[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

Moduladores cronobiológicos en la efectividad de la trombolisis prehospitalaria / Circadian modulation of effectiveness in prehospital thrombolysis

Objetivo: Investigar si la hora del día influye en la efectividad de la terapia trombolítica prehospitalaria en pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST). Método: Estudio observacional de cohortes retrospectivo con pacientes diagnosticados de IAMCEST a quienes se les realizó trombolisis precoz prehospitalaria. Se analizaron, como variables predictoras independientes de la efectividad de la terapia trombolítica, la hora del día de administración de la terapia trombolítica (variable principal), divididos en periodos horarios de 6 h y de 12 h, la edad, el sexo, la hora inicio del dolor torácico, tiempo de evolución del infarto, los factores de riesgo cardiovascular y el área de localización del infarto. Los datos se obtuvieron de la historia clínica y del seguimiento de preavisos hospitalarios a las 24 h. Resultados: Se incluyó a 206 pacientes. Dos variables se muestran como predictores independientes de la efectividad de la trombolisis prehospitalaria: la hora del día de administración de la terapia trombolítica, en el rango de cronorriesgo cardiovascular de 6a 12 h, con respecto al resto de franjas horarias (0-6 h, 12-18 h, 18-24 h) [p = 0,005odds ratio (OR) = 2,46; intervalo de confianza (IC) del 95%, 1,30-4,64] y presentar cardiopatía isquémica previa) (p = 0,003, OR = 5,30; IC del 95%, 1,74-16,15).Conclusiones: Encontramos variaciones circadianas clínicamente significativas en la efectividad del tratamiento trombolítico prehospitalario administrado a los pacientes con IAMCEST, independientemente del agente trombolítico empleado, de manera que existe una tromborresistencia matinal (6-12 am) al tratamiento y una mayor efectividad de reperfusión coronaria cuando se administra en el resto de franjas horarias diurnas ,especialmente en la de tarde (12-18 h) (AU)

Objective: To study whether time of day influences the effectiveness of prehospital thrombolysis in patients who have had acute myocardial infarction with ST-segment elevation (STEMI).Methods: Observational study of retrospective cohorts. We included patients diagnosed with STEMI who received early application of prehospital thrombolytic therapy. The main variable studied as an independent predictor of effectiveness was the time of day the thrombolytic agent was administered; this variable was studied in 6-hour periods and 12-hourperiods. Additional independent variables were patient age and sex, onset of chest pain, duration of pain from onset until administration of the thrombolytic agent, cardiovascular risk factors, and location of infarction. Data were extracted from patient records and ambulance pre-alert calls in the next 24 hours. Results: Two hundred six patients were studied. The 2 independent variables that predicted the effectiveness of prehospital thrombolysis were administration of the thrombolytic agent at a time of day within the period of greatest cardiovascular risk (6 AM to 12 noon) in comparison with the other time frames (12 midnight to 6 AM, 12 noon to 6 PM and 6 PM to midnight) (odds ratio [OR], 2.46; 95% CI, 1.30-4.64; P=.005) and history of ischemic heart disease (OR,5.30; 95% CI, 1.74-16.15; P=.003).Conclusions: We found that circadian rhythm had a clinically significant effect on the effectiveness of prehospital thrombolysis in STEMI patients. The effect was present regardless of which thrombolytic agent was used. The greatest resistance to therapy was observed in the morning hours between 6 AM and 12 noon. The response was greater in the remaining time frames and greatest in the hours between noon and 6 PM (AU)

El control de la calidad en las compresiones torácicas y su relación con la recuperación de pulso / Feedback on chest compression quality variables and their relationship to rate of return of spontaneous circulation

Objetivos: Varios estudios demuestran el incumplimiento de las recomendaciones internacionales en la ejecución de las compresiones torácicas durante la reanimación cardiopulmonar(RCP). Existen dispositivos de ayuda para la realización de la RCP y SAMUR Protección Civil ha implementado uno de ellos (Q-CPR®). El presente estudio analiza si existe asociación entre uso del dispositivo y la recuperación de pulso (RP), describe la ejecución de las compresiones en relación a los estándares de calidad y verifica si alguno de los parámetros medidos puede relacionarse con la RP. Método: Estudio prospectivo de cohortes. El periodo de reclutamiento fue de noviembre de 2007 a diciembre de 2010. Se incluyó a todo paciente atendido por una parada cardiorrespiratoria (PCR), y el factor de exposición fue el uso de dispositivo Q-CPR®. Resultados: Se atendieron 892 PCR: 108 con Q-CPR® y 784 sin Q-CPR®. Las dos poblaciones fueron comparables en cuanto a las variables predictoras analizadas. Se encontró (..) (AU)

Background: Studies have revealed failure to follow international guidelines for performing chest compressions in cardiopulmonary resuscitation (CPR). Certain feedback devices are available for use. One such device (the Q-CPR) has been used in the Madrid Emergency and Rescue Service (SAMUR).Objectives. To analyze whether there is an association between the rate of return of spontaneous circulation (ROSC) and the use of a feedback device, to describe the performance of compressions in comparison with quality standards, and to determine whether any of the measured variables are related to the rate of ROSC. Methods: Prospective cohort study. Recruitment period: November 2007 to December 2010. Inclusion criteria: patients with cardiorespiratory arrest attended by the SAMUR. Exposure factor: use of a CPR measurement and feedback device. Results: SAMUR attended 892 cases of cardiorespiratory arrest: the Q-CPR was used in 108 patients and 784 were given (AU)

La aplicación de hipotermia moderada tras la reanimación cardiaca iniciada en el medio extrahospitalario puede incrementar la supervivencia sin deterioro neurológico. Estudio de casos y controles / Prehospital induction of moderate hypothermia after cardiac resuscitation can increase survival without increasing neurologic impairment: a case-control study

Objetivos: Evaluar el efecto que tiene la aplicación por un servicio de emergencias de una hipotermia moderada precoz en el medio extrahospitalario sobre la evolución neurológica de los pacientes recuperados de una parada cardiaca. Método: Estudio comparativo caso-control. Se incluyeron como casos los 40 primeros pacientes en parada cardiorrespiratoria (PCR) que fueron reanimados por el SAMUR Protección Civil y tratados con hipotermia en la propia ambulancia, continuada posteriormente en el medio hospitalario. En el grupo control, se incluyeron los últimos 40 pacientes que habiendo sufrido una PCR de origen médico, fueron reanimados por el SAMUR Protección Civil antes de la implantación del protocolo de hipotermia postresucitación, y fueron sometidos, también, al procedimiento de hipotermia tras el ingreso en el hospital. Se descartaron las PCR de origen neurológico, dado que se pretende conocer la influencia de la técnica en ese órgano diana. Para valorar el deterioro neurológico de de los pacientes, se utilizó la escala CPC (Cerebral Perfomance Category). Se consideró en el estudio los grados I y II como "buena evolución neurológica". Resultados: El 50% de los casos presentaron una buena recuperación neurológica frente al 27,5% de los controles (p = 0,039). Esas diferencias se mantuvieron tanto si el ritmo inicial era desfibrilable (58,3% frente a 37,5% de los controles) como no desfibrilable(42,8% frente a 14,2% respectivamente).Conclusiones: Los datos demuestran que existe una relación estadísticamente significativa entre la aplicación de hipotermia moderada prehospitalaria y una mayor probabilidad de recuperación neurológica (CPC I y II). Así, existe una probabilidad de 2,6 veces mayor de que el paciente que ha sufrido una parada cardiorrespiratoria tenga una buena recuperación neurológica si el inicio de la hipotermia moderada se realiza antes de llegar al hospital (AU)

Objectives: To assess the effect of early prehospital emergency responder implementation of moderate hypothermia on neurologic outcome in patients recovering from cardiac arrest. Methods: Case-control comparative study. The cases were the first 40 patients in cardiorespiratory arrest in who mhypothermia was induced in the ambulance after resuscitation by responders from the Citizen Protection Emergency Service of Madrid (SAMUR); hypothermia was also later used in the hospital. The controls were the last 40 patients in cardiorespiratory arrest who were resuscitated by the SAMUR responders before the prehospital hypothermia protocol had been established; hypothermia was later induced after the control patients’ arrival at the hospital. Patients whose cardiorespiratory arrest had neurologic causes were excluded given that the effect on neurologic outcome was underevaluation. The Cerebral Performance Category scale was used to assess impairment. A grade 1 or 2 assessment was considered to indicate a good neurologic outcome. Results: Neurologic outcome was good for 50% of the patients in whom hypothermia was induced early; outcome was good for 27.5% of the control patients (P=.039). The significant difference between cases and controls was maintained regardless of whether the initial heart rhythm was shockable (58.3% of such cases had good neurologic outcomes with early hypothermia vs 37.5% of the controls with shockable rhythm) or not (42.8% of such cases had good outcomes vs14.2% of the controls with non shockable rhythm).Conclusions: Our findings show a significant relationship between prehospital induction of moderate hypothermia and a higher probability of neurologic recovery (performance categories 1 and 2). If moderate hypothermia is initiated before arrival at the hospital, the likelihood of good neurologic recovery is 2.6-times greater (AU)

La calidad asistencial y la competencia médica en la práctica clínica de emergencias, evaluada a travésde un sistema de valoración del desempeño en la escena / Health care quality and medical competencies in the practice of emergency medicine: on-scene job performance evaluation

Objetivo: Mostrar el sistema de valoración del desempeño médico de un servicio de emergencias extrahospitalario y detectar si existe asociación existente entre el tiempo de experiencia y la evolución en la competencia médica de los médicos de nueva incorporación, a través de un sistema de valoración del desempeño (VD) en la asistencia. Método: Estudio prospectivo observacional de cohortes con observación directa del proceso asistencial. Se establecen 4 grupos de médicos según los años de experiencia en emergencias extrahospitalarias: A (0-1 años), B (2-3 años), C (4-5 años) y D (> 5años), cuyos resultados en VD se comparan. Resultados: Se realizaron 6.450 observaciones asistenciales entre el año 2006 y el2010 que incluyeron 85 médicos: 22 del grupo A, 21 del grupo B, 16 del C y 26 del D, sin diferencias significativas en edad, sexo y media de observaciones entre grupos. El perfil en formación especializada en el grupo de médicos de nueva incorporación(grupos A, B y C) frente a los antiguos (grupo D) fue mucho mayor. 68,2% en el A vs11,5% en el D (p < 0,05) y 61,9% en el B vs 11,5% en el D (p < 0,05). Se encontraron diferencias estadísticamente significativas en la VD del grupo A (p < 0,001) y del grupo B (p = 0,049) frente al grupo D. La mayor tasa de VD suficiente está entre los 3y 4 años. Conclusiones: En nuestro estudio, sólo cuando el urgenciólogo tiene una experiencia de4-5 años presta una calidad asistencial comparable a la de los médicos más experimentados, según el sistema de VD in situ que se describe (AU)

Objective: To demonstrate a job performance evaluation system for an out-of-hospital emergency service. The specific aim was to study the association between length of experience and the demonstration of medical competencies by means of job performance evaluations of newly hired physicians. Methods: Prospective observational cohort study based on direct observation of the care process in the Madrid Emergency and Rescue Service (SAMUR). Four subgroups were identified according to years of experience in this out-of hospital emergency service: up to 1 year, up to 3 years, up to 5 years, and 5 years. The job performances of physicians in the different groups were compared to that of the most experienced physicians. Results: A total of 6450 care process observations were carried out between 2006 and 2010. Twenty-two had worked for up to 1 year, 21 for up to 3 years, 16 for up to 5 years, and 16 for 5 years. There were no significant differences between the groups in age, sex, or mean number of performance observations. Considerably more newly hired physicians had specialist training. Only 11.5% of the most experienced physicians had such training, whereas 68.2% of those with up to 1 year’s experience and 61.9% of those with up to 3 years’ experience had training (P<.05). In the job performance comparisons by years of out-of-hospital emergency practice experience, significant differences were found between the evaluations of the most experienced ( 5 years) and those with only up to 1 year on the job (P<.001) and also between the most experienced and those who had been on the job between 2 and 3 years (P=.049). The largest number of satisfactory ratings came in the group of physicians with 3 to 4 years of experience. Conclusions: On-scene job performance evaluations revealed that only physicians with between 4 and 5 years of experience were able to provide emergency care comparable to that given by physicians with more 5 years of experience (AU)

El 10-M / March: the day before

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