Futuras líneas de investigación en cuidados sobre dolor, sedación, contenciones y delirium en el paciente crítico / Future lines of research on pain care, sedation, restraints and delirium in the critically ill patient

La valoración y manejo del dolor-analgesia, agitación-sedación, contenciones mecánicas (CM) y delirium en el paciente critico ha ido evolucionando en los últimos años, tal y como recogen las recomendaciones de las Guías de Práctica Clínica (GPC) 1. Sin embargo, todavía quedan cuestiones pendientes, en las que las enfermeras pueden investigar destacando el efecto que los cuidados pueden tener en los resultados de salud sensibles a la práctica enfermera. A continuación, se proponen doce líneas de investigación en cuidados para la orientación de futuros proyectos sobre dolor, sedación, CM y delirium. (AU)

Guía de práctica clínica del American College of Critical Care Medicine sobre prevención y manejo del dolor, agitación/sedación, contenciones mecánicas, delirio, inmovilidad y alteraciones del sueño del paciente adulto / Clinical Practice Guidelines of the American College of Critical Care Medicine for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients

Objetivo: Actualizar y ampliar la Guía de Práctica Clínica de 2013 para el manejo del dolor, agitación y delirio en pacientes adultos de la UCI. Diseño: Treinta y dos expertos internacionales, cuatro expertos en metodología, y cuatro supervivientes de enfermedades críticas se reunieron virtualmente, al menos una vez al mes. Todos los grupos de sección se reunieron personalmente en los congresos anuales de la Sociedad de Medicina de Cuidados Críticos; las conexiones virtuales incluyeron a aquellas personas que no pudieron asistir. A priori, se desarrolló una política formal de conflicto de intereses, que se hizo cumplir a lo largo del proceso. Las teleconferencias y debates electrónicos entre los subgrupos, así como el panel al completo, formaron parte del desarrollo de la guía. Todos los miembros del panel realizaron personalmente una revisión general del contenido en enero de 2017. Métodos: Los expertos contenidos, los expertos en metodología, y los supervivientes de la UCI estuvieron representados en cada una de las cinco secciones de la guía: Dolor, Agitación/sedación, Delirio, Inmovilidad (movilización/rehabilitación), y Sueño (interrupción). Cada sección creó preguntas descriptivas y no procesables sobre Población, Intervención, Comparación, y Resultados, basadas en la relevancia clínica percibida. A continuación, el grupo responsable de la guía votó su clasificación, y los pacientes priorizaron su importancia. Para cada pregunta sobre Población, Intervención, Comparación, y Resultados, las distintas secciones buscaron la evidencia mejor disponible, determinaron su calidad, y formularon recomendaciones del tipo declaraciones sobre prácticas "sólidas," "condicionales," o "buenas" basándose en los principios de calificación de valoración, desarrollo y evaluación de recomendaciones. Además, se identificaron explícitamente las brechas de la evidencia y las salvedades clínicas. Resultados: El panel sobre dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción) emitió 37 recomendaciones (3 sólidas y 34 condicionales), dos declaraciones de prácticas buenas, y 32 declaraciones no calificables y no procesables. Tres preguntas procedentes de la lista de preguntas priorizadas centradas en el paciente carecieron de recomendación. Conclusiones: Concluimos un acuerdo sustancial entre una gran cohorte interdisciplinaria de expertos internacionales en cuanto a la evidencia que respalda las recomendaciones y las brechas en la literatura pendientes en cuanto a evaluación, prevención y tratamiento del dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción) en adultos críticos. Subrayar dicha evidencia y las necesidades de investigación mejorarán el manejo del dolor, agitación/sedación, delirio, inmovilidad (movilización/rehabilitación), y sueño (interrupción), y aportarán las bases para mejorar los resultados y la ciencia en esta población vulnerable

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Factores que favorecen el reingreso en intensivos de pacientes con síndrome coronario agudo / Factors that favor re-entry in intensive patients with acute coronary syndrome

Introducción: Alrededor del 7% de los pacientes que ingresan en las Unidades de Cuidados Intensivos (UCI) por síndrome coronario agudo (SCA) en España, reingresan de nuevo tiempo después. Objetivos: Identificar posibles causas y factores predisponentes a reingresar en UCI por SCA. Metodología: Estudio retrospectivo, descriptivo, comparativo y longitudinal de pacientes ingresados por SCA en una UCI polivalente entre enero de 2008 y diciembre de 2013. Se recogen variables demográficas, número de ingresos, factores de riesgo al ingreso (dislipemias, hipertensión arterial y diabetes) y hábitos de vida no cardiosaludables (sedentarismo/obesidad, tabaquismo, enolismo) de pacientes que reingresan y se comparan con grupo de control (pacientes que no reingresan). Se realiza test Chi 2 de Pearson y significación estadística. Resultados: Ingresaron 2.506 pacientes por SCA. Reingresaron 140 (5,58%) a los 12,93±16,41 meses después del primer ingreso. Los que reingresan están en UCI 4.97± 3.3 días (4.03±1.8 grupo control) en su primer ingreso. Se adjunta tabla con incidencia de factores de riesgo y hábitos de vida no saludables de ambos grupos. El tabaquismo y enolismo se relacionan con los reingresos (χ²=5.67; p<0.01). Conclusiones: Los pacientes que reingresan, están más días en UCI en su primer ingreso, presentan un menor control de factores de riesgo y menor índice de abandono de hábitos nocivos que el grupo control. El tabaco y el alcohol son factores que favorecen el reingreso. Parece indicar que existe un problema de adherencia terapéutica en la muestra estudiada

Introduction: About 7% of patients admitted in Intensive Care Units (ICUs) due to acute coronary syndrome (ACS) in Spain, are readmitted again later. Objectives: Identify the possible causes and predisposing factors for returning to ICU because of ACS Methodology: Retrospective, descriptive, comparative and longitudinal study of patients admitted for ACS in the ICU between January 2008 and December 2013.Demographic variables, number of admissions, admission risk factors (dyslipidemia, hypertension and diabetes) and non heart-healthy life habits (sedentary / obesity, smoking, alcoholism) of patients who come back were collected and were compared with control group (not readmitted patients). Pearson’s Chi 2 test and statistical significance were performed. Results: 2.506 patients were admitted by ACS. Readmissions were 140 (5,58%) after 12,93±16,41 months from their first admission. The ICU’s reentering patients stayed4.97± 3.3 days (4.03±1.8 control group) in their first admission. A table is attached with risk factors' incidence and non heart-healthy life habits of both groups. Smoking and alcoholism habits are related with readmissions (χ²=5.67; p<0.01). Conclusions: The patients who are readmitted stay more days in ICU in their first admission, have less control about risk factors and less quitting index of nocive habits than control group. It seems to exist an adherence therapeutic problem in the sample studied

Trabajo en equipo: visión de los enfermeros de un hospital de Murcia/España / Trabalho em equipe: visão de enfermeiros de um hospital de Murcia/Espanha / Teamwork: vision of nurses in a hospital of Murcia / Spain

Objetivo: Conocer la visión de las enfermeras, que trabajan en un hospital de Murcia, en España, sobre el trabajo en equipo. Método: Un estudio cualitativo, descriptivo y exploratorio, fue realizado desde noviembre de 2011 a enero de 2012, con 14 enfermeras en el Hospital General Universitario Reina Sofía. La recolección de datos ocurrió a través de dos reuniones de grupos focales. Los datos se analizaron por la propuesta operativa de Minayo. Resultados: Los enfermeros reconocen que todos los miembros del equipo son importantes y que cada uno aporta sus especificidades. Sin embargo, hay muchas dificultades en el trabajo diario: individualismo, alta rotación de personal, falta de autonomía, relaciones verticales de poder, falta de tiempo para las reuniones y de líderes para construir y fomentar el trabajo en equipo. Conclusión: Se destaca que la comunicación efectiva en el lugar de trabajo puede ser capaz de reducir conflictos y promover la formación de vínculos profesionales saludables. Por lo tanto, las actitudes dialógicas son fundamentales para promover el trabajo colectivo (AU)

Objetivo: conhecer a visão de enfermeiros, que atuam em um Hospital de Múrcia na Espanha, sobre trabalho em equipe. Método: trata-se de um estudo qualitativo do tipo descritivo e exploratório, realizado em novembro de 2011 a janeiro de 2012, com 14 enfermeiros que trabalhavam no Hospital Geral Universitário Reina Sofía. A coleta de dados ocorreu por meio de dois encontros de grupo focal. Os dados foram analisados pela proposta operativa de Minayo. Resultados: os enfermeiros reconhecem que todos os integrantes da equipe são importantes e que cada um contribui com suas especificidades. Entretanto, inúmeras dificuldades são enfrentadas na realização do trabalho cotidiano, como: individualismo, alta rotatividade da equipe, falta de autonomia, relações de poder verticais, falta de momentos de encontros e de líderes para a construção e estímulo do trabalho em equipe. Conclusão: destaca-se que comunicação efetiva no ambiente de trabalho pode ser capaz de diminuir os conflitos e favorecer a formação de vínculos profissionais saudáveis. Desta forma, posturas dialógicas são fundamentais para promover o trabalho coletivo

Objective: To know the vision of nurses who work in a Hospital of Murcia in Spain, a bout teamwork. Method: This was a qualitative, descriptive and exploratory study, conducted from November 2011 to January 2012, with 14 nurses who worked at the University Hospital Reina Sofía. The data collection occurred through two focus group meetings. Data were analyzed by the proposed operative of Minayo. Results: The nurses recognize that all team members are important and that each one contributes with its specificities. However, many difficulties are faced in carrying out the daily work, such as individualism, high staff turnover, lack of autonomy, vertical power relations, lack of time for meetings and of leaders to build and to encourage the teamwork. Conclusion: It is emphasized that effective communication in the workplace may be able to reduce conflicts and promote the formation of healthy professional links. Thus, dialogical attitudes are fundamental to promote collective work (AU)

Evaluation of the effectiveness of hospital discharge planning and follow-up in the primary care of patients with chronic obstructive pulmonary disease.

AIMS AND OBJECTIVES: To evaluate the effectiveness of protocolised intervention for hospital discharge and follow-up in the primary care of patients with chronic obstructive pulmonary disease (COPD). BACKGROUND: Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. DESIGN: A quasi-experimental design was adopted, with a control group and it was pseudorandomised by services. METHODS: Patients with COPD admitted to two tertiary-level public hospitals in Spain were recruited (2007-2008). The outcome variables included: readmission rate, patient satisfaction (LOPSS12), quality of life (St. George's Respiratory Questionnaire) and level of knowledge about COPD. 48 hours after admission, both groups were evaluated by specialist coordinating nurses. At the hospital, a coordinating nurse visited each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, explain treatment, identify care problems and needs and facilitate communication between professionals. 24 hours after discharge, the coordinating nurses informed the primary care nurses about patient discharge. The two nurses made the first home visit together. There were follow-up phone calls at 2, 6, 12 and 24 weeks after discharge. A total of 143 patients were recruited (Intervention group=56; Control group=87). RESULTS: The results showed a significant improvement in the evolution of quality of life, at 12 and 24 weeks after discharge; the level of knowledge about COPD revealed significant differences between the groups. There were no differences according to satisfaction or readmission rate. Multivariate analysis (non-conditional logistic regression) showed the intervention to be ineffective in reducing the readmission rate. CONCLUSIONS: The planning of discharge for patients with COPD is effective in terms of improving the patients' quality of life and level of knowledge about the disease. RELEVANCE TO CLINICAL PRACTICE: The characteristics of patients with COPD make it necessary to include them in hospital discharge planning programmes.

[A descriptive study of the socio-demographic and clinical profile of the patient with chronic obstructive pulmonary disease]. / Estudio descriptivo sobre el perfil socio-demográfico y clínico del paciente con enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To find out the socio-demographic and clinical profile of the patient with Chronic Obstructive Pulmonary Disease (COPD): characteristics, state of health, situation of disease and social resources. METHOD: A descriptive, longitudinal and prospective study, in the Morales Meseguer and Reina Sofía Hospitals in Murcia (Spain), was performed between June 2007 and April 2008. The inclusion criteria was hospital admission due to COPD and patients with cognitive deterioration, a hospital stay > 30 days or < 2 days, or were institutionalised, were excluded. Socio-demographic, state of health and social variables were collected using the patient's clinical history and an interview during hospital stay and at discharge. The descriptive statistical analysis was carried out using SPSS v.15. RESULTS: A total of 143 patients were studied, of which 90.2% were males who had a mean age of 72.76 ± 8.04 years, 95.1% were in an inactive work situation and had a mean score on the social problem scale of 8.08 ± 2.1. Most were in a fragile state (71.3%), approximately half (44.8%) suffered heart disease as the main co-morbidity factor, and the impact of the disease on quality of life was 55.1 ± 19.01. The level of knowledge on the therapeutic regime was 3.13 ± 0.7. A total of 72% were independent for carrying out Basic Activities of Daily Living (BADL) after hospital discharge. CONCLUSIONS: Most of the population that suffers from COPD were elderly males, who were retired without social problems, with a high percentage of co-morbidity, an intermediate alteration in their quality of life, having a moderate level of knowledge about the therapeutic regime and were independent for BADL, but fragile.

Estudio descriptivo sobre el perfil socio-demográfico y clínico del paciente con enfermedad pulmonar obstructiva crónica / A descriptive study of the socio-demographic and clinical profile of the patient with chronic obstructive pulmonary disease

Objetivo. Conocer el perfil sociodemográfico y clínico del paciente con enfermedad pulmonar obstructiva crónica (EPOC): características, estado de salud, situación de enfermedad y recursos sociales. Método Estudio descriptivo:, longitudinal y prospectivo, en los Hospitales Morales Meseguer y Reina Sofía de Murcia, entre junio de 2007 y abril de 2008. El criterio de inclusión fue ingreso por EPOC, y se excluyó a pacientes con deterioro cognitivo, ingreso superior a 30 días o inferior a 2 e institucionalizados. Se recogieron variables sociodemográficas, estado de salud y social (escalas validadas) mediante historia clínica y entrevista durante la estancia y al alta. El análisis estadístico descriptivo se realizó mediante SPSS v.15.ResultadosSe estudió a 143 pacientes; el 90,2% eran varones; la media de edad, 72,76±8,04 años; el 95,1% estaba en situación laboral inactiva y tenía una puntuación media en la escala de problemas sociales de 8,08±2,1. El 71,3% es frágil, el 44,8% padece cardiopatía como principal factor de comorbilidad, y el impacto de la enfermedad en la calidad de vida fue de 55,1±19,01. El nivel de conocimientos sobre el régimen terapéutico fue de 3,13±0,7. El 72% son independientes para actividades básicas de la vida diaria (ABVD) tras el alta hospitalaria. Conclusiones. La mayor parte de la población que padece EPOC son varones de edad avanzada, jubilados sin problemas sociales, con un elevado porcentaje de comorbilidad, una alteración intermedia en la calidad de vida y un nivel moderado de conocimientos sobre el régimen terapéutico y son independientes para ABVD, pero frágiles (AU)

Objective. To find out the socio-demographic and clinical profile of the patient with Chronic Obstructive Pulmonary Disease (COPD): characteristics, state of health, situation of disease and social resources. Method. A descriptive, longitudinal and prospective study, in the Morales Meseguer and Reina Sofía Hospitals in Murcia (Spain), was performed between June 2007 and April 2008. The inclusion criteria was hospital admission due to COPD and patients with cognitive deterioration, a hospital stay >30 days or<2 days, or were institutionalised, were excluded. Socio-demographic, state of health and social variables were collected using the patient's clinical history and an interview during hospital stay and at discharge. The descriptive statistical analysis was carried out using SPSS v.15. Results. A total of 143 patients were studied, of which 90.2% were males who had a mean age of 72.76±8.04 years, 95.1% were in an inactive work situation and had a mean score on the social problem scale of 8.08±2.1. Most were in a fragile state (71.3%), approximately half (44.8%) suffered heart disease as the main co-morbidity factor, and the impact of the disease on quality of life was 55.1±19.01. The level of knowledge on the therapeutic regime was 3.13±0.7. A total of 72% were independent for carrying out Basic Activities of Daily Living (BADL) after hospital discharge. Conclusions. Most of the population that suffers from COPD were elderly males, who were retired without social problems, with a high percentage of co-morbidity, an intermediate alteration in their quality of life, having a moderate level of knowledge about the therapeutic regime and were independent for BADL, but fragile (AU)

Effects of competitive computer-assisted learning versus conventional teaching methods on the acquisition and retention of knowledge in medical surgical nursing students.

PURPOSE: This paper presents a novel approach of computer-assisted learning for nursing education in university undergraduate courses. BACKGROUND: The most innovative aspect of the proposal is the design of nursing assignments as on-line competitions. The effects of competitive e-learning versus conventional teaching methods on the acquisition and retention of knowledge were compared in a course on medical-surgical nursing. METHOD: A total of 116 students of mixed gender, age, computer experience and educational background in a second-year course on medical-surgical nursing participated in the study. Data were collected from nursing students at four time points. The on-line activities were carried out using a web-based automatic evaluation system. RESULTS: The study revealed that the competitive e-learning method produced significant cognitive gains for the experimental group students in the immediate follow-up test. Nevertheless, both teaching methods resulted in similar knowledge retention in the 10-week follow-up test. CONCLUSION: Significant benefits were found following our approach. The work of the students could be evaluated along the course, the workload of instructors was reduced and students received immediate feedback by the on-line judge, which promoted both independent learning and reflective thinking. The approach is applicable to any other nursing educational institution.

Effectiveness of planning hospital discharge and follow-up in primary care for patients with chronic obstructive pulmonary disease: research protocol.

AIM: To evaluate the effectiveness of a protocolized intervention for hospital discharge and follow-up planning for primary care patients with chronic obstructive pulmonary disease. BACKGROUND: Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. These patients suffer from high rates of exacerbation and hospital readmission due to active problems at the time of hospital discharge. METHODS: A quasi-experimental design will be adopted, with a control group and pseudo-randomized by services (protocol approved in 2006). Patients with pulmonary disease admitted to two tertiary-level public hospitals in Spain and their local healthcare centres will be recruited. The outcome variables will be readmission rate and patient satisfaction with nursing care provided. 48 hours after admission, both groups will be evaluated by specialist coordinating nurses, using validated scales. At the hospital, a coordinating nurse will visit each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, and explain treatment. In addition, the visits will be used to identify care problems and needs, and to facilitate communication between professionals. 24 hours after discharge, the coordinating nurses will inform the primary care nurses about patient discharge and nursing care planning. The two nurses will make the first home visit together. There will be follow-up phone calls at 2, 6, 12 and 24 weeks after discharge. DISCUSSION: The characteristics of patients with this pulmonary disease make it necessary to include them in hospital discharge planning programmes using coordinating nurses.