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1.
J Cardiovasc Electrophysiol ; 30(10): 2041-2050, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31402492

RESUMO

INTRODUCTION: QTc-interval prolongation is associated with ventricular arrhythmias and mortality in a general population. Bazett's correction formula (QTcB) is routinely used despite its overcorrection at high heart rates. Recently, we proposed a patient-specific QT correcting algorithm (QTcA) resulting in improved rate correction and predictive value in a general population. We hypothesize risk stratification at the Emergency Department (ED) could be improved using QTcA. METHODS AND RESULTS: A retrospective case-control study including a randomized age- and sex-matched control population was performed at a tertiary care ED. A total of 1930 patients were included in the analysis (63.0% males, age 71.5 ± 15.6 years). Patient characteristics, history, and test results at the time of the electrocardiogram were collected. QTc was dichotomized as prolonged (>450 millisecond for men, >470 millisecond for women) or severely prolonged (>500 millisecond). Implementation of QTcA would reduce the number of patients considered to have a prolonged QTc by 65.2%, for severely prolonged QTc 79.6%. Multivariate regression was performed for in-hospital mortality, cardiovascular endpoints, and hospital admission. Neither a prolonged QTcB (HR 1.04; 95% CI, 0.64-1.69) nor QTcA (HR 0.76; 95% CI, 0.42-1.38) was an independent predictor of in-hospital mortality. A severely prolonged QTcA (OR, 2.54; 95% CI, 1.04-6.23) was an independent predictor of cardiovascular events. Both a prolonged QTcA (OR, 1.52; 95% CI, 1.06-2.18) and a prolonged QTcB (OR, 1.37; 95% CI, 1.05-1.79) were associated with higher hospitalization rates. CONCLUSIONS: QTcA reduced the number of patients considered at risk. Neither QTcB nor QTcA were predictors of in-hospital mortality. A severely prolonged QTcA was associated with cardiovascular events.

2.
Turk J Emerg Med ; 19(3): 111-112, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31321344

RESUMO

Introduction: Around 0.1-0.2% of all pregnancies are complicated by respiratory failure. The altered physiology of pregnancy predisposes mother and child to develop hypoxia and respiratory failure more easily than a non-pregnant patient. Respiratory failure in pregnancy may have detrimental fetal complications, therefore extensive knowledge of the range of therapeutic options is necessary. If conventional lung-protective mechanical ventilation strategies fail, alternative approaches such as veno-venous extracorporeal membrane oxygenation (VV-ECMO) should be considered. Case presentation: A previously healthy 30-year-old P1G2 at 26 weeks and 6 days of gestation was admitted to the emergency department because of a severe respiratory infection. She suffered of severe hypoxic respiratory failure due to an overwhelming pneumonia (influenza type A) with acute respiratory distress syndrome (ARDS). Because long protective ventilation strategies and ventilation in prone positioning were inadequate, and further respiratory deterioration occurred, VV-ECMO was initiated. Conclusion: In a pregnant patient with severe respiratory failure, when other interventions fail, initiation of VV-ECMO should not be delayed. The use of VV-ECMO in pregnancy is a multi-disciplinary team approach.

3.
World Neurosurg ; 114: e546-e558, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29548947

RESUMO

OBJECTIVE: According to level 2 evidence, earlier evacuation of acute subdural or epidural hematomas necessitating surgery is associated with better outcome. Hence, guidelines recommend performing these procedures immediately. Literature on the extent and causes of prehospital and intrahospital intervals in patients with trauma requiring emergent craniotomies is almost completely lacking. Studies delineating and refining the interval before thrombolytic agent administration in ischemic stroke have dramatically reduced the door-to-needle time. A similar exercise for trauma-to-decompression time might result in comparable reductions. We aim to map intervals in emergent trauma craniotomies in our level 1 trauma center, screen for associated factors, and propose possible ways to reduce these intervals. METHODS: We analyzed patients who were primarily referred (1R; n = 45) and secondarily referred (after computed tomography imaging in a community hospital [2R; n = 22]) to our emergency department (ED) and underwent emergent trauma craniotomies between 2010 and 2016. RESULTS: Median prehospital interval (between emergency call and arrival at the ED) was 42 minutes for 1R patients. Median intrahospital interval (between initial ED arrival and skin incision [SI]) was 140 minutes and 268 minutes for 1R and 2R patients, respectively. In 1R patients, ED-SI interval was positively correlated with Glasgow Coma Scale score (ρ=.49; P < 0.001), but not with age, time of ED arrival, or extended Glasgow Outcome Scale score at 6 months. Based on outlier analysis, we propose prehospital and intrahospital measures to improve performance. CONCLUSIONS: This is the first report on emergency call-SI interval in emergent trauma craniotomy, with a median of 174 minutes and >297 minutes for 1R and 2R patients, respectively, in our center.


Assuntos
Craniotomia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Centros de Traumatologia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Lesões Encefálicas , Criança , Pré-Escolar , Craniotomia/métodos , Serviço Hospitalar de Emergência/organização & administração , Feminino , Escala de Coma de Glasgow , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Tomografia Computadorizada por Raios X/métodos , Adulto Jovem
4.
Int Emerg Nurs ; 39: 68-76, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-28865753

RESUMO

BACKGROUND: As an emergency department (ED) is a complex adaptive system, the analysis of continuously gathered data is valuable to gain insight in the real-time patient flow. To support the analysis and management of ED operations, relevant data should be provided in an intuitive way. AIM: Within this context, this paper outlines the development of a dashboard which provides real-time information regarding ED crowding. METHODS: The research project underlying this paper follows the principles of design science research, which involves the development and study of artifacts which aim to solve a generic problem. To determine the crowding indicators that are desired in the dashboard, a modified Delphi study is used. The dashboard is implemented using the open source Shinydashboard package in R. RESULTS: A dashboard is developed containing the desired crowding indicators, together with general patient flow characteristics. It is demonstrated using a dataset of a Flemish ED and fulfills the requirements which are defined a priori. CONCLUSIONS: The developed dashboard provides real-time information on ED crowding. This information enables ED staff to judge whether corrective actions are required in an effort to avoid the adverse effects of ED crowding.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Administração de Recursos Humanos em Hospitais/instrumentação , Carga de Trabalho/normas , Arquitetura Hospitalar/instrumentação , Arquitetura Hospitalar/métodos , Humanos , Administração de Recursos Humanos em Hospitais/métodos , Fatores de Tempo , Carga de Trabalho/estatística & dados numéricos
5.
Int J Antimicrob Agents ; 51(4): 562-570, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29180278

RESUMO

Recent studies suggest that intensive care unit patients treated with amikacin frequently do not attain the desired pharmacokinetic/pharmacodynamic (PK/PD) target, i.e. peak amikacin concentration (Cpeak) to minimum inhibitory concentration (MIC) ratio of ≥8, when a single dose of 15 mg/kg is used. No data are available for patients admitted to the emergency department (ED). The aim of this prospective randomised controlled study was to determine PK/PD target attainment in ED patients presenting with severe sepsis or septic shock treated with 15 mg/kg versus 25 mg/kg amikacin. Patients were randomly assigned to receive amikacin 25 mg/kg or 15 mg/kg. Amikacin Cpeak values were determined. The primary outcome was target attainment defined as Cpeak/MIC ≥ 8 both using EUCAST susceptibility breakpoints and actually documented MICs as denominator. A total of 104 patients were included. The EUCAST-based target was attained in 76% vs. 40% of patients assigned to the 25 mg/kg vs. 15 mg/kg dose groups (P <0.0001). Target attainment using actual MICs (median of 2 mg/L, documented in 48 isolated Gram-negative pathogens) was achieved in 95% vs. 94% of patients in the 25 mg/kg vs. 15 mg/kg dose groups (P = 0.969). Risk factors associated with PK/PD target failure were identified in the multivariable analysis. At least 25 mg/kg amikacin as a single dose should be used in ED patients with severe sepsis and septic shock to attain the EUCAST-based PK/PD target. However, when using local epidemiology as denominator, 15 mg/kg appears to be sufficient. [ClinicalTrials.gov ID: NCT02365272.


Assuntos
Amicacina/farmacocinética , Amicacina/uso terapêutico , Antibacterianos/farmacocinética , Antibacterianos/uso terapêutico , Choque Séptico/tratamento farmacológico , Idoso , Idoso de 80 Anos ou mais , Amicacina/administração & dosagem , Antibacterianos/administração & dosagem , Cuidados Críticos , Relação Dose-Resposta a Droga , Serviço Hospitalar de Emergência , Enterobacteriaceae/efeitos dos fármacos , Infecções por Enterobacteriaceae/tratamento farmacológico , Feminino , Humanos , Masculino , Testes de Sensibilidade Microbiana , Pessoa de Meia-Idade , Estudos Prospectivos , Infecções por Pseudomonas/tratamento farmacológico , Pseudomonas aeruginosa/efeitos dos fármacos , Choque Séptico/microbiologia
6.
Emerg Med J ; 34(8): 502-508, 2017 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-28490484

RESUMO

BACKGROUND: The process of obtaining a complete medication history for patients admitted to the hospital from the ED at hospital admission, without discrepancies, is error prone and time consuming. OBJECTIVES: The goal of this study was the development of a clinical decision rule (CDR) with a high positive predictive value in detecting ED patients admitted to hospital at risk of at least one discrepancy during regular medication history acquisition, along with favourable feasibility considering time and budget constraints. METHODS: Data were based on a previous prospective study conducted at the ED in Belgium, describing discrepancies in 3592 medication histories. Data were split into a training and a validation set. A model predicting the number of discrepancies was derived from the training set with negative binomial regression and was validated on the validation set. The performance of the model was assessed. Several CDRs were constructed and evaluated on positive predictive value and alert rate. RESULTS: The following variables were retained in the prediction model: (1) age, (2) gender, (3) medical discipline for which the patient was admitted, (4) degree of physician training, (5) season of admission, (6) type of care before admission, number of (7) drugs, (8) high-risk drugs, (9) drugs acting on alimentary tract and metabolism, (10) antithrombotics, antihaemorrhagics and antianaemic preparations, (11) cardiovascular drugs, (12) drugs acting on musculoskeletal system and (13) drugs acting on the nervous system; all recorded by the ED physician on admission. The final CDR resulted in an alert rate of 29% with a positive predictive value of 74%. CONCLUSION: The final CDR allows identification of the majority of patients with a potential discrepancy within a feasible workload for the pharmacy staff. Our CDR is a first step towards a rule that could be incorporated into electronic medical records or a scoring system.


Assuntos
Técnicas de Apoio para a Decisão , Reconciliação de Medicamentos/métodos , Farmacêuticos/tendências , Serviço de Farmácia Hospitalar/normas , Idoso , Bélgica , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Erros de Medicação/prevenção & controle , Reconciliação de Medicamentos/tendências , Pessoa de Meia-Idade , Serviço de Farmácia Hospitalar/métodos , Estudos Prospectivos
8.
J Emerg Med ; 49(6): 949-61, 2015 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-26279514

RESUMO

BACKGROUND: Emergency department (ED) crowding has been linked with adverse medical events. However, this association was inadequately controlled for potential confounding variables. OBJECTIVES: To investigate whether ED crowding is independently associated with risk of in-hospital death and morbidity, and longer total hospital stay. METHODS: Prospective observational cohort study of all patients (≥ 18 years) presenting to the ED of an academic teaching hospital in Leuven, Belgium from June 21, 2010 to July 20, 2012. Multivariate logistic regression and proportional hazard analysis was used to control for risk factors. ED occupancy was determined for 108,229 included patients and labeled "ED crowding" when occupancy was within the highest quartile of occupancy. Outcomes within 10 days of ED admission included in-hospital death, hospital-acquired morbidities, and total hospital stay. RESULTS: During ED crowding, a median of 58 (interquartile range 55-63) patients were present for 40 licensed treatment bays. After controlling for all baseline risk factors and as compared with the lowest quartile of ED occupancy (30 [26-32] patients), ED crowding was not independently associated with mortality (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.74-1.19; p = 0.6), but tended to be associated with higher incidence of hospital-acquired pneumonia (OR 1.24, 95% CI 0.96-1.62; p = 0.09). CONCLUSIONS: Failing to control for baseline risk factors may have led to false-positive associations between ED crowding and mortality in previous studies. After controlling for risk factors, we showed that ED crowding was associated with longer hospital stays but not with increased mortality.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/organização & administração , Mortalidade Hospitalar , Morbidade , Adolescente , Adulto , Bélgica/epidemiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
9.
J Emerg Med ; 47(2): 131-9, 2014 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-24642045

RESUMO

BACKGROUND: Emergency department (ED) crowding is a major international concern that affects patients and providers. STUDY OBJECTIVE: We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding. METHODS: Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding. RESULTS: Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding. CONCLUSION: Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bélgica , Aglomeração , Feminino , Humanos , Tempo de Internação , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
10.
J Emerg Nurs ; 40(6): 592-7, 2014 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-24629665

RESUMO

INTRODUCTION: Triage aims to categorize patients based on their clinical need and the available departmental resources. To accomplish this goal, one needs to ensure that the implemented triage system is reliable and that staff use it correctly. Therefore this study assessed the ability of Belgium nurses to apply the Emergency Severity Index (ESI), version 4, to hypothetical case scenarios after an educational intervention. METHODS: An ESI educational intervention was implemented in accordance with the ESI manual. Using paper case scenarios, nurses' interrater agreement was assessed by comparing triage nurse ESI levels with the reference answers noted in the implementation manual. Interrater agreement was measured by the percentage of agreement and Cohen's κ coefficient using different weighting schemes. RESULTS: Overall, 77.5% of the scenario cases were coded according the ESI guidelines, resulting in a good interrater agreement (κ = 0.72, linear weighted κ = 0.84, quadratic weighted κ = 0.92, and triage-weighted scheme = 0.79). Interrater agreement varied when evaluating each ESI level separately. Undertriage was more common than overtriage. The highest misclassification range (37.8%) occurred in ESI level 2 scenarios, with 99.2% of the misclassifications being undertriaged. DISCUSSION: Implementation of the ESI into a novel setting guided by a locally developed training program resulted in suboptimal interrater agreement. Existing weighted κ schemes overestimated the interrater agreement between the triage nurse-assigned ESI level and the reference standard. By providing an aggregated measure of agreement, which allows partial agreement, clinically significant misclassification was masked by a misleading "good" interrater agreement.


Assuntos
Enfermagem em Emergência/educação , Serviço Hospitalar de Emergência/normas , Avaliação em Enfermagem , Índice de Gravidade de Doença , Triagem/métodos , Bélgica , Estudos Transversais , Humanos , Avaliação de Programas e Projetos de Saúde
11.
Int Emerg Nurs ; 22(4): 185-9, 2014 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-24529530

RESUMO

BACKGROUND: Emergency department (ED) crowding and prolonged waiting times have been associated with adverse consequences towards quality and patient safety. OBJECTIVE: This study investigates whether the number of patients simultaneously present at the ED might be an indicator of unsafe waiting and at what threshold hospital-wide measures to improve patient outflow could be justified. METHODS: Data were retrospectively collected during a 1-year period; all ED patients aged ≥16 years, and triaged as ESI-1 or ESI-2 were eligible for inclusion. The number of patients simultaneously present was used as occupancy rate. Waiting time was considered unsafe if it was longer than 10 min for ESI-1 patients, or longer than 30 min for ESI-2 patients. Differences in waiting time and occupancy between patients with safe and unsafe waiting times were analysed using the Mann-Whitney U test. The ability of the occupancy rate to discriminate unsafe waiting times was analysed using a receiver operating characteristic curve. RESULTS: The overall median waiting time was 5 min (IQR=4-8) for ESI-1, and 12 min (IQR=6-24) for ESI-2 patients. Unsafe waiting times occurred in 16.0% of ESI-1 patients (median waiting time=17 min, IQR=13-23), and in 18.9% of ESI-2 patients (median waiting time=48 min, IQR=37-68). The occupancy rate was a weak indicator for unsafe waiting times in ESI-1 patients (AUC=0.625, 95%CI 0.537-0.713) but a fair indicator for unsafe waiting times in ESI-2 patients (AUC=0.740, 95%CI 0.727-0.753) for which the threshold to predict unsafe waiting times with 90% sensitivity was 51 patients. CONCLUSION: The number of patients simultaneously present is a moderate indicator of unsafe waiting times. Future initiatives to improve safe waiting times should not focus solely on occupancy, and expand their focus towards other factors affecting waiting time.


Assuntos
Ocupação de Leitos/normas , Serviço Hospitalar de Emergência/normas , Segurança do Paciente , Triagem/normas , Bélgica , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , Estudos Retrospectivos , Fatores de Tempo
12.
Int Emerg Nurs ; 22(2): 112-5, 2014 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-24055373

RESUMO

OBJECTIVE: To evaluate an automatic forecasting algorithm in order to predict the number of monthly emergency department (ED) visits one year ahead. METHODS: We collected retrospective data of the number of monthly visiting patients for a 6-year period (2005-2011) from 4 Belgian Hospitals. We used an automated exponential smoothing approach to predict monthly visits during the year 2011 based on the first 5 years of the dataset. Several in- and post-sample forecasting accuracy measures were calculated. RESULTS: The automatic forecasting algorithm was able to predict monthly visits with a mean absolute percentage error ranging from 2.64% to 4.8%, indicating an accurate prediction. The mean absolute scaled error ranged from 0.53 to 0.68 indicating that, on average, the forecast was better compared with in-sample one-step forecast from the naïve method. CONCLUSION: The applied automated exponential smoothing approach provided useful predictions of the number of monthly visits a year in advance.


Assuntos
Algoritmos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Bélgica , Previsões , Humanos , Análise de Séries Temporais Interrompida , Valor Preditivo dos Testes , Estudos Retrospectivos
14.
Emerg Med J ; 30(1): e9, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-22328636

RESUMO

STUDY OBJECTIVE: The epidemiology, management and cost of emergency department (ED) visits for deliberate self-poisoning (DSP) are described. METHODS: In a retrospective study, the medical records of all DSP patients older than 16 years, who presented to the ED from 1 January 2009 to 31 December 2009, were reviewed. RESULTS: 312 episodes of DSP were included, accounting for 0.6% of all ED visits. 190 patients were women, with a female to male ratio of 1.56:1. Mean patient age was 37 years. More than 60% (n=190) of DSP patients were <40 years of age. Most patients presented to the ED between 18:00 and 23:00. A single drug was ingested in 39% (n=121) of patients. Alcohol was co-ingested by 36% of patients who were mostly middle-aged men. Of the overdoses, 50.8% were due to benzodiazepines, 23.2% were due to antidepressants and 16.4% were due to antipsychotics. Two-thirds of patients were treated with oral activated charcoal and 89% were seen by a psychiatrist. Nearly 90% of patients were admitted to the ED observation ward, with a mean length of stay of 16.7 h. The estimated total cost was €;266 134.89, with an average of €;872.57 per patient. CONCLUSION: Self-poisoning cases in Belgium are grossly similar to those in other Western countries. Supportive treatment alone should be considered in the majority of patients presenting with oral drug overdose. Overall, DSP leads to a significant financial burden on the community.


Assuntos
Overdose de Drogas/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Comportamento Autodestrutivo/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Bélgica/epidemiologia , Overdose de Drogas/economia , Serviço Hospitalar de Emergência/economia , Feminino , Custos Hospitalares , Hospitais Universitários , Humanos , Incidência , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Comportamento Autodestrutivo/economia , Distribuição por Sexo , Adulto Jovem
15.
Alcohol Alcohol ; 47(4): 433-8, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-22493048

RESUMO

AIMS: The aim of the study was to describe the epidemiology, management and cost of emergency department (ED) visits due to alcohol intoxication. METHODS: A retrospective review of medical records of all episodes of alcohol intoxication was made, excepting those where another diagnosis such as trauma or psychiatric illness was primary, in patients older than 16 years, who presented to the ED of a large university hospital in Belgium over a 12-month period from 1 January 2009. RESULTS: A total of 635 such patients accounted for 1.2% of all ED visits; 429 were males and 48.3% were aged between 41 and 60 years; 63.8% of the patients had a history of alcohol use disorder and 60.3% had a history of psychiatric disorder; 74.3% of the patients received some form of medical treatment and 62% were seen by a psychiatrist. Of the total, 57.5% of the patients were admitted to the ED observation ward, with a mean length of stay of 8.4 h. The estimated total cost was €318 838.25, with an average of €541.32 per patient. CONCLUSION: Alcohol intoxication leads to a financial burden on the community. In addition to imposing physical, social and psychological stress on the community, the often agitated or aggressive patient imposes stress on ED staff. Close surveillance of trends in alcohol abuse is warranted, and the ED should consider implementing a questionnaire method of screening for alcohol abuse.


Assuntos
Intoxicação Alcoólica/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Intoxicação Alcoólica/economia , Intoxicação Alcoólica/terapia , Análise de Variância , Bélgica , Serviço Hospitalar de Emergência/economia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Distribuição por Sexo
17.
J Eval Clin Pract ; 18(2): 485-97, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21210898

RESUMO

RATIONALE, AIMS AND OBJECTIVES: Adverse events are unintended patient injuries or complications that arise from health care management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the health care system, but also their global impact on patients and society is probably underestimated. The objectives of this systematic review were to synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission, to determine the type and consequences [mortality, length of intensive care unit (ICU) stay and costs] of these adverse events. METHODS: MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions on ICUs. Several other sources were searched for additional studies. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. For the purposes of this systematic review, ICUs were defined as specialized hospital facilities which provide continuous monitoring and intensive care for acutely ill patients. Studies that were published in the English, Dutch, German, French or Spanish language were eligible for inclusion. Two reviewers independently extracted data and assessed the methodological quality of the included studies. RESULTS: A total of 27 studies were reviewed. Meta-analysis of the data was not appropriate because of methodological and statistical heterogeneity between studies; therefore, results are presented in a descriptive way. The percentage of surgical and medical adverse events that required ICU admission ranged from 1.1% to 37.2%. ICU readmissions varied from 0% to 18.3%. Preventability of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event. Consequences of the adverse events included a mean length of ICU stay that ranged from 1.5 days to 10.4 days for the patient's first stay in ICU and mortality percentages between 0% and 58%. CONCLUSIONS: Adverse events are an important reason for (re)admission to the ICU and a considerable proportion of these are preventable. It was not possible to estimate an overall incidence and preventability rate of these events as we found considerable heterogeneity. To decrease adverse events that necessitate ICU admission, several systems are recommended such as early detection of patients with clinical instability on general wards and the implementation of rapid response teams. Step-down or intermediate care units could be a useful strategy for patients who require monitoring to avoid ICU readmissions. However, the effectiveness of such systems needs to be investigated.


Assuntos
Doença Iatrogênica , Unidades de Terapia Intensiva/estatística & dados numéricos , Erros Médicos , Admissão do Paciente/estatística & dados numéricos , Humanos , Doença Iatrogênica/prevenção & controle , Incidência , Erros Médicos/prevenção & controle
18.
Int J Health Care Qual Assur ; 25(8): 649-62, 2012.
Artigo em Inglês | MEDLINE | ID: mdl-23276060

RESUMO

PURPOSE: The purpose of this article is to assess the reliability of an in-depth analysis on causation, preventability, and disability by two separate review teams on five selected adverse events in acute hospitals: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection. DESIGN/METHODOLOGY/APPROACH: The analysis uses a retrospective medical record review of 1,515 patient records by two independent teams in eight acute Belgian hospitals for the year 2005. The Mann-Whitney U-test is used to identify significant differences between the two review teams regarding occurrence of adverse events as well as regarding the degree of causation, preventability, and disability of found adverse events. FINDINGS: Team 1 stated a high probability for health care management causation in 95.5 per cent of adverse events in contrast to 38.9 per cent by Team 2. Likewise, high preventability was considered in 83.1 per cent of cases by Team 1 versus 51.7 per cent by Team 2. Significant differences in degree of disability between the two teams were also found for pressure ulcers, postoperative pulmonary embolism or deep vein thrombosis and postoperative wound infection, but not for postoperative sepsis and ventilator-associated pneumonia. ORIGINALITY/VALUE: New insight on the degree of and reasons for the huge differences in adverse event evaluation is provided.


Assuntos
Hospitais/estatística & dados numéricos , Erros Médicos/estatística & dados numéricos , Complicações Pós-Operatórias/etiologia , Sepse/prevenção & controle , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Bélgica , Causalidade , Interpretação Estatística de Dados , Hospitais/normas , Humanos , Erros Médicos/prevenção & controle , Registros Médicos/estatística & dados numéricos , Pneumonia Associada à Ventilação Mecânica/etiologia , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Lesão por Pressão/etiologia , Lesão por Pressão/prevenção & controle , Embolia Pulmonar/etiologia , Embolia Pulmonar/prevenção & controle , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sepse/etiologia , Estatísticas não Paramétricas , Infecção da Ferida Cirúrgica/etiologia , Infecção da Ferida Cirúrgica/prevenção & controle , Trombose Venosa/etiologia , Trombose Venosa/prevenção & controle
19.
JBI Libr Syst Rev ; 9(25): 925-959, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-27820505

RESUMO

BACKGROUND: Adverse events are unintended patient injuries or complications that arise from healthcare management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the healthcare system. Medical record review seems to be a reliable method for detecting adverse events. OBJECTIVES: To synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission; to determine the type and consequences (patient harm, mortality, length of ICU stay and direct medical costs) of these adverse events. METHODS: MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions to intensive care units (ICUs). Databases of reports, conference proceedings, grey literature, ongoing research, relevant patient safety organizations and two journals were searched for additional studies. Reference lists of retrieved papers were searched and authors were contacted in an attempt to find any further published or unpublished work. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. Studies that were published in the English, Dutch, German, French or Spanish language were included. Two reviewers independently extracted data and assessed the methodological quality of the included studies. RESULTS: 28 studies in the English language and one study in French were included. Of these, two were considered duplicate publications and therefore 27 studies were reviewed. Meta-analysis of the data was not appropriate due to statistical heterogeneity between studies; therefore, results are presented in a descriptive way. Studies were categorized according to the population and the providers of care. 1) The majority of the included studies investigated unplanned intensive care admissions after anesthetic procedures (UIA). 2) Only a few studies examined patients on general wards being at risk for clinical deterioration. The overall incidence of surgical and medical adverse events compared with ICU admissions ranged from 1.1% to 37.2%. 3) The third category of studies examined patients that were readmitted on ICUs. ICU readmission rates varied from 0% to 18.3%. Nine studies explicitly reported on the preventability of adverse outcomes. The preventability rates of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event and patterns of preventability are being formulated. Consequences of the adverse events included a mean length of ICU stay that ranged from 1.5 days to 10.4 days for the patient's first stay in ICU. Mortality rates varied between 0% and 58%. CONCLUSIONS: Adverse events are a persistent and an important reason for admission to the ICU. However, there is relatively weak evidence to estimate an overall incidence and preventability rate of these events. In addition, estimates on preventability are prone to subjective judgments. Variability in methodology and definitions, and poor reporting in studies may be the main reasons for study heterogeneity. IMPLICATIONS FOR PRACTICE: Unplanned intensive care admission within 24 hours of a procedure with an anesthetist in attendance (UIA) is a recommended clinical indicator in surgical patients. Several authors recommend early detection of patients with clinical instability on general wards and the implementation of rapid response teams. Step-down or intermediate care units could be a useful strategy for patients that require monitoring to avoid ICU readmissions. IMPLICATIONS FOR RESEARCH: There is a need for further studies on the detection of adverse events. The poor quality of current research evidence and the heterogeneity across studies requires that planning of future studies should aim to standardize measures of outcomes to allow for comparisons across studies. This area of research is important in order to identify and explain failure of healthcare systems leading to patient harm, with the ultimate aim to improve the quality and safety of care.

20.
Qual Saf Health Care ; 19(5): e25, 2010 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-20427309

RESUMO

OBJECTIVE: To assess whether the Belgian Hospital Discharge Dataset (B-HDDS) is a valid source for the detection of adverse events in acute hospitals. DESIGN, SETTING AND PARTICIPANTS: Retrospective review of 1515 patient records in eight acute Belgian hospitals for the year 2005. MAIN OUTCOME MEASURES: Predictive value of the B-HDDS and medical record reviews and degree of correspondence between the B-HDDS and medical record reviews for five indicators: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection. RESULTS: Postoperative wound infection received the highest positive predictive value (62.3%), whereas postoperative sepsis and ventilator-associated pneumonia were rated as only 44.2% and 29.9% respectively. Excluding present on admission from the screening substantially decreased the positive predictive value of pressure ulcer from 74.5% to 54.3%, as pressure ulcers present on admission were responsible for more B-HDDS-medical record mismatches than any other indicator. Over half (56.8%) of false-positive cases for postoperative sepsis were due to a lack of specificity of the ICD-9-CM code, whereas in 58.6% of false-positive cases for ventilator-associated pneumonia, clinical criteria appeared to be too stringent. CONCLUSIONS: The B-HDDS has the potential to accurately detect some but not all adverse events. Adding a code 'present on admission' and improving the ICD-9-CM codes might already partially improve the correspondence between the B-HDDS and the medical record review.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/diagnóstico , Serviço Hospitalar de Emergência , Programas de Rastreamento/instrumentação , Idoso , Bélgica , Feminino , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Estudos Retrospectivos
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