La comunicación efectiva para mejorar la interacción del personal de enfermería durante el enlace de turno / Effective communication to improve the interaction of nursing staff during shift change

La razón del ser y del saber que es objeto de estudio de la enfermería es el cuidado de las personas. Para garantizar la continuidad en el cuidado de las personas, el personal de enfermería realiza el enlace de turno en los diversos escenarios clínicos, durante el cual es imprescindible una actitud de compromiso, empatía y habilidad de comunicación efectiva para compartir ­transferir­ el estado de las personas que son sujetos de cuidados. Se han desarrollado herramientas que ayudan a reducir errores durante la transferencia de pacientes y el enlace de turno, como el protocolo Escuchar-escribir-leer-confirmar y la técnica SAER (Situación, antecedentes, evaluación y recomendaciones) o SBAR por sus siglas en inglés.

The entire purpose which is the object of study of nursing is the care of individuals. To guarantee continuity on this task, the nursing staff performs the shift change in the various clinical scenarios, during which an attitude of commitment, empathy and effective communication skills is essential to share ­transfer­ the status of the individuals under care. Tools that help reducing errors during patient transfer and shift change have been developed, such as the Listen-Write-Read-Confirm protocol, and the SBAR technique

[An ethical Response in the Care of Nursing Homes in the COVID-19 Pandemic]. / Una Respuesta ÉTica en la AtenciÓN a Residencias de Ancianos en la Pandemia COVID-19.

With the arrival of the COVID-19 pandemic, the risk of a possible lack of care for the elderly in nursing homes became evident. We summarize the experience of a multidisciplinary team with volunteer professionals from different specialties who carried out support for healthcare professionals in nursing homes. This team was implemented from both Primary and Specialty Care managements. Its work paradigm was proposed by our home hospitalization team, which included direct care of the most complex patients and general counselling on isolation, hygiene and preventive measures within the nursing homes. Thanks to this support, the elderly population placed there, with suspected or diagnosed COVID-19, received adequate care from an interdisciplinary team, which led part of the pressure to be released from their professional workers, and many family members were aware that there was no neglect of the elderly. Commitment from various levels of care in a coordinated effort has prevented a vulnerable population from being left unattended during the pandemic.

The Charlie Gard Case, and the Ethics of Obstructing International Transfer of Seriously Ill Children.

In 2017, the court case over medical treatment of UK infant, Charlie Gard, reached global attention. In this article, I will analyze one of the more distinctive elements of the case. The UK courts concluded that treatment of Charlie Gard was not in his best interests and that it would be permissible to withdraw life-sustaining treatment. However, in addition, the court ruled that Charlie should not be transferred overseas for the treatment that his parents sought, even though specialists in Italy and the US were willing to provide that treatment. Is it ethical to prevent parents from pursuing life-prolonging treatment overseas for their children? If so, when is it ethical to do this? I will outline arguments in defense of obstructing transfer in some situations. I will argue, however, that this is only justified if there is good reason to think that the proposed treatment would cause harm.

Reflections on Charlie Gard and the Best Interests Standard From Both Sides of the Atlantic Ocean.

Charlie Gard (August 4, 2016, to July 28, 2017) was an infant in the United Kingdom who was diagnosed with an encephalopathic form of mitochondrial DNA depletion syndrome caused by a mutation in the RRM2B gene. Charlie's parents raised £1.3 million (∼$1.6 million US) on a crowdfunding platform to travel to New York to pursue experimental nucleoside bypass treatment, which was being used to treat a myopathic form of mitochondrial DNA depletion syndrome caused by mutations in a different gene (TK2). The case made international headlines about what was in Charlie's best interest. In the medical ethics community, it raised the question of whether best interest serves as a guidance principle (a principle that provides substantive directions as to how decisions are to be made), an intervention principle (a principle specifying the conditions under which third parties are to intervene), both guidance and intervention, or neither. I show that the United Kingdom uses best interest as both guidance and intervention, and the United States uses best interest for neither. This explains why the decision to withdraw the ventilator without attempting nucleoside bypass treatment was the correct decision in the United Kingdom and why the opposite conclusion would have been reached in the United States.

The ethics of blood transfusion refusal in clinical practice among legal and medical professions in Japan.

We investigated the differences in Japanese and United States medical and legal professional opinions on ethical support for clinical ethical issues using the refusal of blood transfusions on the grounds of religious principles as an example of a clinical ethical issue. In ethical support systems for medical institutions in Japan, 95.0% of "clinical training designation hospitals" have hospital ethics committees, and 63.1% have medical safety divisions; clinical ethical support is provided in accordance with their scale and function. In terms of clinical ethical support limits the discretion of physicians, 59.2% of lawyers responded "No" and 54.4% of doctors responded "Yes". In addition, on the feasibility of government or academic guidelines in clinical practice, 37.7% of lawyers responded "Yes" and 63.0% of doctors responded "No". In terms of "relative transfusion-free" policy, 83.2% of lawyers and 76.8% of doctors responded that it is "unavoidable," while 81.6% of U.S. committee heads responded that it is a "violation of rights." In terms of hospital transfers due to a hospital being unable to treat patients refusing blood transfusion, 62.6% of lawyers reported that it is "unavoidable" while 57.1% of U.S. committee heads reported that it "should be avoided". The results of this study indicate that medical and legal professionals and U.S. ethics committee heads recognize clinical ethical issues in slightly different ways.

Learning From Lawsuits: Using Malpractice Claims Data to Develop Care Transitions Planning Tools.

OBJECTIVES: Our understanding of care transitions from hospital to home is incomplete. Malpractice claims are an important and underused data source to understand such transitions. We used malpractice claims data to (1) evaluate safety risks during care transitions and (2) help develop care transitions planning tools and pilot test their ability to evaluate care transitions from the hospital to home. METHODS: Closed malpractice claims were analyzed for 230 adult patients discharged from 4 hospital sites. Stakeholders participated in 2 structured focus groups to review concerns. This led to the development of 2 care transitions planning tools-one for patients/caregivers and one for frontline care providers. Both were tested for feasibility on 53 patient discharges. RESULTS: Qualitative analysis yielded 33 risk factors corresponding to hospital work system elements, care transitions processes, and care outcomes. Providers reported that the tool was easy to use and did not adversely affect workflow. Patients reported that the tool was acceptable in terms of length and response burden. Patients were often still waiting for information at the time they applied the tool. CONCLUSIONS: Malpractice claims provided insights that enriched our understanding of suboptimal care transitions and guided the development of care transitions planning tools. Pilot testing suggested that the tools would be feasible for use with minor adjustment. The malpractice data can complement other approaches to characterize systems failures threatening patient safety.

Drama and Trauma: Unpacking Moral Distress in the Context of Discharge Planning.

This series of personal stories about hospital discharge experiences expose how fraught this transition can be. Not only do the authors reveal personal angst, feelings of endangerment, frank safety problems, lack of structural supports, but even more concerning are their perceptions of callous disregard, lack of adequate preparation and education, and unilateral decision-making by the health care teams. The "invisible hand" of our corporate health care system percolates, with some authors questioning whether the health professionals are advocating for their (i.e., the patient's) best interest or the best interest of their institution. There are also some shining examples though-moments when a health care team member takes the time, listens, problem-solves, advocates and expresses concern. In this commentary I will explore common themes in the narratives, and conclude with some suggestions-some simple, others aspirational, for how to make the discharge process more patient-centered and less traumatic for all moving forward.

Discharge Planning: It's About the Destination and the Journey.

Hospitalization is a distressing time for patients and their care partners. While in the hospital, they are often thinking about how they will manage their healthcare once they leave the hospital. The hospital providers are tasked with conducting discharge planning with the patient and their care partners to ensure a smooth transition from the hospital. However, as the narratives in this symposium illustrate, the patients and their care partners often feel too little attention paid to ensuring their unique needs are met, including their preferences for where they go when they leave the hospital. Patients and their care partners desire increased and improved communication with healthcare providers, including those in the hospital as well as insurers, as they attempt to take control of their discharge through self-advocacy. While these are three common themes across the stories, the authors share a variety of views, circumstances, and opinions that speak to the variability in patients' discharge experiences and preferences.

Medical evacuation from abroad of critically ill patients: A case report and ethical issues.

RATIONALE: Patients repatriated from foreign hospitals are sources of extensively drug-resistant (XDR) bacteria outbreaks. Thus, an individual benefit potential for the patient opposes a collective ecological risk potential. These ethical issues have not been well studied. PATIENT CONCERNS: We report the case of a 74-year-old patient repatriated from Mauritius to the French island of Reunion who presented mesenteric infarction evolving over several days, and who suffered a cardiac arrest before transfer. DIAGNOSES: In Reunion Island, a CT-scan revealed a multisegmental enlarged parietal enlargement associated with free peritoneal effusion and a suboccluded aspect of the superior mesenteric artery. INTERVENTIONS: Surgical exploration showed a severe mesenteric infarction with peritonitis, and a resection of 120cm of the small intestine was conducted. This patient was infected with a vanA glycopeptide-resistant Enterococcus faecium and a carbapenem-resistant Klebsiella pneumoniae which produced carbapenemases NDM-1 and OXA-181, which required specific care and could have led to a local epidemic. OUTCOMES: The patient died after 9 days after being admitted to the ICU. LESSONS: Repatriation of critically ill patients from abroad should be considered according to ethical criteria, evaluating, if possible, the expected benefits, and ecological risks incurred. Limiting unnecessary transfers could be an effective measure to limit the spread of XDR bacteria.

Implementing post-trial access plans for HIV prevention research.

Ethics guidance increasingly recognises that researchers and sponsors have obligations to consider provisions for post-trial access (PTA) to interventions that are found to be beneficial in research. Yet, there is little information regarding whether and how such plans can actually be implemented. Understanding practical experiences of developing and implementing these plans is critical to both optimising their implementation and informing conceptual work related to PTA. This viewpoint is informed by experiences with developing and implementing PTA plans for six large-scale multicentre HIV prevention trials supported by the HIV Prevention Trials Network. These experiences suggest that planning and implementing PTA often involve challenges of planning under uncertainty and confronting practical barriers to accessing healthcare systems. Even in relatively favourable circumstances where a tested intervention medication is approved and available in the local healthcare system, system-level barriers can threaten the viability of PTA plans. The aggregate experience across these HIV prevention trials suggests that simply referring participants to local healthcare systems for PTA will not necessarily result in continued access to beneficial interventions for trial participants. Serious commitments to PTA will require additional efforts to learn from future approaches, measuring the success of PTA plans with dedicated follow-up and further developing normative guidance to help research stakeholders navigate the complex practical challenges of realising PTA.

Racial and Geographic Disparities in Interhospital ICU Transfers.

OBJECTIVES: Interhospital transfer, a common intervention, may be subject to healthcare disparities. In mechanically ventilated patients with sepsis, we hypothesize that disparities not disease related would be found between patients who were and were not transferred. DESIGN: Retrospective cohort study. SETTING: Nationwide Inpatient Sample, 2006-2012. PATIENTS: Patients over 18 years old with a primary diagnosis of sepsis who underwent mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We obtained age, gender, length of stay, race, insurance coverage, do not resuscitate status, and Elixhauser comorbidities. The outcome used was interhospital transfer from a small- or medium-sized hospital to a larger acute care hospital. Of 55,208,382 hospitalizations, 46,406 patients met inclusion criteria. In the multivariate model, patients were less likely to be transferred if the following were present: older age (odds ratio, 0.98; 95% CI, 0.978-0.982), black race (odds ratio, 0.79; 95% CI, 0.70-0.89), Hispanic race (odds ratio, 0.79; 95% CI, 0.69-0.90), South region hospital (odds ratio, 0.79; 95% CI, 0.72-0.88), teaching hospital (odds ratio, 0.31; 95% CI, 0.28-0.33), and do not resuscitate status (odds ratio, 0.19; 95% CI, 0.15-0.25). CONCLUSIONS: In mechanically ventilated patients with sepsis, we found significant disparities in race and geographic location not explained by medical diagnoses or illness severity.

Six Change Ideas that Significantly Minimize Alternate Level of Care (ALC) Days in Acute Care Hospitals.

A significant issue affecting the healthcare system across Ontario is the number of patients admitted to hospitals that are then subsequently being designated alternate level of care (ALC). In 2016, 14.5% of Ontario in-patient beds were occupied by ALC-designated patients. Contributing to this phenomenon are ethical errors that can affect decision-making around discharge. Since 2012, William Osler Health System has redesigned their discharge process to eliminate ethical errors and align more fully with the Health Care Consent Act (HCCA) and the Public Hospitals Act (PHA). Through quality improvement processes including the use of scripting, education, checklists, mentoring and role clarity, Osler's ALC days are currently the lowest in the province of Ontario. The elimination of such errors also decreased patient confusion and improved the discharge experience.

The PoET (Prevention of Error-Based Transfers) Project.

The PoET (Prevention of Error-based Transfers) Project is one of the Ethics Quality Improvement Projects (EQIPs) taking place at William Osler Health System. This specific project is designed to reduce transfers from long-term care to hospital that are caused by legal and ethical errors related to consent, capacity and substitute decision-making. The project is currently operating in eight long-term care homes in the Central West Local Health Integration Network and has seen a 56% reduction in multiple transfers before death in hospital.

Gestión de traslados potencialmente evitables a los hospitales de agudos desde unidades de rehabilitación geriátrica: aspectos críticos de un protocolo de intervención / Management of avoidable acute transfers from an intermediate care geriatric facility to acute hospitals: critical aspects of an intervention protocol

Objetivo. Los traslados no planificados (TNP) desde centros de atención intermedia, postagudos a agudos se asocian a consecuencias adversas para los pacientes y a un importante coste para el sistema. Presentamos un protocolo práctico y el diseño de un estudio de intervención dirigido a disminuir los TNP evitables desde una unidad de rehabilitación geriátrica a hospitales de agudos. Pacientes y métodos. Estudio cuasiexperimental no aleatorizado. La intervención consiste en dos ejes: 1) protocolo de detección precoz de síntomas con el objetivo de realizar un manejo proactivo de las descompensaciones; 2) protocolo estructurado de directrices avanzadas delante de las descompensaciones agudas, compararemos el grupo de intervención con una cohorte paralela de control y una cohorte histórica. Las muestras se compararán por variables demográficas, funcionales, cognitivas, comorbilidad y sociales. Variable dependiente: número de TNP de la unidad de rehabilitación geriátrica a los hospitales de agudos. Discusión. Este estudio cuasiexperimental, con una importante caracterización práctica, pretende valorar el impacto de un protocolo multidisciplinar y multifactorial para reducir los TNP potencialmente evitables a centros de agudos durante el ingreso en convalecencia y rehabilitación. Además, creemos que los resultados del proyecto podrán resultar útiles para futuros estudios aleatorizados y controlados (AU)

Objective. The unplanned transfers (UT) from post-acute intermediate care facilities, are associated with adverse outcomes for patients, and a significant cost to the system. We present a practical protocol and the design of an intervention study aimed at reducing avoidable UT from a geriatric post-acute rehabilitation setting to acute care hospitals. Patients and Methods. A quasi-experimental non randomized study. The intervention consists in: 1) protocol for early detection of symptoms in order to conduct a pro-active management of decompensation; 2) an advanced care planning structured protocol for the acute decompensations. We will compare the intervention group with a parallel and a historical cohort for demographic, functional, cognitive, comorbidity and social variables. Outcome: number of UT to acute care hospitals. Discussion. This is a quasi-experimental study, focused on everyday care practice that intends to assess the impact of multi-disciplinary and multi-factorial intervention to reduce UT from a post-acute rehabilitation unit. We expect that the project results will be useful for future randomized and controlled studies (AU)

[Transfer of allogeneic stem cell transplant recipients to the intensive care unit: Guidelines from the Francophone society of marrow transplantation and cellular therapy (SFGM-TC)]. / Transfert des patients allogreffés de cellules-souches hématopoïétiques en réanimation : recommandations de la Société francophone de greffe de moelle et de thérapie cellulaire (SFGM-TC).

Transferring a patient undergoing an allogeneic stem cell transplantation to the intensive care unit (ICU) is always a challenging situation on a medical and psychological point of view for the patient and his relatives as well as for the medical staff. Despite the progress in hematology and intensive care during the last decade, the prognosis of these patients admitted to the ICU remains poor and mortality is around 50 %. The harmonization working party of the SFGM-TC assembled hematologists and intensive care specialist in order to improve conditions and modalities of the transfer of a patient after allogeneic stem cell transplantation to the ICU. We propose a structured medical form comprising all essential information necessary for optimal medical care on ICU.

A Misdirected Patient Transfer Raises Emergency Medical Treatment and Labor Act Liability Issues.

Children often require transfer to pediatric hospital emergency departments (EDs) after evaluation in community hospital EDs. Such transfers are regulated by the federal Emergency Medical Treatment and Labor Act. Unusual circumstances, such as logistical errors in the physical transfer of the patient, may increase Emergency Medical Treatment and Labor Act-related liability risks for hospitals and ED physicians.