea: 20,6% y nutrición parenteral: 26,5%. Conclusiones: El tratamiento quirúrgico del CCR en España tiene un nivel de calidad y unos resultados perioperatorios similares al resto de Europa. Respecto a estudios previos, se observan avances en la preparación del paciente, estudio preoperatorio, técnicas de imagen y mejoras en técnica quirúrgica con adopción de escisión del mesorrecto, linfadenectomías adecuadas y preservación de esfínteres. Existen áreas de mejora como disminución de la infección de la herida quirúrgica, mayor uso de estomas de protección, uso adecuado de antibióticos, nutrición parenteral o neoadyuvancia y colonoscopias completas (AU)

Objective: A national study conducted for the Spanish Association of Surgeons with the aim of analysing the surgical treatment of colorectal cancer (CRC) in Spain and to compare it with scientific literature. Material and methods: A multicentre, descriptive, prospective and longitudinal study of patients with CRC who were treated by elective surgery. A total of 50 hospitals in 15 Autonomous Regions took part, with 496 treated cases in 2008. A total of 88 variables were collected. Results: The median age was 72 years, increase in ASA III patients; correct preoperative studies, 4% with no staging in the rectum. There was a tendency not to use the colon cleansing or to do it only one day. The percentage of complications is within the ranges in the literature, with the exception of surgical wound infections (19%). Mean of resected lymph nodes: 13.2; 4.3% no mesorectal resection. Mechanical anastomosis: 80.8%, 65.9% of the operations performed by a colorectal surgeon. Preoperative radiotherapy in 43.5% of rectal cancers. Chemotherapy: 32.9%. Laparoscopy: 35.1% of cases, conversion rate 13.8%. Use of antibiotics: 37.1%, blood transfusion: 20.6% and parenteral nutrition: 26.5%. Conclusions: Surgical treatment of CRC in Spain has a level of quality and peri-operative results similar to the rest of Europe. Compared to previous studies, it was observed that there were advances in preparation of the patient, preoperative studies, imaging techniques, and improvements in surgical techniques with adoption of mesorectal excision, appropriate lymphadenectomies and preservation of sphincters There are areas for improvement, such as a reduction in surgical wound infections, increase use of protective stoma, appropriate use of antibiotics, parenteral nutrition or neoadjuvants and complete colonoscopies (AU)

[Analysis of the quality of surgical treatment of colorectal cancer, in 2008. A national study]. / Análisis de la calidad asistencial del tratamiento quirúrgico del cáncer colorrectal en 2008. Estudio de ámbito nacional.

OBJECTIVE: A national study conducted for the Spanish Association of Surgeons with the aim of analysing the surgical treatment of colorectal cancer (CRC) in Spain and to compare it with scientific literature. MATERIAL AND METHODS: A multicentre, descriptive, prospective and longitudinal study of patients with CRC who were treated by elective surgery. A total of 50 hospitals in 15 Autonomous Regions took part, with 496 treated cases in 2008. A total of 88 variables were collected. RESULTS: The median age was 72 years, increase in ASA III patients; correct preoperative studies, 4% with no staging in the rectum. There was a tendency not to use the colon cleansing or to do it only one day. The percentage of complications is within the ranges in the literature, with the exception of surgical wound infections (19%). Mean of resected lymph nodes: 13.2; 4.3% no mesorectal resection. Mechanical anastomosis: 80.8%, 65.9% of the operations performed by a colorectal surgeon. Preoperative radiotherapy in 43.5% of rectal cancers. Chemotherapy: 32.9%. Laparoscopy: 35.1% of cases, conversion rate 13.8%. Use of antibiotics: 37.1%, blood transfusion: 20.6% and parenteral nutrition: 26.5%. CONCLUSIONS: Surgical treatment of CRC in Spain has a level of quality and peri-operative results similar to the rest of Europe. Compared to previous studies, it was observed that there were advances in preparation of the patient, preoperative studies, imaging techniques, and improvements in surgical techniques with adoption of mesorectal excision, appropriate lymphadenectomies and preservation of sphincters. There are areas for improvement, such as a reduction in surgical wound infections, increase use of protective stoma, appropriate use of antibiotics, parenteral nutrition or neoadjuvants and complete colonoscopies.

Guías y vías clínicas, ¿existe realmente diferencia? / Guidelines and clinical pathways. Is there really a difference?

Las actividades de diseño de la calidad de guías de práctica clínica (GPC) o protocolos y vías clínicas (VC) comprenden aquellos planes asistenciales previstos para los pacientes con una determinada enfermedad. Se deben basar en la evidencia científica, en el análisis del proceso y en el consenso de los profesionales que participan en la atención del paciente. Es habitual cuando se plantea a los profesionales de la cirugía introducirse en esta problemática que afirmen que no entienden cuál es la diferencia entre VC y protocolos o GPC. De hecho, estamos hablando de actividades de diseño de calidad con los mismos objetivos de disminuir la variabilidad injustificada y ayudar en la toma de decisiones sobre un problema clínico concreto. En este trabajo vamos a tratar de establecer diferencias y definir qué se entiende por VC y por protocolo o GPC (AU)

Quality Design Activities of Good Clinical Practice guidelines or protocols and clinical pathways (CP) include those clinical plans intended for the patients with a particular disease. They must be based on the clinical evidence, the analysis of the process, and the consensus of the professionals involved in the care of the patient. When these are introduced to surgical professionals, they usually say that they do not understand the the difference between CP and protocols or guidelines. In fact we are speaking quality design activities with the same objectives of decreasing the unjustified variability and helping in the decision making on a specific clinical problem. In this work we attempt to show the differences by defining what is understood by a clinical pathway and protocol or guideline (AU)

[Guidelines and clinical pathways. Is there really a difference?]. / Guías y vías clínicas, ¿existe realmente diferencia?

Quality Design Activities of Good Clinical Practice guidelines or protocols and clinical pathways (CP) include those clinical plans intended for the patients with a particular disease. They must be based on the clinical evidence, the analysis of the process, and the consensus of the professionals involved in the care of the patient. When these are introduced to surgical professionals, they usually say that they do not understand the the difference between CP and protocols or guidelines. In fact we are speaking quality design activities with the same objectives of decreasing the unjustified variability and helping in the decision making on a specific clinical problem. In this work we attempt to show the differences by defining what is understood by a clinical pathway and protocol or guideline.

[Adverse events in general and digestive surgery departments in Spanish hospitals]. / Sucesos adversos en cirugía general y de aparato digestivo en los hospitales españoles.

OBJECTIVE: To determine the incidence of patients with adverse events (AE) in Spanish general surgery units, describe the immediate causes of AE, identify avoidable AE, and determine the impact of these events. MATERIAL AND METHOD: We performed a retrospective cohort study of a randomized stratified sample of 24 hospitals. Six of the hospitals were small (fewer than 200 beds), 13 were medium-sized (between 200 and 499 beds) and five were large (500 or more beds). Patients admitted for more than 24 hours to the selected hospitals and who were discharged between the 4th and 10th of June 2005 were included. AE detected during hospitalization and those occurring as a consequence of previous admissions in the same hospital were analyzed. RESULTS: The incidence of patients with AE associated with medical care was 10.5% (76/735; 95%CI: 8.1%-12.5%). The presence of intrinsic risk factors increased the risk of AE (14.8% vs 7.2%; P=.001). Likewise, 16.2% of patients with an extrinsic risk factor had an AE compared with 7.0% of those without these risk factors (P< .001). Comorbidity influenced the occurrence of AE (33.7% of AE vs. 2.2% without comorbidity; P< .001). The severity of the AE was related to ASA risk (P=.036). AE were related to nosocomial infection (41.7%), procedures (27.1%) and medication (24%). A total of 31.3% of the AE were mild, 39.6% were moderate, and 29.2% were severe. Preventable AE accounted for 36.5%. AE caused an additional 527 days of stay (6.3 additional days of stay per patient), of which 216 were due to preventable AE. CONCLUSIONS: Patients in general and digestive surgery units have an increased risk of AE. Risk factors for these events are age, comorbidity, and the use of external devices. A substantial number of AE are related to nosocomial infection (especially surgical wound infection) and to surgical procedures. AE have an important impact on patients and a considerable proportion of these events are preventable. AE have strong health, social and economic repercussions and until recently have constituted a silent epidemic in Spain. Consequently, study of these events should be a public health priority.

Cuidados al final de la vida en la unidad de cuidados intensivos pediátricos. Empleo de técnicas de investigación cualitativa para el análisis del afrontamiento de la muerte y situaciones críticas / End-of-life care in the pediatric intensive care unit. Use of qualitative research techniques for analyzing coping with death and critical situations

Fundamento: En la última década, se aprecia un creciente interés por los aspectos más humanos de la enfermedad que se traduce en un acercamiento a la familia y a su sufrimiento. Objetivo: Conocer en profundidad la experiencia de los profesionales y de los padres de niños ingresados en la unidad de cuidados intensivos pediátricos (UCIP). Material y métodos: Se organizaron grupos focales (GF) de padres de hijos fallecidos o con secuelas graves ingresados en la UCIP los años 1999-2002. Asimismo, se desarrollaron reuniones de GF de profesionales. Se revisó desde el ingreso hasta la muerte y el seguimiento del duelo. Se recogieron las inquietudes y las necesidades expresadas por el personal sanitario. Resultados: Se contactó con 133 familias (40% de hijos fallecidos y 60% de hijos con secuelas), de los que acudieron un 75% y un 44%, respectivamente. Las madres acudieron más (61%) en el caso de fallecidos, y las parejas (51%), en el caso de niños con secuelas. Asimismo, se organizaron GF con 22 personas (5 médicos, 11 enfermeras y 5 auxiliares de enfermería). Se recogieron los principales problemas, discrepancias y soluciones. Se instauraron medidas de mejora acordes con la información recibida. Conclusiones: La aplicación de GF ha permitido el acercamiento a las necesidades y problemas más importantes de los padres de niños que ingresan en la UCIP, así como de los profesionales. Esta información ha facilitado la implantación de medidas de mejora de una forma realista y ajustada a estas necesidades

Background: In the last 10 years, there has been increasing concern for a more human approach to illness, which has led to a better understanding of families and their suffering. Objective: To gain greater insight into the experience of the parents of children admitted to the PICU and of the health workers in these units. Material and methods: Focus groups (FG) composed of parents with children who had died or who were having serious sequels were organized in the PICU from 1999-2002. Likewise, FG meetings with health professionals were set up. The period from admission to death and support for grieving families were reviewed. At the same time, the concerns and needs mentioned by health professionals were collected. Results: A total of 133 families were contacted by surface mail (40% had children who had died and 60% had children with sequels who survived); of these, 75% of the families in the first group and 44% of those in the second group attended the FG. Attendance by mothers (61%) was more frequent in the case of death, and attendance by couples (51%) was more frequent in children with sequels. Focus groups were organized with 22 health professionals (five physicians, 11 nurses and five nurses' aids). The main problems, discrepancies and solutions identified by the distinct groups were recorded. Improvement measures were implemented according to the available information. Conclusions: The use of FG allowed us to approach to the most important needs and problems of parents with children admitted to the PICU, as well as those of the heath workers in the unit. This information allowed improvement measures adjusted to these needs to be implemented in a realistic manner