La inserción del enfermero en la comisión intrahospitalaria de donación de órganos y tejidos / A inserção do enfermeiro em comissão intra-hospitalar de doação de órgãos e tecidos / The insertion of the nurse in intra-hospital commission of organ and tissue donation

Objetivo: Conocer cómo es la inserción del enfermero en la comisión intrahospitalaria de donación de órganos y tejidos para trasplante, así como la adquisición de conocimientos para actuar en ella. Método: Investigación cualitativa, descriptiva y exploratoria, realizada con 12 enfermeros de la comisión intrahospitalaria de donación de órganos y tejidos. Los datos fueron recolectados a través de entrevistas semiestructuradas y analizados mediante análisis de contenido. Resultados: Mostraron que los enfermeros son señalados para trabajar en la comisión intrahospitalaria de donación de órganos y tejidos para trasplante sin la preparación adecuada. El conocimiento se produce después de la inclusión en la referida comisión, normalmente con los eventos y apoyo en la literatura de área, ya que no existe un enfoque consistente sobre el tema en la formación profesional. Conclusión: Las medidas educativas deben ser incluidas en la academia y en los servicios de salud, con el fin de proporcionar los apoyos necesarios para que el enfermero puedan tener una participación más efectiva en estas comisiones

Objetivo: conhecer como se dá a inserção do enfermeiro em comissão intra-hospitalar de doação de órgãos e tecidos para transplante, bem como a obtenção de conhecimento para atuação nesta. Método: pesquisa qualitativa, descritiva e exploratória, realizada com 12 enfermeiros de comissão intra-hospitalar de doação de órgãos e tecidos. Os dados foram coletados por meio de entrevista semiestruturada e analisados através de análise de conteúdo. Resultados: evidenciou-se que os enfermeiros são indicados para atuar em comissão intra-hospitalar de doação de órgãos e tecidos para transplante, sem o preparo adequado. O conhecimento ocorre posteriormente à inserção na referida comissão, normalmente, junto a eventos e apoio na literatura da área, já que não há abordagem consistente sobre o tema na formação profissional. Conclusão: medidas educativas devem ser inseridas na academia e serviços de saúde, como forma de prover subsídios necessários para que o enfermeiro possa ter uma participação mais efetiva nessas comissões

Objective: To recognize how the insertion of the nurse in an in-hospital commission of donation of organs and tissues for transplantation is, as well as the obtaining of knowledge to act in this one. Method: It is a qualitative, descriptive and exploratory research, carried out with 12 nurses of intra-hospital commission of organ and tissue donation. Data were collected through a semi-structured interview and analyzed through content analysis. Results: It was evidenced that the nurses are indicated to act in intra-hospital commission of donation of organs and tissues for transplantation without adequate preparation. The knowledge occurs later to the insertion in the referred committee, usually, next to events and support in the literature of the area, since there is no consistent approach about the subject in the professional formation. Conclusion: Educational measures should be included in the health services and academia as a way of providing the necessary subsidies so that nurses can have a more effective participation in these commissions

Presente y futuro de la especialidad desde la perspectiva de la Comisión Nacional / Present and future of the specialty from the perspective of the National Committee

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Competency-Based Medical Education in the Internal Medicine Clerkship: A Report From the Alliance for Academic Internal Medicine Undergraduate Medical Education Task Force.

As medical educators continue to redefine learning and assessment across the continuum, implementation of competency-based medical education in the undergraduate setting has become a focus of many medical schools. While standards of competency have been defined for the graduating student, there is no uniform approach for defining competency expectations for students during their core clerkship year. The authors describe the process by which an Alliance for Academic Internal Medicine task force developed a paradigm for competency-based assessment of students during their inpatient internal medicine (IM) clerkship. Building on work at the resident and fellowship levels, the task force focused on the development of key learning outcomes as defined by entrustable professional activities (EPAs) that were specific to educational experiences on the IM clerkship, as well as identification of high-priority assessment domains. The work was informed by a national survey of clerkship directors.Six key EPAs emerged: generating a differential diagnosis, obtaining a complete and accurate history and physical exam, obtaining focused histories and clinically relevant physical exams, preparing an oral presentation, interpreting the results of basic diagnostic studies, and providing well-organized clinical documentation. A model for assessment was proposed, with descriptors aligned to the scale of supervision and mapped to Accreditation Council for Graduate Medical Education domains of competence. The proposed paradigm offers a standardized template that may be used across IM clerkships, and which would effectively bridge competency evaluation in the clerkship to fourth-year assessment as well as eventual postgraduate training.

Tumores neuroendocrinos de páncreas: claves para afrontar la heterogeneidad / Neuroendocrine tumors of the pancreas: keys issues in dealing with heterogeneity

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The new opt-out Dutch National Breast Implant Registry - Lessons learnt from the road to implementation.

An estimated 1-3% of all women in the Netherlands carry breast implants. Since the introduction five decades ago, problems with a variety of breast implants have emerged with direct consequences for the patients' health. Plastic surgeons worldwide reacted through campaigning for auditing on long-term implant quality, surgeon performance, and institutional outcomes in implant registries. Especially, the PIP implant scandal of 2010 demonstrated the paucity of epidemiological data and uncovered a weakness in our ability to even 'track and trace' patients. In addition, a recent report of the Dutch Institute of National Health showed a lack of compliance of 100% of breast implant producers to CE requirements. These arguments stress the need for an independent implant registry. Insufficient capture rates or dependence from the implant producers made the variety of national and international patient registries unreliable. The Dutch Breast Implant Registry (DBIR) is unique because it is an opt-out registry without the need for informed consent and thus a high capture rate. Furthermore, an estimated 95% of breast implants are implanted by board-certified plastic surgeons. Funding was received from a non-governmental organisation to increase the quality of health care in the Netherlands, and maintenance is gathered by 25 euros per implant inserted. This article describes the way the Dutch have set up their system, with special attention to the well-known hurdles of starting a patient registry. Examples include: funding, medical ethical issues, opt out system, benchmarking, quality assurance as well as governance and collaboration. The Dutch consider their experience and data shareware for others to be used globally to the benefit of patient safety and quality improvement.

Fourth consensus of the International Society for Premenstrual Disorders (ISPMD): auditable standards for diagnosis and management of premenstrual disorder.

Whilst professional bodies such as the Royal College and the American College of Obstetricians and Gynecologists have well-established standards for audit of management for most gynaecology disorders, such standards for premenstrual disorders (PMDs) have yet to be developed. The International Society of Premenstrual Disorders (ISPMD) has already published three consensus papers on PMDs covering areas that include definition, classification/quantification, clinical trial design and management (American College Obstetricians and Gynecologists 2011; Brown et al. in Cochrane Database Syst Rev 2:CD001396, 2009; Dickerson et al. in Am Fam Physician 67(8):1743-1752, 2003). In this fourth consensus of ISPMD, we aim to create a set of auditable standards for the clinical management of PMDs. All members of the original ISPMD consensus group were invited to submit one or more auditable standards to be eligible in the inclusion of the consensus. Ninety-five percent of members (18/19) responded with at least one auditable standard. A total of 66 auditable standards were received, which were returned to all group members who then ranked the standards in order of priority, before the results were collated. Proposed standards related to the diagnosis of PMDs identified the importance of obtaining an accurate history, that a symptom diary should be kept for 2 months prior to diagnosis and that symptom reporting demonstrates symptoms in the premenstrual phase of the menstrual cycle and relieved by menstruation. Regarding treatment, the most important standards were the use of selective serotonin reuptake inhibitors (SSRIs) as a first line treatment, an evidence-based approach to treatment and that SSRI side effects are properly explained to patients. A set of comprehensive standards to be used in the diagnosis and treatment of PMD has been established, for which PMD management can be audited against for standardised and improved care.

[Physicians with access to point-of-care tests significantly reduce the antibiotic prescription for common cold]. / Los médicos que disponen de pruebas rápidas disminuyen significativamente la prescripción de antibióticos en el resfriado común.

OBJECTIVE: This study was aimed at evaluating the effect of two levels of intervention on the antibiotic prescribing in patients with common cold. METHODS: Before and after audit-based study carried out in primary healthcare centres in Spain. General practitioners registered all the episodes of common cold during 15 working days in January and February in 2008 (preintervention). Two types of intervention were considered: full intervention, consisting in individual feedback based on results from the first registry, courses in rational antibiotic prescribing, guidelines, patient information leaflets, workshops on rapid tests -rapid antigen detection and C-reactive protein tests- and provision of these tests in the surgeries; and partial intervention, consisting of all the above intervention except for the workshop and they did not have access to rapid tests. The same registry was repeated in 2009 (postintervention). In addition, new physicians filled out only the registry in 2009 (control group). RESULTS: 210 physicians underwent the full intervention, 71 the partial intervention and 59 were assigned to the control group. The 340 doctors prescribed antibiotics in 274 episodes of a total of 12,373 cases registered (2.2%).The greatest percentage of antibiotic prescription was found in the control group (4.6%). The partial intervention increased the antibiotic prescription percentage from 1.1% to 2.7% while only doctors who underwent the complete intervention lead to a significant reduction of antibiotics prescribed, from 2.9% before to 0.7% after the intervention (p<0.001). CONCLUSION: Only physicians with access to rapid tests significantly reduced antibiotic prescription in patients with common cold.

An institutional review board-based clinical research quality assurance program.

Despite the acknowledged importance of quality assurance in the clinical research process, the problem of how such a program should be implemented at the level of an academic teaching hospital or a similar institution has not been addressed in the literature. Despite the fact that quality assurance is expected in programs which certify and accredit Institutional Review Boards (IRBs), very little is known about the role of the IRB in programs of clinical research quality assurance. In this article we consider the definition of clinical research quality assurance, and describe a program designed to achieve it. The key elements of such a program are education at the site level, which has both mandatory and voluntary components, and an auditing and monitoring program, which reinforces the education on quality assurance. The role of the IRB in achieving the program goals and the organizational placement of the quality assurance program within the IRB structure and function are important items of discussion.

Audit of audit: review of a clinical audit programme in a teaching hospital intensive care unit.

OBJECTIVE: A comprehensive review of the clinical audit programme in a teaching hospital intensive care unit. DESIGN: A retrospective analysis of the clinical audit projects undertaken within the intensive care unit over the preceding 2 years and compared with published national guidelines for clinical audit. SETTING: A 27-bedded teaching hospital intensive care unit in the UK. MEASUREMENTS: Each audit project was reviewed independently by two assessors. The following questions were assessed. 1. Were the projects true audits? 2. Were they prospective of retrospective? 3. Did the projects have input from appropriate members of the multidisciplinary team. 4. How many of the audit projects were re-audits? 5. Of the re-audits how many showed evidence of service improvement? each audit project was also scored against the Audit Project Assessment Tool produced by the UK Clinical Governance Support Team. RESULTS: Of the twenty five audit projects reviewed twenty two were considered to be true audits. All of the projects used only retrospective data. Audit projects were contributed from all sections of the multidisciplinary critical care team but there were few truly multidisciplinary projects. Four of the audit projects were re-audits, of these three showed service improvement and one showed deterioration. Of the twenty two true audit projects reviewed, eleven were classified as good quality projects using the Audit Project Assessment Tool. CONCLUSIONS: Despite the clinical audit programme being active and well supported, objective evidence of clinical governance benefit was lacking. The overall clinical audit programme has been revitalised by a series of improvements since undertaking this review and this approach is recommended to other organizations who are interested in improving their clinical audit performance.

Cooperativa de pediatras. Una alternativa para garantizar la atención pediátrica en áreas de difícil cobertura / A cooperative of pediatricians. A model for providing universar pediatric primary care in underserved areas

Fundamento. Dado el déficit de pediatras, existen dificultades para la cobertura pediátrica en diferentes zonas, obligando a buscar nuevas alternativas. Objetivo. Presentamos los resultados de dos años de funcionamiento de un modelo innovador de autogestión, basado en una cooperativa de profesionales ligada a un hospital docente de referencia. Métodos. En octubre de 2009 se realizó un convenio entre la Fundació Sant Hospital de la Seu d’Urgell (FSH), el Institut Català de la Salut, el Hospital Sant Joan de Déu de Barcelona y el Departament de Salut, para prestar asistencia pediátrica (primaria y hospitalaria) en la comarca del Alt Urgell. Los pediatras se constituyeron en una sociedad cooperativa catalana limitada professional, Pediatria dels Pirineus, asumiendo las decisiones asistenciales, organizativas, económicas y legales. Resultados. Se ha conseguido cubrir el 100% de la asistencia pediátrica, dotar de una excelente accesibilidad en el ambulatorio (100% de éxito para visitas pediátricas <48 horas y 0,46-0,66 días de demora para cita previa), incrementar notablemente los estándares de calidad asistencial y disminuir en un 30% las visitas pediátricas en el Servicio de Urgencias de la FSH (del 66% en horarios de obertura del ambulatorio). Se ha objetivado una disminución del 33% de las derivaciones a otros centros y del 41% de los traslados interhospitalarios. A nivel docente se han consolidado las sesiones en el territorio y mejorado la asistencia de los profesionales a los cursos formativos (media de 6,5 cursos/profesional año 2010 y 5,6 año 2011). Conclusiones. Este modelo permite una mejor cobertura pediátrica, con visión territorial, continuidad en la atención, integración en el sistema de salud y sostenibilidad(AU)

Background. The shortage of pediatricians makes universal pediatric coverage of some areas difficult to achieve; new approaches are needed. Objective. We present the results of two years of operation of an innovative model of self-management, based on a cooperative of health care professionals linked to a tertiary academic center. Method. An agreement was signed in October 2009 between the Sant Hospital Foundation of La Seu d’Urgell (SHF), the Catalan Institute of Health, the Sant Joan de Deu Hospital in Barcelona, and the Department of Health, to provide primary and hospital pediatric care in the Alt Urgell county. As part of this agreement, pediatricians were organized around the professional cooperative society Pyrenees Pediatrics, assuming the patient care, organizational, legal, and financial responsibilities. Results. Pyrenees Pediatrics provides coverage to 100% of children in the region, with excellent access to primary clinics. There has been a 100% success rate for pediatric visits in < 48 hours, and 0.46-0.66 days delay for appointments, a remarkable improvement in the quality of care standards, and a decrease from 60% to 30% in the pediatric visits to the Emergency Department at SHF during primary clinic hours. There has been a decrease of referrals to centers outside the region and hospital transfers of 33% and 41%, respectively. Finally, there has been a significant improvement in attendance to continuing medical education courses (average of 6.5 and 5.6 courses/professional in 2010 and 2011, respectively). Conclusions. This model allows for the provision of a better pediatric coverage, with a regional vision, continuity in care, integration within the health care system, and sustainability(AU)

[Scientific monitoring of the visitation procedure in inpatient rehabilitation centres of the German statutory pension insurance fund--the "Visit II" Project]. / Wissenschaftliche Begleitung der Weiterentwicklung des Visitationsverfahrens für Reha-Kliniken der Deutschen Rentenversicherung Bund--Das Projekt "Visit II".

Visitation procedures are an established method of external quality assurance. They have been conducted for many years in the German statutory pension insurance's medical rehabilitation centres and have continuously been refined and standardized. The overall goal of the visitation procedure implemented by the German statutory pension fund is to ensure compliance with defined quality standards as well as information exchange and counselling of rehabilitation centres. In the context of advancing the visitation procedure in the German statutory pension funds' medical rehabilitation centres, the "Visit II" Project was initiated to evaluate the perspectives and expectations of the various professional groups involved in the visitations and to modify the materials used during visitations (documentation form and manual). Evaluation data from the rehabilitation centres visited in 2008 were gathered using both written surveys (utilization analysis) and telephone-based interviews with administration managers and chief physicians. The utilization analysis procedure was evaluated with regard to its methodological quality. In addition, the pension insurance physicians in charge of patient allocation during socio-medical assessment were surveyed with regard to potential needs for revision of the visitation procedure. Data collection was complemented by expert panels with auditors. Interviews with users as part of the formative evaluation of the visitation procedure showed positive results regarding acceptance and applicability of the visitations as well as of the utilization analysis procedures. Various suggestions were made with regard to modification and revision of the visitation materials, that could be implemented in many cases. Documentation forms were supplemented by current scientifically-based topics in rehabilitation (e. g., vocationally oriented measures), whereas items with minor relevance were skipped. The manual (for somatic indications) was thoroughly revised. The transparent presentation of visitation processes and visitation criteria has proven to be a useful basis for strengthening the cooperation between the statutory pension insurance funds and the rehabilitation centres. Moreover, it is a helpful tool for the systematic and continuous advancement of this complex method by including all parties involved.

Percepción de los profesionales sobre la utilización y la utilidad del listado de verificación quirúrgica / The healthcare professional's perceptions on the implementation and usefulness of the surgical safety checklist

Objetivo. Conocer la percepción de los profesionales sobre el grado de utilización y la utilidad del listado de verificación quirúrgica (LVQ) tras su implantación en un hospital terciario. Material y métodos. Estudio descriptivo transversal. Cuestionario autocumplimentado con 5 preguntas sobre utilidad, 5 sobre utilización, 1 pregunta abierta y 4 preguntas de control. La población objetivo: cirujanos, anestesiólogos, enfermeras de planta y de quirófano del hospital. Resultados. La tasa de respuesta fue del 73% (entre el 51 y el 88%, según perfil profesional). El 95,7% de los profesionales manifestó utilizar siempre o casi siempre el LVQ cuando se interviene a un paciente quirúrgicamente. Los profesionales otorgaron al LVQ una utilidad media de 6,6 puntos (escala, 0-10), el 11,6% manifestó que gracias al LVQ se habían evitado errores, el 32,5% consideró que es una herramienta que mejora la comunicación entre los profesionales, y al 68% le gustaría que se cumplimentase el LVQ si ellos mismos fuesen a ser intervenidos. Los profesionales que contestaron que gracias al LVQ se consiguió evitar errores otorgaron valores de utilidad 1,4 puntos por encima de la media, en este mismo grupo, al 100% de los profesionales les gustaría que se utilizase el LVQ en ellos mismos y el 63,2% consideró que mejoraba la comunicación. No hubo diferencias en la utilidad en función de la experiencia profesional o el sexo. Conclusiones. Los profesionales utilizan casi siempre el LVQ y le otorgan una utilidad moderada. Los profesionales que experimentaron que gracias al LVQ se había conseguido evitar errores confirieron al LVQ una utilidad mayor que los que no lo experimentaron(AU)

Objective. To find out the perception of the health care professionals on the level of implementation and the usefulness of the surgical safety checklist (LVQ) after its introduction in a tertiary care hospital. Material and method. A descriptive cross-sectional study was conducted using a specially designed self-completion questionnaire. This consisted of 5 questions on the usefulness, 5 questions on the use of the LVQ, one open question and 4 control questions. The target population was hospital surgeons, anaesthetists, ward nurses, and surgical nurses. Results. The response rate was 73%, ranking from 51% to 88% depending on the respondent profile. Almost all (95.7%) of the respondents declared they always or almost always used the LVQ when performing a surgical operation. The health care professionals rated the usefulness of the LVQ with a mean of 6.6 (scale, 1-10); 11.6% mentioned that actual errors had been avoided through the use of the LVQ; 32.5% considered the LVQ as a tool that improves communication between professionals; and 68% of the respondents declared they would like the LVQ to be used if they were surgical patients. Those respondents who answered that the LVQ had prevented errors gave higher usefulness scores, 1.4 above the mean. In this same group, 100% of the respondents would like the LVQ to be used on themselves and 63.2% considered that communication had improved. There were no differences in usefulness scores as regards professional experience or gender. Conclusions. The health care professionals use the LVQ very frequently, and consider that it has a moderate usefulness. Those professionals with experience of the LVQ preventing errors considered it to be more useful than those who did not experience an error being prevented(AU)

Nuevos criterios de acreditación de unidades docentes de Reumatología / No disponible

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