Implementación del sistema triaje en los hospitales públicos de la Provincia de Buenos Aires / Triage System Implementation in Public Hospitals of Buenos Aires Province

RESUMEN INTRODUCCIÓN El objetivo de este informe fue describir las acciones realizadas para la ejecución del Plan Integral de Guardias Hospitalarias (PIGH) y compartir los principales resultados sanitarios que se desprenden del Sistema TRIAGE implementado. MÉTODOS El PIGH se constituyó como uno de los objetivos más importantes de la gestión de Gobierno y se ejecutó exitosamente durante 2017-2019 en 58 hospitales públicos dependientes del Ministerio de Salud de la Provincia de Buenos Aires. Se establecieron alianzas estratégicas inter e intraministeriales con actores clave, que posibilitaron su concreción. Diferentes fases fueron necesarias para implementar el PIGH, y el corazón del proceso fue el Sistema TRIAGE. RESULTADOS El triaje categoriza según nivel de criticidad a pacientes que requieren asistencia. Es un recurso ineludible para optimizar los servicios de emergencias, reduciendo la vulnerabilidad de pacientes en situaciones de riesgo, agilizando la capacidad de los trabajadores y promoviendo una mejor comunicación integrada entre todos los usuarios del sistema. DISCUSIÓN El dato de producción más relevante que se desprende del sistema implementado es que casi el 90% de los pacientes resultaron ser código verde, es decir, no poseen riesgo de vida. Por primera vez esta cartera cuenta con una caracterización formal e inmediata de los usuarios de las guardias.

ABSTRACT INTRODUCTION The purpose of this report was to describe the actions taken to execute the Comprehensive Hospital Emergency Room Plan (PIGH, for its acronym in Spanish) and to share the main health results from the implemented TRIAGE system. METHODS The PIGH was set as one of the main government objectives and was successfully applied during 2017 to 2019 in 58 public hospitals belonging to the Ministry of Health of Buenos Aires Province. Intra- and interministerial strategic alliances with key actors were established and made it possible to carry out the plan. Different phases were necessary to implement the PIGH, with the TRIAGE system being the heart of the process. RESULTS triage classifies patients requiring assistance by level of criticality. This resource optimizes the emergency room services, reducing the vulnerability of the patients in risky situations, improving workers' capacity and promoting a better communication between all system users. DISCUSSION The most relevant information coming from the implementation of this system is that almost 90% of the patients were green code, which means that they are not in life risk. For the first time this Ministry has a formal and immediate characterization of emergency room users.

Intensive care treatments associated with favorable discharge outcomes in Argentine children with severe traumatic brain injury: For the South American Guideline Adherence Group.

OBJECTIVE: Little is known about the critical care management of children with traumatic brain injury (TBI) in low middle income countries. We aimed to identify indicators of intensive care unit (ICU) treatments associated with favorable outcomes in Argentine children with severe TBI. METHODS: We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with severe TBI who were admitted to an ICU in one of the seven study centers. Severe TBI was defined by head AIS ≥ 3, head CT with traumatic lesion, and admission GCS < 9. Seven indicators of best practice TBI care were examined. The primary outcome was discharge Pediatric Cerebral Performance Category Scale [PCPC] and Pediatric Overall Performance category Scale [POPC]. We also examined variation in ICU care and in-patient mortality. RESULTS: Of the 117 children, 67% were male and 7.5 (4.3) years on average, 92% had isolated TBI. Hypotension (54%) was more common than hypoxia (28%) and clinical or radiographic signs of high intracranial pressure (ICP) were observed in 92%. Yet, ICP monitoring occurred in 60% and hyperosmolar therapy was used in only 36%. Adherence to indicators of best TBI practice ranged from 55.6% to 83.7% across the seven centers and adherence was associated with favorable discharge PCPC (aRR 0.98; 95% CI [0.96, 0.99]), and POPC (aRR 0.98; 95% CI [0.96, 0.99]). Compared to patients whose adherence rates were below 65%, patients whose adherence rates were higher between 75%-100% had better discharge PCPC (aRR 0.28; 95% CI [0.10, 0.83]) and POPC (aRR 0.32; 95% CI [0.15, 0.73]. Two indicators were associated with favorable discharge PCPC: Avoidance of hypoxia (aRR 0.46; 95% CI [0.23, 0.93]), and Nutrition started in 72 hours (aRR 0.45; 95% CI [0.21, 0.99]). Avoiding hypoxia was also associated with favorable discharge POPC (aRR 0.47; 95% CI [0.22, 0.99]). CONCLUSION: There is variation in Argentine ICU practice in the care of children with severe TBI. Second insults are common and hyperosmolar therapy use is uncommon. Adherence to best practice TBI care by avoiding hypoxia and providing timely nutrition were associated with significantly favorable discharge outcomes. Implementing strategies that prevent hypoxia and facilitate early nutrition in the ICUs are urgently needed to improve pediatric TBI outcomes.

Benchmarking Prehospital and Emergency Department Care for Argentine Children with Traumatic Brain Injury: For the South American Guideline Adherence Group.

OBJECTIVE: There is little information on the type of early care provided to children with traumatic brain injury (TBI) in low middle income countries. We benchmarked early prehospital [PH] and emergency department [ED] pediatric TBI care in Argentina. METHODS: We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with TBI. Eligible participants were patients 0-18 years, and had diagnosis of TBI (admission Glasgow Coma scale score [GCS] < 13 or with GCS 14-15 and abnormal head CT scan within 48 hours of admission, and head AIS > 0). Outcomes were transport type, transport time, PH and ED adherence to best practice, and discharge Pediatric Cerebral Performance Category Scale (PCPC) and Pediatric Overall Performance category Scale (POPC). RESULTS: Of the 366 children, mean age was 8.7 (5.0) years, 58% were male, 90% had isolated TBI and 45.4% were transported by private vehicle. 50 (34.7%) of the 144 children with severe TBI (39.3% of all TBI patients) were transported by private vehicle. Most (267; 73%) patients received initial TBI care at an index hospital prior to study center admission, including children with severe (81.9%) TBI. Transport times were shorter for those patients who were directly transported by ambulance to study center than for the whole cohort (1.4 vs.5.5 hours). Ambulance blood pressure data were recorded in 30.9%. ED guideline adherence rate was higher than PH guideline adherence rate (84.8% vs. 26.4%). For patients directly transferred from scene to study trauma centers, longer transport time was associated with worse discharge outcome (PCPC aOR 1.10 [1.04, 1.18] and (POPC aOR 1.10 [1.04, 1.18]). There was no relationship between PH or ED TBI guideline adherence rate and discharge POPC and PCPC. CONCLUSION: This study benchmarks early pediatric TBI care in Argentina and shows that many critically injured children with TBI do not receive timely or best practice PH care, that PH guideline adherence rate is low and that longer transport time was associated with poor discharge outcomes for patients with direct transfer status. There is an urgent need to improve the early care of children with TBI in Argentina, especially timely transportation to a hospital.

Postdischarge Care of Pediatric Traumatic Brain Injury in Argentina: A Multicenter Randomized Controlled Trial.

OBJECTIVE: To develop, in partnership with families of children with traumatic brain injury, a postdischarge intervention that is effective, simple, and sustainable. DESIGN: Randomized Controlled Trial. SETTING: Seven Level 1 Pediatric Trauma Centers in Argentina. PATIENTS: Persons less than 19 years of age admitted to one of the study hospitals with a diagnosis of severe, moderate, or complicated mild traumatic brain injury and were discharged alive. INTERVENTIONS: Patients were randomly assigned to either the intervention or standard care group. A specially trained Community Resource Coordinator was assigned to each family in the intervention group. We hypothesized that children with severe, moderate, and complicated mild traumatic brain injury who received the intervention would have significantly better functional outcomes at 6 months post discharge than those who received standard care. We further hypothesized that there would be a direct correlation between patient outcome and measures of family function. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was a composite measured at 6 months post injury. There were 308 patients included in the study (61% men). Forty-four percent sustained a complicated mild traumatic brain injury, 18% moderate, and 38% severe. Sixty-five percent of the patients were 8 years old or younger, and over 70% were transported to the hospital without ambulance assistance. There was no significant difference between groups on the primary outcome measure. There was a statistically significant correlation between the primary outcome measure and the scores on the Family Impact Module of the Pediatric Quality of Life Inventory (ρ = 0.57; p < 0.0001). Children with better outcomes lived with families reporting better function at 6 months post injury. CONCLUSIONS: Although no significant effect of the intervention was demonstrated, this study represents the first conducted in Latin America that documents the complete course of treatment for pediatric patients with traumatic brain injury spanning hospital transport through hospital care and into the postdischarge setting.

Utilidad de la procalcitonina y proteina C reactiva en la unidad de terapia intensiva pediatrica / Utility of procalcitonin and C-reactive protein in pediatric intensive care unit / Utilidade da procalcitonina e proteína C-reativa na unidade de terapia intensiva pediátrica

El objetivo de este trabajo fue evaluar la utilidad de la Procalcitonina (PCT) y Proteina C Reactiva (PCR) en pacientes pediatricos con sospecha de infeccion bacteriana o sepsis al ingreso a la Unidad de Terapia Intensiva Pediatrica (UTIP) y posterior seguimiento como pronostico de internacion prolongada o muerte en un hospital de tercer nivel. Se realizo un estudio prospectivo observacional, unicentrico. Punto final primario: se considero un punto final combinado de muerte hospitalaria o internacion prolongada en la UTIP (mayor de 12 dias). Se dosaron Procalcitonina (VIDASR BRAHMS PCT) y PCR (Ensayo turbidimetrico BT 3000) al ingreso y al tercer dia de internacion y se calculo el aclaramiento de ambos marcadores. De 41 pacientes, 24 (58%) fallecieron o tuvieron internacion prolongada. El aclaramiento de PCT y PCR al tercer dia se asocio significativamente con menos mortalidad y menos dias de Internacion en UTIP (p=0,01 para PCT; p=0,0036 para PCR). El area bajo la curva ROC de PCR fue 0,773 y de PCT 0,735, sin diferencias significativas entre ambas curvas, No hubo diferencias significativas entre los dos grupos para los valores al ingreso de PCT y PCR (p=0,82 y p=0,95 respectivamente). Se concluye que los valores del aclaramiento de ambos marcadores pueden ser una herramienta util para el pronostico clinico.

The aim of the present work was to evaluate the usefulness of procalcitonin and C-reactive protein in pediatric patients with suspected bacterial infection or sepsis on admission to the Pediatric Intensive Care Unit (PICU) and subsequent monitoring and prognosis of prolonged hospitalization or death in a third level hospital. A prospective observational, single center study was performed and a combined endpoint of hospital death or prolonged hospitalization in the PICU (over 12 days) was considered as primary end point. Values of Procalcitonin (VIDAS ® BRAHMS PCT) and PCR (BT turbidimetric 3000) were obtained on admission and on the third day of hospitalization and clearance of both markers was calculated. Out of 41 patients, 24 (58%) died or had prolonged hospitalization. PCT and CRP clearance on the third day was significantly associated with lower mortality and shorter hospital stays in PICU (p=0.01 for PCT, p=0.0036 for PCR). The area under the ROC curve was 0.773 for CRP and PCT was 0.735, with no significant difference between both curves. No significant differences were observed between both groups for the PCT and CRP values at admission (p=0,82 and p=0,95 respectively). It can be concluded that clearance values of both markers can be a useful tool for clinical prognosis.

O objetivo de avaliar a utilidade da Procalcitonina e Proteína C-Reativa em pacientes pediátricos com suspeita de infecção bacteriana ou sepse na admissão na Unidade de Terapia Intensiva Pediátrica (UTIP) e posterior acompanhamento e prognóstico de hospitalização prolongada ou morte em um hospital de terceiro nível. Foi realizado um estudo prospectivo observacional, único centro. Ponto final primário: foi considerado um ponto final combinado de óbito hospitalar ou hospitalização prolongada na UTIP (mais de 12 dias). Foi dosada Procalcitonina (VIDAS ® BRAHMS PCT) e PCR (ensaio turbidimétrico BT 3000) na admissão e no terceiro dia de internação e foi calculado como se aclararam ambos os marcadores. Dos 41 pacientes, 24 (58%) morreram ou tiveram internação prolongada. A aclaração do PCT e PCR no terceiro dia foi significativamente associado a menor mortalidade e menor tempo de internação em UTI (p=0,01 para PCT, p=0,0036 para PCR). A área sob a curva ROC foi de 0,773 para PCR e PCT foi 0,735, sem diferença significativa entre as duas curvas. Não houve diferença significativa entre os dois grupos para os valores de PCT e renda PCR (p=0,82 e p=0,95 respectivamente). Concluiu-se que os valores de aclaração de ambos os marcadores podem ser uma ferramenta útil para o prognóstico clínico.

Utilidad de la procalcitonina y proteina C reactiva en la unidad de terapia intensiva pediatrica / Utility of procalcitonin and C-reactive protein in pediatric intensive care unit / Utilidade da procalcitonina e proteína C-reativa na unidade de terapia intensiva pediátrica

El objetivo de este trabajo fue evaluar la utilidad de la Procalcitonina (PCT) y Proteina C Reactiva (PCR) en pacientes pediatricos con sospecha de infeccion bacteriana o sepsis al ingreso a la Unidad de Terapia Intensiva Pediatrica (UTIP) y posterior seguimiento como pronostico de internacion prolongada o muerte en un hospital de tercer nivel. Se realizo un estudio prospectivo observacional, unicentrico. Punto final primario: se considero un punto final combinado de muerte hospitalaria o internacion prolongada en la UTIP (mayor de 12 dias). Se dosaron Procalcitonina (VIDASR BRAHMS PCT) y PCR (Ensayo turbidimetrico BT 3000) al ingreso y al tercer dia de internacion y se calculo el aclaramiento de ambos marcadores. De 41 pacientes, 24 (58%) fallecieron o tuvieron internacion prolongada. El aclaramiento de PCT y PCR al tercer dia se asocio significativamente con menos mortalidad y menos dias de Internacion en UTIP (p=0,01 para PCT; p=0,0036 para PCR). El area bajo la curva ROC de PCR fue 0,773 y de PCT 0,735, sin diferencias significativas entre ambas curvas, No hubo diferencias significativas entre los dos grupos para los valores al ingreso de PCT y PCR (p=0,82 y p=0,95 respectivamente). Se concluye que los valores del aclaramiento de ambos marcadores pueden ser una herramienta util para el pronostico clinico.(AU)

The aim of the present work was to evaluate the usefulness of procalcitonin and C-reactive protein in pediatric patients with suspected bacterial infection or sepsis on admission to the Pediatric Intensive Care Unit (PICU) and subsequent monitoring and prognosis of prolonged hospitalization or death in a third level hospital. A prospective observational, single center study was performed and a combined endpoint of hospital death or prolonged hospitalization in the PICU (over 12 days) was considered as primary end point. Values of Procalcitonin (VIDAS « BRAHMS PCT) and PCR (BT turbidimetric 3000) were obtained on admission and on the third day of hospitalization and clearance of both markers was calculated. Out of 41 patients, 24 (58%) died or had prolonged hospitalization. PCT and CRP clearance on the third day was significantly associated with lower mortality and shorter hospital stays in PICU (p=0.01 for PCT, p=0.0036 for PCR). The area under the ROC curve was 0.773 for CRP and PCT was 0.735, with no significant difference between both curves. No significant differences were observed between both groups for the PCT and CRP values at admission (p=0,82 and p=0,95 respectively). It can be concluded that clearance values of both markers can be a useful tool for clinical prognosis.(AU)

O objetivo de avaliar a utilidade da Procalcitonina e Proteína C-Reativa em pacientes pediátricos com suspeita de infecþÒo bacteriana ou sepse na admissÒo na Unidade de Terapia Intensiva Pediátrica (UTIP) e posterior acompanhamento e prognóstico de hospitalizaþÒo prolongada ou morte em um hospital de terceiro nível. Foi realizado um estudo prospectivo observacional, único centro. Ponto final primário: foi considerado um ponto final combinado de óbito hospitalar ou hospitalizaþÒo prolongada na UTIP (mais de 12 dias). Foi dosada Procalcitonina (VIDAS « BRAHMS PCT) e PCR (ensaio turbidimétrico BT 3000) na admissÒo e no terceiro dia de internaþÒo e foi calculado como se aclararam ambos os marcadores. Dos 41 pacientes, 24 (58%) morreram ou tiveram internaþÒo prolongada. A aclaraþÒo do PCT e PCR no terceiro dia foi significativamente associado a menor mortalidade e menor tempo de internaþÒo em UTI (p=0,01 para PCT, p=0,0036 para PCR). A área sob a curva ROC foi de 0,773 para PCR e PCT foi 0,735, sem diferenþa significativa entre as duas curvas. NÒo houve diferenþa significativa entre os dois grupos para os valores de PCT e renda PCR (p=0,82 e p=0,95 respectivamente). Concluiu-se que os valores de aclaraþÒo de ambos os marcadores podem ser uma ferramenta útil para o prognóstico clínico.(AU)

¿Quién traslada los pacientes a la unidad de cuidados intensivos pediátricos del Hospital El Cruce? / Who transfers patients to the pediatric intensive care unit of El Cruce Hospital?

INTRODUCCION: La demanda de atención de situaciones críticas no se da habitualmente cerca del centro terciario, por lo que es imprescindible una coordinación entre los centros asistenciales y un adecuado traslado de estos pacientes. Las condiciones de traslado de pacientes críticos influirán en la sobrevida y calidad de vida. OBJETIVO: El presente estudio tiene como objetivo describir las características generales de los traslados de pacientes admitidos en la UCIP del HEC. METODOS: Se ha realizado un estudio prospectivo, observacional en el que fueron evaluados de manera consecutiva todos los pacientes que ingresaron a la UCIP del HEC desde el 1° de noviembre de 2008 hasta el 31 de marzo de 2009. Se registraron datos demográficos e inherentes al traslado (tipo de transporte, tiempos de traslado, médico que realiza el traslado, presencia de enfermero en ambulancia, consentimiento informado). RESULTADOS: Dentro de los resultado obtenidos ochenta pacientes (72,7%) completaron los datos al ingreso. Los pacientes fueron trasladados en su mayoría por médicos en formación (68,4%). Las ambulancias no contaban con enfermero en 72,5% de los traslados. Dos pacientes (2,5%) fueron trasladados con el consentimiento informado correspondiente. Se identifica que el traslado de pacientes críticos a la UCIP del HEC fue realizado en un alto porcentaje por médicos en formación, sin enfermero acompañante y sin el consentimiento informado correspondiente.

INTRODUCTION: Because of critical care is not usually near the tertiary Center, coordination between centers and an adequate transfer of these patients is essential. The conditions for transfer critical patients influence on survival and quality of life. OBJECTIVE: Describe the General characteristics of transport of patients admitted to the Hospital El Cruce from November the 1st 2008 up to march 31st. METHODS: Prospective, observational study. All patients admitted the Hospital El Cruce´s UCIP from November the 1st 2008 up to march 31st 2009 were assessed consecutively. Demographic and inherent to transport (transport type, time of transfer, the physician who performed the transport, presence of nurse in ambulance, informed consent) data were recorded. RESULT: Eighty patients (72,7%) completed the data entry. Professionals responsible for transports were majority training doctors (68.4%).

Recuperación cardiovascular pediátrica: relevamiento estadístico 2009 - 2012 / Pediatric cardiovascular recovery: statistical survey 2009 - 2012

INTRODUCCION: Las cardiopatías congénitas son una patología prevalente en nuestra comunidad generando una importante demanda que requiere una respuesta rápida y efectiva para lograr mejores resultados en los tratamientos. Esta necesidad ha sido cubierta en gran medida desde la implementación del Plan Nacer (Cardiopatías Congénitas), con un gran impacto en la disminución de la mortalidad infantil. En el siguiente trabajo se comunican los resultados de las cirugías cardiovasculares en cardiopatías congénitas en el Hospital de Alta Complejidad El Cruce. Dr. Néstor Carlos Kirchner. MATERIALES Y METODOS: Los datos se identificaron por medio de la revisión de la Historia Clínica Digital en el Sistema SIGHEOS. RESULTADOS: los resultados obtenidos durante el período julio 2009 - octubre 2012 se realizaron 64 cirugías cardiovasculares. Diez cirugías fueron en neonatos, treinta y seis en pacientes de 31 días a 1 año y dieciocho en mayores de 1 año. Se concluye con que el crecimiento de los Servicios de Cirugía Cardiovascular Pediátrica y Recuperación Cardiovascular Pediátrica, ha sido exponencial desde el inicio de la realización de la primera cirugía en el año 2009. Desde el inicio de las actividades del servicio de Cirugía Cardiovascular Pediátrica y de Recuperación Cardiovascular Pediátrica en UCIP (Unidad Cuidados Intensivos Pediátricos), tanto el número, como la complejidad de las patologías operadas han ido en aumento.

INTRODUCTION: Congenital heart disease is a disease prevalent in our community generating significant demand that requires a rapid and effective response to achieve better results in treatment. This need has been met largely from the implementation of the Plan nacer (congenital heart disease), with a great impact on reducing child mortality. In this paper, we report the results of cardiovascular surgery in congenital heart disease in the High Complexity Hospital El Cruce. Dr. néstor Carlos Kirchner. MATERIAL AND METHODS: review of Medical records. SIGHEOS System. RESULTS: During the period July 2009 - 64 October 2012 cardiovascular surgeries were performed. Ten surgeries were in neonates, thirty-six patients under one year and eighteen in over 1 year.

Sistema de registro informático en una unidad de cuidados intensivos pediátricos en tiempo real y sin papeles / Computer registration system in a pediatric intensive care unit in real time and without papers

Las bases de datos constituyen una importante herramienta en la gestión de un servicio. Para ello es indispensable que el registro se realice en tiempo real, permitiendo un monitoreo efectivo de la situación, con intervenciones oportunas que admitan modificar situaciones que compremeten la calidad de atención de un servicio.

Avaliação da adaptação marginal de uma liga de cobalto-crômio variando o término cervical / Evaluation of marginal fit of a cobalt-chromium alloy varying the cervical design

O objetivo deste trabalho foi avaliar a adaptação marginal de copings, antes e após aplicação da porcelana, confeccionados com uma liga de cobalto-crômio, variando o término cervical. Três modelos padrão de ácido inoxidável foram usinados simulando preparo de coroa total, com términos cervicais em chanfro, ombro arredondado e bisel de 135o. Quinze moldagens com polivinilsiloxano, pela técnica da dupla impressão, foram feitas para cada troquel. Um delineador modificado foi utilizado para manter constante o eixo de inserção e remoção do modelo padrão durante as moldagens. Os moldes foram vazados com resina de poliuretano e sobre os moldes aplicado espaçador de troquel a 1mm aquém da margem. Com auxílio de uma matriz, enceramentos com 0,4mm de espessura foram confeccionaods e fundidos em liga de cobalto-crômio. Cinco camadas de porcelana foram aplicadas e as medidas de desadaptação realizadas antes e após sua aplicação com auxílio de microscópio óptico de 30 vezes de aumento. Os dados de desadaptação obtidos foram submetidos ao teste ANOVA de medidas repetidas (2 fatores, alfa = 5%). Verificou-se a presença do efeito interação (p = 0,004) e, também, do efeito prncipal porcelana (p = 0,001). Com os resultados obtidos, cncluiu-se que os términos com porcelana apresentam maiores desajustes em comparação com os términos sem a porcelana