Formación en Medicina Intensiva. Un reto a nuestro alcance / Training in Intensive Care Medicine. A challenge within reach

La formación médica se encuentra actualmente inmersa en un proceso de cambio de modelo. El nuevo paradigma pretende ser más efectivo, más integrado en el sistema sanitario y muy dirigido a la aplicación directa del conocimiento en la práctica clínica. Frente al sistema de formación actual basado en la certificación del cumplimiento de una serie de rotaciones y estancias en determinadas unidades asistenciales, el nuevo modelo propone un proceso formativo más estructurado, basado en la adquisición progresiva de competencias específicas, y en el que el residente debe jugar un papel activo en el diseño de su programa de formación. La formación basada en competencias garantiza un aprendizaje más transparente, de calidad objetiva, actualizada, homogénea y homologable internacionalmente. Los tutores juegan un papel esencial como gestores principales del proceso, es imprescindible el compromiso institucional con su labor, se les debe proporcionar tiempo y formación específica para la evaluación formativa, que es la piedra angular del nuevo modelo. Se deben incorporar nuevas formas de evaluación objetiva tanto formativa como sumativa, que garanticen que se están consiguiendo las competencias predefinidas. El movimiento libre de especialistas en Europa es un objetivo muy deseable que implica quela calidad de la formación recibida ha de ser alta y homologable en los diferentes países. El programa Competency Based Training in Intensive Care Medicine in Europe es nuestra principal fortaleza para conseguir este objetivo. Las sociedades científicas deben impulsar y facilitar todas aquellas iniciativas que mejoren la calidad asistencial y, por lo tanto, la formación del especialista. Su misión es el diseño de estrategias y procesos para favorecer la formación, la acreditación y las relaciones de asesoramiento con los gobiernos

The medical training model is currently immersed in a process of change. The new paradigm is intended to be more effective, more integrated within the healthcare system, and strongly oriented towards the direct application of knowledge to clinical practice. Compared with the established training system based on certification of the completion of a series or rotations and stays in certain healthcare units, the new model proposes a more structured training process based on the gradual acquisition of specific competences, in which residents must play an active role in designing their own training program. Training based on competences guarantees more transparent, updated and homogeneous learning of objective quality, and which can be homologated internationally. The tutors play a key role as the main directors of the process, and institutional commitment to their work is crucial. In this context, tutors should receive time and specific formation to allow the evaluation of training as the cornerstone of the new model. New forms of objective summative and training evaluation should be introduced to guarantee that the predefined competences and skills are effectively acquired. The free movement of specialists within Europe is very desirable and implies that training quality must be high and amenable to homologation among the different countries. The Competency Based training in Intensive Care Medicine in Europe program is our main reference for achieving this goal. Scientific societies in turn must impulse and facilitate all those initiatives destined to improve healthcare quality and therefore specialist training. They have the mission of designing strategies and processes that favor training, accreditation and advisory activities with the government authorities

Training in intensive care medicine. A challenge within reach.

The medical training model is currently immersed in a process of change. The new paradigm is intended to be more effective, more integrated within the healthcare system, and strongly oriented towards the direct application of knowledge to clinical practice. Compared with the established training system based on certification of the completion of a series or rotations and stays in certain healthcare units, the new model proposes a more structured training process based on the gradual acquisition of specific competences, in which residents must play an active role in designing their own training program. Training based on competences guarantees more transparent, updated and homogeneous learning of objective quality, and which can be homologated internationally. The tutors play a key role as the main directors of the process, and institutional commitment to their work is crucial. In this context, tutors should receive time and specific formation to allow the evaluation of training as the cornerstone of the new model. New forms of objective summative and training evaluation should be introduced to guarantee that the predefined competences and skills are effectively acquired. The free movement of specialists within Europe is very desirable and implies that training quality must be high and amenable to homologation among the different countries. The Competency Based training in Intensive Care Medicine in Europe program is our main reference for achieving this goal. Scientific societies in turn must impulse and facilitate all those initiatives destined to improve healthcare quality and therefore specialist training. They have the mission of designing strategies and processes that favor training, accreditation and advisory activities with the government authorities.

[Early invasive strategy in non-ST-segment elevation acute coronary syndrome. The paradox continues]. / Uso de la estrategia invasiva precoz en el síndrome coronario agudo sin elevación de ST. La paradoja continúa.

OBJECTIVE: Observational studies have reported a paradoxical inverse relationship between the use of an early invasive strategy (EIS) and the risk of events in patients with non-ST-segment elevation acute coronary syndrome (NSTE ACS). The study objectives are: 1) to examine the association between baseline risk in patients with NSTE ACS and the use of EIS; and 2) to identify some of the factors independently associated to the use of EIS. DESIGN: Retrospective cohort study. SETTING: Intensive care units participating in the SEMICYUC ARIAM Registry. PATIENTS: Consecutive patients admitted with a diagnosis of NSTE-ACS within 48 hours of evolution between the months of April-July 2010. INTERVENTIONS: None. MAIN OUTCOMES: Coronary angiography with or without angioplasty within 72 hours, risk stratification using the GRACE scale. RESULTS: We analyzed 543 patients with NSTE-ACS, of which 194 were of low risk, 170 intermediate risk and 179 high risk. The EIS was used in 62.4% of the patients at low risk, in 60.2% of those with intermediate risk, and in 49.7% of those at high risk (p for tendency 0.0144). The EIS was used preferentially in patients with low severity and comorbidity. In the logistic regression model, EIS was independently associated to the availability of a catheterization laboratory (OR 2.22 [CI 95% 1.55 to 3.19]), the presence of ST changes on ECG (OR 1.80 [1.23 to 2.64]), or the existence of a low risk of bleeding (OR 0.76 [0.66 to 0.88)]. Conversely, EIS was less prevalent in patients with diabetes (OR 0.60 [0.41 to 0.88]) or tachycardia upon admission (OR 0.54 [0 36 to 0.82]). CONCLUSIONS: In 2010 there remained a lesser relative use of EIS in patients at high risk, due in part to an increased risk of bleeding in these patients.

Indicadores de calidad en el síndrome coronario agudo para el análisis del proceso asistencial pre e intrahospitalario / Quality indicators in the acute coronary syndrome for the analysis of the pre- and in-hospital care process

Se presenta un mapa de 27 indicadores para medir la calidad de la asistencia prestada a los pacientes con síndrome coronario agudo (SCA) que son atendidos en el ámbito pre e intrahospitalario. Se incluyen indicadores de proceso técnicos (registro de los intervalos asistenciales, realización del ECG, monitorización y acceso venoso, evaluación de los riesgos pronóstico, hemorrágico y de mortalidad intrahospitalaria, empleo de técnicas de reperfusión y realización de ecocardiografía), indicadores de proceso farmacológicos (antiagregación plaquetaria, anticoagulación, trombolisis, administración de beta-bloqueantes, inhibidores de conversión de la angiotensina e hipolipemiantes) e indicadores de resultado (escalas de calidad de la atención prestada y mortalidad) (AU)

We present a map of 27 indicators to measure the care quality given to patients with acute coronary syndrome attended in the pre- and hospital area. This includes technical process indicators (registration of care intervals, performance of electrocardiogram, monitoring and vein access, assessment of prognostic risk, hemorrhage and in-hospital mortality, use of reperfusion techniques and performance of echocardiograph), pharmacological process indicators (platelet receptors inhibition, anticoagulation, thrombolysis, beta-blockers, angiotensin converting inhibitors and lipid lowering drugs) and outcomes indicators (quality scales of the care given and mortality) (AU)

[Quality indicators in the acute coronary syndrome for the analysis of the pre- and in-hospital care process]. / Indicadores de calidad en el síndrome coronario agudo para el análisis del proceso asistencial pre e intrahospitalario.

We present a map of 27 indicators to measure the care quality given to patients with acute coronary syndrome attended in the pre- and hospital area. This includes technical process indicators (registration of care intervals, performance of electrocardiogram, monitoring and vein access, assessment of prognostic risk, hemorrhage and in-hospital mortality, use of reperfusion techniques and performance of echocardiograph), pharmacological process indicators (platelet receptors inhibition, anticoagulation, thrombolysis, beta-blockers, angiotensin converting inhibitors and lipid lowering drugs) and outcomes indicators (quality scales of the care given and mortality).

[Use of antibiotics for the treatment of multiresistant gram positive cocci infections in critical patients]. / Utilización de antibióticos en el tratamiento de infecciones por cocos grampositivos multirresistentes en pacientes críticos.

INTRODUCTION: This study has been designed to know the use of these antibiotics (ATB) in Intensive Care Units (ICUs). DESIGN AND PATIENTS: A multicentric, prospective, observational study was conducted. In cluded as cases were the indications of vancomycin (VAN), teicoplanin (TPN), quinupristin/dalfopristin (Q/D) and linezolid (LZD). RESULTS: A total of 826 indications (VAN 52.1%, TPN 36.6%, LZD 11.6% and Q/D 0%) were analyzed, 793 (96%) as treatment and 33 (4%) as prophylaxis in 818 patients. Serious sepsis or septic should occurred in 55.9% of the patients treated. The most common infections were pneumonia and catheter-related bacteremia, 48.3% of all the infections being acquired in ICUs. LZD was used mostly in mechanical-ventilation related pneumonia (p = 0.001), VAN in community Central Nervous System infections (p = 0.01) and in catheter-related bacteremia (p = 0.001), TPN in community pneumonia (p = 0.01) and in catheter-related bacteremia (p = 0.001). Treatments were empirical in 65.8% and diagnosis of gram positive cocci was confirmed in 48.3% of them. Staphylococcus aureus was isolated more in the LZD-treated group. Initial treatment was modified 224 times, this occurring more frequently in the VAN-treated group. The reason for this change was clinical failure 59 times, this being more frequent in the TPN group and less frequent in the patients treated with LZD, which was the drug used the most in rescue therapies (43/69, 62.3%). Adverse events, probably related to the ATB, were identified in 36/826 (4.4%) cases. CONCLUSIONS: The most common use of this ATB was to treat ICU-acquired infections. VAN was the most frequently used drug. Treatments with LZD were modified less frequently for clinical failure and this drug was the one most used in rescue therapies. This information indicates an appropriate use of these ATB in an important percentage of critically patients.

Utilización de antibióticos en el tratamiento de infecciones por cocos grampositivos multirresistentes en pacientes críticos / Use of antibiotics for the treatment of multiresistant gram positive cocci infections in critical patients

Introducción. Este estudio se ha diseñado paraconocer el uso de antibióticos (ATB) específicosfrente a cocos grampositivos multirresistentes enCuidados Intensivos.Diseño y pacientes. Estudio observacional, prospectivo y multicéntrico. Se incluyeron como casos las indicaciones de vancomicina (VAN), teicoplanina (TPN), quimipristina/dalfopristina (Q/D) y linezolid (LZD).Resultados. Se analizaron 826 indicaciones (VAN 52,1%; TPN 36,6%; LZD 11,6% y Q/D 0%), 793 (96%) como tratamiento y 33 (4%) como profilaxis en 818 pacientes. El 55,9% de las infecciones se presentaron con sepsis grave o shock séptico. Las más frecuentes fueron neumonías y bacteriemias relacionadas con catéter, y el48,3% fueron adquiridas en la Unidad de Cuidados Intensivos (UCI). LZD fue más utilizado en neumonías relacionadas con ventilación mecánica (p = 0,001), VAN en infecciones del sistema nervioso central (p = 0,01) y en bacteriemias relacionadas con catéter (p = 0,001) y TPN en neumonías comunitarias (p = 0,01) y en bacteriemias relacionadas con catéter (p = 0,001). El 65,8% de los tratamientos fueron empíricos. Staphylo cocus aureus resistente a meticilina fue el más aisladoen el grupo de pacientes tratados con LZD.El tratamiento inicial se modificó en 224 ocasiones,circunstancia más frecuente en tratados con VAN. El motivo de esta modificación fue por fracaso clínico en 59 ocasiones, siendo más frecuente en el grupo tratado con TPN y menos en el tratado con LZD, que además fue el fármaco más utilizado en los tratamientos de rescate(43/69, 62,3%). Se han identificado efectos adversosprobablemente relacionados con los ATB en 36/826 (4,4%) casos.Conclusiones. Las indicaciones más frecuentesfueron para tratar infecciones adquiridas en laUCI. VAN fue el fármaco más utilizado. El tratamientocon LZD se modificó en menos ocasiones por fracaso clínico y fue el más empleado como tratamiento de rescate. El conjunto de la información muestra un empleo adecuado de estos ATB en un importante porcentaje de pacientes críticos

Introduction. This study has been designed toknow the use of these antibiotics (ATB) in Intensive Care Units (ICUs).Design and patients. A multicentric, prospective,observational study was conducted. Included as cases were the indications of vancomycin(VAN), teicoplanin (TPN), quinupristin/dalfopristin (Q/D) and linezolid (LZD).Results. A total of 826 indications (VAN 52.1%,TPN 36.6%, LZD 11.6% and Q/D 0%) were analyzed,793 (96%) as treatment and 33 (4%) as prophylaxis in 818 patients. Serious sepsis or septic should occurred in 55.9% of the patients treated.The most common infections were pneumonia and catheter- related bacteremia, 48.3% of all the infections being acquired in ICUs. LZD was used mostly in mechanical-ventilation related pneumonia (p = 0.001), VAN in community Central Nervous System infections (p = 0.01) and in catheter-related bacteremia (p = 0.001), TPN in community pneumonia (p = 0.01) and in catheter-related bacteremia (p = 0.001). Treatments were empirical in65.8% and diagnosis of gram positive cocci wasconfirmed in 48.3% of them. Staphylococcus aureuswas isolated more in the LZD-treated group.Initial treatment was modified 224 times, this occurringmore frequently in the VAN-treated group.The reason for this change was clinical failure 59times, this being more frequent in the TPN groupand less frequent in the patients treated with LZD,which was the drug used the most in rescue therapies(43/69, 62.3%). Adverse events, probably relatedto the ATB, were identified in 36/826 (4.4%)cases.Conclusions. The most common use of this ATBwas to treat ICU-acquired infections. VAN was themost frequently used drug. Treatments with LZDwere modified less frequently for clinical failureand this drug was the one most used in rescuetherapies. This information indicates an appropriateuse of these ATB in an important percentageof critically patients