Comparison of clinical outcomes of venous thromboembolic disease between outpatient and inpatient management.

Objectives: To compare the occurrence of death, bleeding, and recurrence according to inpatient or outpatient management of venous thromboembolic disease (VTE). Materials and methods: . Retrospective cohort that included a consecutive sampling of VTE consultations between 2016 and 2019 diagnosed in the Emergency Center of a private hospital in Argentina. Results: There were 1202 cases, 908 with isolated deep vein thrombosis (DVT), 205 with isolated pulmonary embolism (PE), and 89 cases of combined DVT - PE. 66% were women, with a median age of 77 years; 72% of cases were managed on an outpatient basis (n= 862). Comorbidities associated with hospitalization were obesity (p=0.03), chronic obstructive pulmonary disease (COPD) (p=0.01), heart failure (CHF) (p=0.01), chronic renal failure (CKD) (p=0.01), and cancer (p=0.01). At 90 days, the cumulative incidence of bleeding was 2.6% in inpatient compared to 2.9% in outpatient management (p=0.81); recurrence was 0% versus 0.9% (p=0.07), and mortality was 42.9% versus 18.9%, respectively (p=0.01). The HR for 90-day mortality in hospitalized patients adjusted for confounders (sex, age, type of VTE, obesity, CKD, CHF, COPD, and cancer) was 1.99 (95% CI 1.49-2.64; p=0.01). Conclusions: In this elderly, and predominantly female Argentine population, the 90-day mortality in patients hospitalized for VTE was higher than mortality in patients with outpatient management, without differences in recurrence or major bleeding.

[Gender perspective in the care experience and in the results of patients who consult for chest pain in an emergency department]. / Perspectiva de género en la experiencia asistencial y en los resultados de pacientes que consultan por dolor torácico en un servicio de urgencias.

Objective: Clinical practice guidelines suggest performing an electrocardiogram (EKG) in patients with chest pain within the first 10 minutes in the emergency department, warning about subdiagnosis in women. Possible differences based on sex were analyzed. Method: An observational and retrospective study in an Emergency Department, with adult patients admitted to the Chest Pain Unit in 2021. Results: There were 1,469 patients, of whom 774 were men (52.7%). The men were younger (60 vs. 65 years), were less overweight (17.18 vs. 22.16%), and had more previous admissions to the Coronary Unit (12 vs. 7%), compared to women. No gender differences were observed in EKG performance (91 vs. 90%), EKG time (median 4.1 vs. 4.5 minutes), or delay in care attention (median 25 vs. 26 minutes). In terms of healthcare resources, men underwent more biomarkers: troponins (63 vs. 55%; odds ratio [OR]: 1.35; 95% confidence interval [95%CI]: 1.10-1.67) and creatine phosphokinase (24.8 vs. 19.1%), received more aspirin (6.7 vs. 3.1%), nitrates/nitrites (6 vs. 3%), and hospitalization (17.18 vs. 10.50%; OR: 1.76; 95%CI; 1.30-2.40). Of 206 hospitalized, 112 had a final diagnosis of acute coronary syndrome (54%), more men than women (81 vs. 31). There were no significant differences in revascularization time, medication schedule at discharge, hospital stay, or mortality. Conclusions: Gender did not affect precordial pain care, diagnosis, and treatment times, highlighting the quality of hospital care.

Objetivo: Las guías de práctica clínica sugieren realizar electrocardiograma (ECG) en pacientes con dolor precordial dentro de los primeros 10 minutos en urgencias, advirtiendo sobre el subdiagnóstico en mujeres. Se analizaron las posibles diferencias en función del sexo. Método. Método: Estudio observacional y retrospectivo en una central de emergencias de adultos, con pacientes ingresados a la unidad de dolor torácico durante 2021. Resultados: Hubo 1,469 pacientes, de los cuales 774 eran hombres (52.7%). Los hombres eran más jóvenes (60 vs. 65 años), tenían menos sobrepeso (17.18 vs. 22.16%) y más ingresos previos en unidad coronaria (12 vs. 7%). No se observaron diferencias de género en la realización de ECG (91 vs. 90%), tiempo para el ECG (mediana 4.1 vs. 4.5 minutos) o tiempo de demora en atención (mediana 25 vs. 26 minutos). En términos de recursos sanitarios, los hombres se sometieron más a biomarcadores: troponinas (63 vs. 55%; odds ratio [OR]: 1.35; intervalo de confianza del 95% [IC95%]: 1.10-1.67) y creatina fosfocinasa (24.8 vs. 19.1%), recibieron más aspirina (6.7 vs. 3.1%), nitratos/nitritos (6 vs. 3%), y hospitalización (17.18 vs. 10.50%; OR: 1.76; IC95%: 1.30-2.40). De 206 internados, 112 tuvieron diagnóstico final de síndrome coronario agudo (54%), más hombres que mujeres (81 vs. 31). No hubo diferencias significativas en tiempos de revascularización, esquema de medicación al alta, tiempo de estadía ni en mortalidad hospitalaria. Conclusiones: El género no afectó a los tiempos de atención, diagnóstico y tratamiento del dolor precordial, destacando la calidad de atención hospitalaria.

Unscheduled Emergency Department Revisits Within 48 Hours of Discharge.

This study aimed to analyze early revisits (within 48 hours of discharge) in an Emergency Department. Among the 178,295 visits, 11,686 were revisits, resulting in a rate of 6.55% (95%CI 6.43-6.67). A total of 1,410 revisits required hospitalization, and 252 were due to preventable errors (17.87%). These errors were mainly related to an inadequate therapeutic plan at discharge (47.22%), an incomplete diagnostic process (29.37%), and misdiagnoses (13.10%). These findings represent a technology-enabled clinical audit tool. Electronic Healthcare Records have the potential to: provide quality metrics of hospital performance, help to keep revisit rates updated (assessment through a real-time dashboard), and improve clinical management (by transparency initiatives about errors, and a supportive learning environment regarding lessons learned).

Aprendizaje en investigación clínica: experiencia de enseñanza híbrida con estudiantes de medicina / Learning in Clinical Research: Hybrid Teaching Experience with Medical Students

Introducción: la pandemia de COVID-19 indujo un cambio en nuestro sistema de salud y de educación. Los programas formativos también tuvieron que adaptarse y exigieron un cambio rápido. Objetivos: describir una experiencia educativa de enseñanza virtual/híbrida en investigación clínica, entre docentes del Servicio de Clínica de un hospital universitario y estudiantes de Medicina de una institución privada, que participaron del Programa ESIN (EStudiantes en INvestigación). Metodología: los contenidos y las estrategias educativas incluyeron las clases teóricas audiograbadas o videograbadas (asincrónicas y autoadministradas), el aprendizaje basado en proyectos, los talleres prácticos (encuentros sincrónicos virtuales y grupales), mediante la adopción de modelos de aprendizaje como el aula invertida, y la tutoría individual entre docente-estudiante. Los datos se recopilaron mediante la observación en contextos académicos, y basándonos en elementos de encuestas anónimas de satisfacción, previo consentimiento informado de los participantes. Resultados: participaron 14 estudiantes, 6 durante el año 2021 y 8 durante 2022. Todas mujeres y estudiantes de medicina (50% de cuarto año, 35% de sexto año y 15% de quinto año). Las técnicas implementadas favorecieron la participación y promovieron el aprendizaje activo, basado en proyectos. Mencionaron aspectos positivos como el enfoque académico práctico, la disponibilidad del equipo docente para atender cualquier duda, el tiempo y el entusiasmo por enseñar y fomentar la participación. Los videos teóricos resultaron útiles como herramientas de repaso, y los encuentros grupales fueron especialmente valorados, si bien los encuentros individuales fueron destacados como ayuda y apoyo previo a los congresos científicos. En general, manifestaron que fue una experiencia enriquecedora que demostró que se puede lograr lo que se creía imposible. Todas participaron activamente de al menos un congreso científico, y el 50% resultó coautora de una publicación académica. Conclusión: los estudiantes asumieron compromisos y responsabilidades, e incorporaron competencias y habilidades en la implementación y en la difusión de los proyectos. Esta experiencia educativa facilitó que el tiempo de clase pudiera optimizarse para intercambio, discusión y dudas. Los recursos producidos, las actividades desarrolladas y los contenidos abordados quedan disponibles a nivel institución. (AU)

Introduction: the COVID-19 pandemic brought about a change in our health and education system. Training programs also had to adapt and required rapid change. Objectives: to describe an educational experience of virtual/hybrid teaching in clinical research between teachers of the Clinical Service of a university hospital and medical students of a private institution who participated in the ESIN Program (Students in Research). Methodology: the contents and educational strategies included audio or videotaped lectures (asynchronous and self-administered), project-based learning, practical workshops (virtual and group synchronous meetings) by adopting learning models such as the inverted classroom, and individual tutoring between teacher and student. We gathered the data through observation in academic contexts and based on elements of anonymous satisfaction surveys, with prior informed consent of participants. Results: fourteen students participated, six in 2021 and eight in 2022. All were women and medical students (50% fourth year, 35% sixth year, and 15% fifth year). The techniques implemented favored participation and promoted active, project-based learning. They mentioned positive aspects such as the practical academic approach, the availability of the teaching team for any doubts, the time and enthusiasm for teaching, and encouraging participation. The theory videos were a valuable review tool, and team meetings received high praise even if the one-on-one meetings received much attention as help and support before the scientific congresses. In general, they stated that it was an enriching experience that showed that you can achieve what you thought impossible. All of them actively participated in at least one scientific congress, and 50% were co-authors of an academic publication. Conclusion: the students assumed commitments and responsibilities and incorporated competencies and skills in project implementation and dissemination. This educational experience helped to optimize class time for exchange, discussion, and doubts. The resources produced, the activities developed, and the contents addressed are now available at the institutional level. (AU)

Prediction of 30-day unplanned hospital readmission through survival analysis.

Background and Objective: Unplanned hospital readmissions are a severe and recurrent problem that affects all health systems. Estimating the risk of being readmitted the following days after discharge is difficult since many heterogeneous factors can influence this. The extensive work concerning this problem proposes solutions mostly based on classification machine-learning models. Survival analysis methods could make a better match with the assessment of readmission risk and are yet to become well-established in this field. Methods: We compare different statistical and machine learning survival analysis models trained with right-censored all-cause hospital admission data with covariates available at the moment of discharge. The main focus is on tree-ensemble regression methods based on the assumption of proportional hazards. These models are more thoroughly evaluated at a 30-day time period after discharge, although the actual prediction could be set to any time up to 90 days. Results: The mean performance obtained by each of the proposed survival models ranges from 0.707 to 0.716 C-Index and 0.709 to 0.72 ROC-AUC at a 30-day time period after discharge. The model with the lower performance on both metrics was Cox Proportional Hazards, while the model marking the upper end on both ranges is an XGBoost Regression model with a Cox objective function. Conclusions: Our findings indicate that survival models perform well addressing the hospital readmission problem, machine-learning models getting the edge over statistical methods. There seems to be an improvement over classification models when attempting to predict at a 30-day period since discharge, perhaps due to a better handling of cases nearing the 30-day boundary. Some preprocessing steps, such as limiting the observation period to 90 days after discharge, are also highlighted since they resulted in a performance boost.

[Clinical characteristics and care times in a chest pain unit of the emergency department of an argentine center]. / Características clínicas y tiempos de atención en una unidad de dolor torácico del servicio de emergencias de un centro argentino.

Objectives: . To report the frequency of precordial pain, describe clinical characteristics, and care times. Methods: . Retrospective descriptive study that included consultations in the Chest Pain Unit in 2021 in the emergency department of a private hospital in Argentina. Results: There were 1469 admissions for chest pain, yielding a frequency of 1.09% (95%CI 1.04-1.15). They were 52% men, mean age 62 years (SD ±15); 48% had hypertension and 32% dyslipidemia. The median time to initial ECG was 4.3 min (ICR 2.5-7.5); and 26 min (ICR 14-46) to medical evaluation. A total of 206 (14%) were hospitalized with a median of 3 days, 76% were admitted to a closed unit, 9% required non-invasive ventilation/mechanical ventilaction and in-hospital mortality was 2.9%. Those hospitalized presented shorter delay time to medical attention (p<0.01), and greater performance of complementary studies (p<0.01), with no differences in time to ECG (p=0.22). Conclusions: Care times were within the stipulated standards, being an important indicator of quality. Nursing was crucial, taking care of the correct triage, ECG on admission, and guaranteeing care until medical evaluation.

Intervención educativa para mejorar la prescripción de ceftriaxona en un servicio de urgencias / Educational intervention to improve ceftriaxone prescription in an emergency department

Objetivo: Evaluar prevalencia y adecuación de ceftriaxona tras una intervención educativa en un servicio de urgencias.Métodos: Estudio cuasi experimental que incluyó un mues-treo consecutivo de consultas no programadas de pacien-tes adultos, durante dos meses preintervención y posin-tervención. Dicha intervención consistió en capacitación a médicos para limitar su indicación sólo a situaciones clínicas específicas (meningitis, enfermedad pélvica infla-matoria y abdomen agudo). Se utilizaron datos retrospecti-vos, con adicional revisión manual de historias, para validar adecuación de inicio antibiótico y apropiabilidad de droga. Se utilizó estadística descriptiva y analítica.Resultados: De un total de 28.570 consultas, 512 recibie-ron ceftriaxona (1,79%; IC95% 1,64-1,95), y sólo 60,54% se hospitalizaron. En cuanto a la comparación antes-después, se observó una reducción en la tasa de uso (de 3,66% a 0,63%; p<0,001), la adecuación en el inicio de un antimicro-biano se mantuvo (de 84,52% a 86,21%; p=0,778), aunque la adecuación de ceftriaxona aumentó en forma significativa (de 41,78% a 84,00% respectivamente; p<0,001). Adicional-mente, se redujo el tiempo de estadía hospitalaria (media-na de 6 a 5 días; p=0,014), sin diferencias en la mortalidad intrahospitalaria (19,44% vs 17,24%; p=0,691), ni en la mor-talidad a los 30 días (23,41% vs 18,96%; p=0,464).Conclusiones: Esta intervención resultó eficaz. Los hallaz-gos representan un paso fundamental en los programas de optimización del uso de antimicrobianos hospitalarios, que apuntan a reducir su sobreutilización y la consecuente resistencia.

Objective: To evaluate the prevalence and appropriateness of ceftriaxone after an educational intervention in an emergency department.Methods: Quasi-experimental study, which included a consecutive sampling of unscheduled consultations of adult patients, during 2 months pre-intervention and post-intervention. The intervention consisted of training physicians to limit its indication only to specific clinical situations (meningitis, pelvic inflammatory disease, and acute abdomen). Retrospective data were used, with additional manual chart review, to validate appropriateness of antibiotic initiation and drug appropriateness. Descriptive and analytical statistics were used.Results: Among 28570 visits, 512 received ceftriaxone (1.79%; 95%CI 1.64-1.95), and only 60.54% were hospitalized. Regarding the before-after comparison, we observed a reduction in the rate of use (from 3.66% to 0.63%; p<0.001), the appropriateness in starting an antimicrobial was maintained (from 84.52% to 86.21%; p=0.778), and the appropriateness of ceftriaxone increased significantly (from 41.78% to 84.00% respectively; p<0.001). Additionally, hospital length of stay was reduced (median 6 to 5 days; p=0.014), with no difference in in-hospital mortality (19.44% vs 17.24%; p=0.691), nor in 30-day mortality (23.41% vs 18.96%; p=0.464)

Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.

Introducción. La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos. Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados. Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión. Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

[Chemotherapy at the end of life is compatible with dignified death and palliative care] / Quimioterapia al final de la vida es compatible con muerte digna y cuidados paliativos.

Introduction: Cancer treatment is increasingly aggressive. The aim was to estimate who died due to cancer, to report use of chemotherapy (CT) in the last 3 months of life, and to describe clinical-epidemiological characteristics of these patients. Methods: We included a consecutive sample of deceased during 2017, affiliated to Hospital Italiano de Buenos Aires. Through manual review of medical helath records, they were classified according to the cause of death (cancer or other cause), validating diagnosis and baseline stage, performance status (PS). Prevalences with 95% CI are reported and descriptive statistics were used. Results: A total of 2293 adults died, 59% women with a median age of 84 years old. There were a total of 736 deaths from cancer, representing 32% (95%CI 30-34). This last subgroup were 54% women, with a median age of 75 years, and only one patient had advance directives. Regarding the place of death, 80% were hospitalized (65% general ward and 15% intensive care units). The most frequent tumors were: lung, colorectal-gastric, hematological, and breast. A total of 390 patients received CT at the end of life (53%; 95%CI 49-57), 53% being women and with a mean age of 68 years. Regarding the underlying oncological disease: 81% had a solid tumor, 75% advanced stage, and mostly with poor/regular ability to perform daily activities (25% PS3 and 32% PS4, respectively). Conclusion: There is a high frequency of CT at the end of life and deaths continue to be mainly in-hospital.

Introducción: El tratamiento oncológico es cada vez más agresivo. El objetivo de este trabajo fue estimar las personas fallecidas por causa oncológica, reportar la frecuencia de uso de quimioterapia (QT) en los últimos 3 meses de vida, y describir las características clínicas-epidemiológicas de estos pacientes. Métodos: Se incluyó una muestra consecutiva de fallecidos durante el 2017, afiliados a prepaga del Hospital Italiano de Buenos Aires. Mediante revisión de historias clínicas, se los clasificó según la causa de muerte (oncológico u otra causa), validando diagnóstico y estadio de base, performance status (PS). Se reportan prevalencias con IC95% y se utilizó estadística descriptiva. Resultados: Fallecieron 2293 personas, 59% mujeres con mediana de 84 años. Hubo un total de 736 fallecidos por cáncer, representando el 32% (IC95% 30-34). Este último subgrupo presentó una mediana de 75 años, 54% eran mujeres y sólo una paciente tenía directivas anticipadas. En cuanto al lugar de fallecimiento, 80% ocurrió hospitalizado (65% sala general y 15% unidad cerrada). Los tumores más frecuentes fueron: pulmón, colorrectal-gástrico, hematológico, y mama. Un total de 390 pacientes recibieron QT al final de la vida (53%; IC95% 49-57), siendo 53% mujeres y con promedio de 68 años. En cuanto a la enfermedad oncológica de base: 81% tenían tumor sólido, 75% estadío avanzado, y mayoritariamente con mala/regular capacidad para realizar actividades cotidianas (25% PS3 y 32% PS4 respectivamente). Conclusión: Existe una frecuencia preocupante del uso de QT en el fin de vida y los fallecimientos siguen siendo principalmente intrahospitalarios.

Effect of computerized physician order entry inactivation to order complementary studies in an emergency department / [Efecto de la inactivación de las órdenes múltiples para solicitud de estudios complementarios en una central de emergencias.]

Introduction: The computerized provider order entry (CPOE) is a computing tool that could lead to unintended consequences despite its myriad benefits. We aimed to explore the effect of its inactivation on requests for complementary studies and the associated costs. Methods: Cross sectional study at the Emergency Department of Hospital Italiano de Buenos Aires, which included a consecutive sample of pre-intervention (January-February 2020) and post-intervention (2021) consultations. Using secondary bases, the variables included were administrative debits and their respective billing prices. Results: There were 27,671 consultations in 2020 with a total median value of $474, and 20,819 with $1,639 in 2021. After the analysis restricted to the area of ​​moderately complex clinics (excluding COVID-19 consultations), the following was found: a decrease in the median number of practices per consultation (median of 11 vs. 10, p=0.001), a decrease in the request for at least one laboratory practice (45% vs. 39%, p=0.001), without finding significant changes in global costs (median $1,419 vs. $1,081; p=0.122) or in specific laboratory costs (median $1,071 vs. $1,089, p=0.710). Conclusion: Despite inflation, a significant reduction in the number of practices was achieved and overall costs per consultation were maintained. These findings demonstrate the effectiveness of the intervention, but an educational intervention aimed at reminding the potential harm of overuse and the health costs of unnecessary studies will be necessary.

Introducción: La plantilla de órdenes múltiples es una herramienta informática que podría producir consecuencias inadvertidas pese a sus innumerables beneficios. Nos propusimos explorar el efecto de su inactivación sobre las solicitudes de estudios complementarios y los costos asociados. Métodos: Corte transversal en la Central de Emergencias de Adultos del Hospital Italiano de Buenos Aires, que incluyó muestra consecutiva de consultas pre-intervención (Enero-Febrero 2020) y post-intervención (2021). Mediante el uso de bases secundarias, las variables incluidas fueron los débitos administrativos y sus respectivos precios de facturación. Resultados: Hubo 27.671 consultas en 2020 con una mediana de valor total de 474$, y 20.819 con 1.639$ en 2021. Tras el análisis restringido al área de consultorios de moderada complejidad (excluyendo consultas por COVID-19), se encontró: una disminución en la mediana del número de prácticas por consulta (mediana de 11 vs 10, p=0,001), una disminución en la solicitud de al menos una práctica de laboratorio (45% versus 39%, p=0,001), sin encontrar cambios significativos en costos globales (mediana 1.419$ vs 1.081$; p=0,122) ni en costos específicos de laboratorio (mediana 1.071$ vs 1.089$, p=0,710). Conclusión: Pese a la inflación interanual, se logró una reducción significativa en el número de prácticas y se mantuvieron los costos globales por consulta. Estos hallazgos demuestran la efectividad de la intervención, pero serán necesarias medidas educativas que apunten al recordatorio de los potenciales daños en la sobreutilización, y los costos sanitarios de los estudios innecesarios.

Intoxicación por monóxido de carbono: estudio observacional de pacientes que acudieron a Urgencias durante 2020 / Carbon monoxide poisoning: an observational study of patients admitted to Emergency Department during 2020

El objetivo fue describir las intoxicaciones monóxido de carbono. Se diseñó un corte transversal que incluyó una muestra consecutiva de mediciones de carboxihemoglobina (COHb), realizadas Enero y Diciembre 2020 en la Central de Emergencias del Hospital Italiano de Buenos Aires. Se utilizaron bases secundarias y revisión manual de historias clínicas para recolección de varia-bles de interés. Durante el período de estudio hubo 20 pacientes confirmados, con media de 50 años (DE 20), 55% sexo masculino, 20% tabaquistas, y una única embarazada. El 70% correspondieron al trimestre Junio-Julio-Agosto. La fuente de intoxicación más frecuente se debió a accidentes domésticos (calefón, estufa, brasero, hornalla, salamandra) que representaron el 50% de los casos, 30% por incendios, y el 20% restante explicado por tabaco o factor desconocido. Los estudios de laboratorio más solicitados fueron: 95% recuento de glóbulos blancos, 85% glucemia, 70% CPK, y 55% troponina. Los hallazgos relevantes fueron COHb con mediana de 7.15%, CPK con mediana de 89 U/mL, y troponina con mediana de 8.5 pg/mL. La totalidad se realizó electrocardiograma: 15% presentaron arritmia como hallazgo patológico, y ninguno isquemia. En cuanto la presentación clínica: 30% presentó cefalea, 15% síncope, 15% coma, 10% mareos y 10% convulsiones. Sólo 25% tuvieron tomografía y 15% resonancia de cerebro, sin hallazgos críticos. Sin embargo, 15% fueron derivados para trata-miento con cámara hiperbárica. La mayoría ocurrieron en invierno y explicados por accidentes domésticos. Será necesario un fortalecimiento del rol preventivo que apunte al control de la instalación y el buen funcionamiento de artefactos, como mantener los ambientes bien ventilados (AU)

The objective was to describe carbon monoxide poisoning. A cross sectional was designed, which included a consecutive sample of carboxyhemoglobin (COHb) measurements, carried from January to December 2020 at the Emergency Department of tHospital Italiano de Buenos Aires. Secondary databases and manual review of medical records were used to collect variables of interest. During the study period there were 20 confirmed patients, with a mean age of 50 (SD 20), mostly male (55%), 20% smokers, and only one pregnant woman, 70% corresponded to June-July-August. The most frequent source of poisoning was explained to domestic accidents (water heater, stove, brazier, stove, salamander) which represented 50% of cases, 30% due to fires, and the remaining 20% by tobacco or unknown factor. The most laboratory studies were: 95% white blood cell count, 85% glycemia, 70% CPK, and 55% troponin. Meanwhile, relevant findings were carboxyhemoglobin with a median of 7.15%, CPK with a median of 89 U/mL, and troponin with a median of 8.5 pg/mL. All underwent an electrocardiogram: 15% presented arrhythmia as a pathological finding, and none ischemia. Regarding the clinical presentation: 30% presented headache, 15% syncope, 15% coma, 10% dizziness and 10% seizures. Only 25% had brain tomography and 15% MRI, without pathological findings. However, 15% were referred for treatment with a hyperbaric chamber. Most of the cases occurred in winter and explained by domestic accidents. It will be necessary to strengthen the preventive role that aims to control the installation and the proper functioning of devices, such as keeping rooms well ventilated (AU)

Planificación anticipada de los cuidados y del uso de recursos hospitalarios en pacientes con COVID-19 en un programa de atención integrada para adultos mayores frágiles en residencias / Advance care planning and use of health resources among COVID-19 nursing home patients in an integrated health care program for frail elders

Objetivos: Evaluar la magnitud y la trascendencia de un proceso de estratificación y planificación anticipada de los cuidados y el uso de recursos hospitalarios en pacientes con COVID-19 en un programa de atención integrada para pacientes adultos mayores frágiles en residencias. Material y métodos: Estudio de cohorte prospectiva de pacientes >64 años con COVID-19 en un programa en residencias, desde marzo a septiembre de 2020. Se evaluó la identificación de pacientes con necesidad de abordaje paliativo (NECPAL positivo), la realización de la planificación anticipada del cuidado y su registro visible en la historia clínica electrónica. Se evaluó la utilización de cuidados intensivos. Resultados: Trescientos setenta y cuatro pacientes tuvieron COVID-19: el 88% eran mujeres, mediana de edad 88 años. El 79% tenían necesidades de abordaje paliativo, de los cuales el 68% tenía registrada la planificación anticipada del cuidado (p<0,001) en su historia clínica electrónica. Solamente el 1% de los pacientes con necesidad de abordaje paliativo con criterios de severidad utilizó cuidados intensivos. La mortalidad global fue del 25%. De los fallecidos, el 74% tenían criterios de severidad (p<0,001) y el 90% tenían necesidad de abordaje paliativo (p<0,001). Conclusiones: Realizar un proceso de atención basado en la estratificación e identificación de pacientes con necesidad de abordaje paliativo y la planificación anticipada del cuidado, con registro en un lugar central y visible de la historia clínica electrónica, podría mejorar la calidad y la seguridad de la atención, adecuando los recursos a las necesidades del paciente en todo momento y especialmente en situaciones de emergencia sanitaria. (AU)

Objectives: To estimate the magnitude and importance of a process of stratification and advance care planning and the use of health resources, among patients in an integrated health care program for frail elderls in nursing homes,that were referred to the hospital with COVID-19. Material and methods: Prospective cohort study of patients >64 years old with COVID-19 infection, in a health care program in nursing homes (from 3/15/2020 to 9/15/2020). The identification of patients with palliative needs, the performing and visible registration in electronic health records of the advance care planning and the use of intensive care were assessed. Results: We included 374 COVID-19 patients. 88% were women, the median age was 88 years old. The 79% were patients with palliative needs, of which 68% had the advance care planning (P<.001) registered in the electronic health record. Only 1% of patients with palliative needs and severity criteria were admitted to the intensive care unit. Overall mortality was 25%. Of those who died, 74% had severity criteria (P<.001) and 90% had palliative needs (P<.001). Conclusions: Carrying out a care process based on identification of patients with palliative needs and advance care planning and a central and visible registration of advance care planning in health records, could improve the quality and safety of care and optimize the use of intensive care health resources at all times and especially in public health emergencies. (AU)

Decrease in Mortality from Sepsis: Impact of the Multidisciplinary Program for the Hematologic Patient at Very High Risk.

A program for the hematologic patient at very high risk of infections (HAR, from its initials in Spanish) was implemented, based on a multidisciplinary team and six measures intended to reduce the colonization and subsequent sepsis by multidrug-resistant organisms (MDRO). We aimed at evaluating the effectiveness of the HAR program in terms of MDRO infections mainly caused by Klebsiella pneumoniae carbapenemase-producing and multidrug-resistant Pseudomona aeruginosa, and sepsis-related mortality. We established retrospective comparisons between the pre-HAR period (2016-2018) and the post-HAR period (2018-2019), in patients who received a hematopoietic stem cell transplant (HSCT) and/or intensive chemotherapy to treat non-M3 acute myeloid leukemia (CH-AML). We included 262 patients: 176 pre-HAR and 86 post-HAR. MDRO infection was 4.6% at 30 days and 6.1% at 90 days (all the cases during the pre-HAR period). Sepsis-related mortality was 6.5%, considering a median follow-up of 608 days: 6.1% in the HSCT group and 12.4% in the CH-AML group (p = 0.306). Sepsis-related mortality was 8.7% in the pre-HAR period and 0% in the post-HAR period (p = 0.014). The implementation of this multidisciplinary program based in preventive measures and the appropriate use of antibiotics enabled a decrease in sepsis-related mortality in very high-risk hematologic patients.

[Advance care planning and use of health resources among COVID-19 nursing home patients in an integrated health care program for frail elders]. / Planificación anticipada de los cuidados y del uso de recursos hospitalarios en pacientes con COVID-19 en un programa de atención integrada para adultos mayores frágiles en residencias.

OBJECTIVES: To estimate the magnitude and importance of a process of stratification and advance care planning and the use of health resources, among patients in an integrated health care program for frail elderls in nursing homes,that were referred to the hospital with COVID-19. MATERIAL AND METHODS: Prospective cohort study of patients >64 years old with COVID-19 infection, in a health care program in nursing homes (from 3/15/2020 to 9/15/2020). The identification of patients with palliative needs, the performing and visible registration in electronic health records of the advance care planning and the use of intensive care were assessed. RESULTS: We included 374 COVID-19 patients. 88% were women, the median age was 88 years old. The 79% were patients with palliative needs, of which 68% had the advance care planning (P<.001) registered in the electronic health record. Only 1% of patients with palliative needs and severity criteria were admitted to the intensive care unit. Overall mortality was 25%. Of those who died, 74% had severity criteria (P<.001) and 90% had palliative needs (P<.001). CONCLUSIONS: Carrying out a care process based on identification of patients with palliative needs and advance care planning and a central and visible registration of advance care planning in health records, could improve the quality and safety of care and optimize the use of intensive care health resources at all times and especially in public health emergencies.

[Participatory Action Research on perceptions, concerns and needs of health professionals in an emergency department from Argentina]. / Investigación-Acción Participativa sobre percepciones, preocupaciones y necesidades de los profesionales de salud en una central de emergencias de Argentina.

INTRODUCTION: To explore perceptions, concerns and needs of healthcare professionals in an emergency department (ED) from Argentina. METHODS: Participatory action research, coordinated and carried out by ED healthcare professionals, which included physicians, nurses and administrative staff who actively engaged in both data collection and analysis. Mixed methodologies were used: documentary analysis of complaints and written claims by patients, 10 individual interviews, and two reflective focus groups of 10 healthcare professionals (who differed in occupation, seniority and experience, including residents in training). RESULTS: The topics that emerged were work factors that lead to errors and threaten patient-centered clinical encounters: work overload and lack of time, the overuse of resources for defensive medicine purposes and technology that replaces physical contact. Healthcare professionals reported episodes of aggression by patients or their families, when long waits and structural insufficiencies (such as lack of beds, saturation of the waiting room, discomfort) threaten patience and tolerance. From these insights, improvements were generated in various areas of the ED. CONCLUSIONS: The identification of problems by the ED stakeholders l was a relevant approach that led to a process of collective management change, promoted reflection and raised awareness, allowing the identification of areas for improvement, design strategies and concrete feasible proposals.

OBJETIVO: Explorar las percepciones, preocupaciones y necesidades del personal de salud en una Central de Emergencias de Adultos (CEA) de Argentina. Métodos: Investigación o acción participativa, coordinada y ejecutada por el propio personal de la CEA, que incluyó médicos/as, personal de enfermería y administrativo/as para participar activamente en la recolección de información y en el análisis. Se utilizaron metodologías mixtas: análisis documental de quejas y reclamaciones escritas por parte de los pacientes, 10 entrevistas individuales y 2 grupos focales reflexivos con 10 integrantes del personal de salud (de diferente cargo y antigüedad, y residentes en formación). RESULTADOS: Los tópicos emergentes fueron factores laborales que inducen al error y atentan contra el encuentro clínico centrado en la persona: la sobrecarga y la falta de tiempo, la sobreutilización de recursos por medicina defensiva y la tecnología que reemplaza el contacto físico. El personal de salud manifestó episodios de agresiones de pacientes o sus familiares, cuando las largas esperas y las insuficiencias estructurales (como falta de camas, saturación de sala de espera, incomodidad) atentan contra la paciencia y la tolerancia. A partir de esta reflexión se generaron mejoras en diversas áreas de la CEA. CONCLUSIONES: La identificación de las problemáticas realizadas por los propios actores de la CEA resultó un método pertinente para generar un proceso de cambio de gestión colectiva, promover la reflexión y concientizar, permitir identificar áreas de mejora, diseñar estrategias y propuestas concretas.

Decision support through risk cost estimation in 30-day hospital unplanned readmission.

Unplanned hospital readmissions mean a significant burden for health systems. Accurately estimating the patient's readmission risk could help to optimise the discharge decision-making process by smartly ordering patients based on a severity score, thus helping to improve the usage of clinical resources. A great number of heterogeneous factors can influence the readmission risk, which makes it highly difficult to be estimated by a human agent. However, this score could be achieved with the help of AI models, acting as aiding tools for decision support systems. In this paper, we propose a machine learning classification and risk stratification approach to assess the readmission problem and provide a decision support system based on estimated patient risk scores.

Eficacia de una intervención educativa en el manejo de un dispositivo de inhalación entre profesionales de enfermería de un servicio de urgencias / Efficacy of an educational intervention in the management of an inhalation device among nursing professionals of an emergency department

Objetivo: Explorar los errores más frecuentes de la técnica inhalatoria (pilar para el tratamiento farmacológico de las exacerbaciones de asma y/o enfermedad pulmonar obstructiva crónica) en enfermeras de un servicio de urgencias, y evaluar la eficacia de una intervención educativa. Métodos: Estudio cuasiexperimental prospectivo, realizado en un hospital de Argentina durante 2019. Para la evaluación de enfermeras se utilizaron los pasos del Consenso Separ-Alat. La intervención educativa consistió en explicación oral y demostración visual de la técnica inhalatoria. Se realizó análisis de datos pareados, y se calcularon las frecuencias absolutas y relativas con sus respectivos intervalos de confianza de 95%. Resultados: Se incluyó una muestra consecutiva de 72 enfermeros, de los cuales el 95,83% (IC 95% 88,30-99,13) cometieron al menos un error en la evaluación basal. Los errores más frecuentes fueron la falta de indicación al paciente de espirar previo a la inhalación (83,72%), el olvido de retirar la aerocámara y repetir los pasos antes de la segunda dosis (81,40%). Tras la evaluación inmediata después de recibir la intervención educativa, el 74,42% (IC 95% 58,83-86,49) corrigió la técnica. Sin embargo, al mes el 53,49% (23/43; IC 95% 37,66-68,86) realizaba la técnica correctamente. Conclusiones: La intervención educativa puede ser eficaz para subsanar errores en esta práctica, aunque sus efectos tienden a extinguirse con el tiempo. Por ende, consideramos relevante la educación periódica y sistemática para mantener una técnica de inhalación correcta entre los profesionales.(AU)

Objetive: To explore the most frequent errors of the inhalation technique (main topic for the pharmacological treatment of exacerbations of asthma and/or chronic obstructive pulmonary disease) in the nursing staff of an emergency department, and to evaluate the efficacy of an educational intervention. Methods: Prospective quasi-experimental study, carried out in a hospital in Argentina during 2019. For the evaluation of the nursing staff, the steps of the Separ-Alat Consensus were used. The educational intervention consisted of oral explanation and visual demonstration of the inhalation technique. Paired data analysis was performed, and absolute and relative frequencies were calculated with their respective 95% confidence intervals. Results: A consecutive sample of 72 nurses was included, of which 95.83% (95% CI 88.30-99.13) made at least one error in the baseline assessment. The most frequent errors were the lack of indication to the patient to exhale prior to inhalation (83.72%), forgetting to remove the air chamber and repeat the steps before the second dose (81.40%). After immediate evaluation after receiving the educational intervention, 74.42% (95% CI 58.83-86.49) corrected the technique. However, at one month, 53.49% (23/43; 95% CI 37.66-68.86) performed the technique correctly. Conclusions: The educational intervention could be effective in correcting errors in this practice, although its effects tend to fade over time. Therefore, we consider periodic and systematic education relevant to maintain a correct inhalation technique among professionals.(AU)

Can CPOE Based on Electronic Order Sets Cause Unintended Consequences (Expensive and Unnecessary Tests) at the Emergency Department?

Computerized Provider Order Entry (CPOE) systems may cause unintended consequences. This study aimed to describe the on-going system for CPOE order sets, and to explore an economic evaluation at the Emergency Department. First, we developed a costs dashboard which showed us the significant and excessive use of medical tests per consultation. We identified the top 10 most widely used and most expensive tests. Additionally we noticed that the labs seemed to continually increase. Then, we found that 27% of the consultations have at least one item of laboratory practice between January and February 2020, and this represents more than 80% of the consultation costs. Health care spending has reached epic proportions globally. We think that it is time to rethink effective strategies. Maybe it is time to deactivate/remove electronic order sets (EOSs) and the functionality to develop and create their own "private" order sets, in order to eliminate waste and inefficiencies.

Evaluation of Telehealth Service for COVID-19 Outpatients: A Dashboard to Measure Healthcare Quality and Safety.

Due to the COVID-19 pandemic, changes and improvements regarding the organization have been made to adapt quickly at the Emergency Department (ED) of the Hospital Italiano de Buenos Aires, Argentina. This article describes the design, implementation, and use of an electronic dashboard which provided monitoring of patients discharged home, during follow-up with telehealth. It was useful to access essential information to organize and coordinate professional work and patients' surveillance, providing highly relevant data in real-time as proxy variables for quality and safety during home isolation. The implemented tool innovated in the integration of technologies within a real context. The information management was crucial to optimize services and decision-making, as well to guarantee safety for healthcare workers and patients.

Impact of COVID-19 Pandemic on Telehealth and In-Person Visits: Implications from an Emergency Department in Argentina.

Since Argentina's government declared a national emergency to combat the COVID-19 pandemic with a lockdown status, it has produced consequences on the healthcare system. We aimed to quantify the effect on the Emergency Department (ED) visits at Hospital Italiano de Buenos Aires. Our electronic health data showed that ED in-person visits declined 46% during the COVID-19 pandemic, from an overall of 176,370 visits during 2019 to 95,421 visits during 2020. Simultaneously, there was a telehealth visits boom when mandatory quarantine began (March 20, 2020): from a median of 12 daily in February 2020 to a median of 338 daily in April 2020; reaching a maximum daily peak of 1,132 on March 26 2020. For a while, teleconsultations replaced ED visits. Then, when face-to-face visits began to increase, teleconsultations began to decrease slowly, as the phenomenon reversed.