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1.
BMC Infect Dis ; 21(1): 212, 2021 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-33632137

RESUMO

BACKGROUND: Healthcare-associated infections (HAIs) are relevant in developing countries where frequencies can be at least 3 times higher than in developed countries. The purpose of this research was to describe the intervention implemented in intensive care units (ICUs) to reduce HAIs through collaborative project and analyze the variation over 18 months in the incidence density (ID) of the three main HAIs: ventilator associated pneumonia (VAP), central line-associated bloodstream infections (CLABSIs) and catheter-related urinary tract infections (CAUTIs) and also the length of stay and mortality in these ICUs. METHODS: A quasi-experimental study in five public adult clinical-surgical ICUs, to reduce HAIs, through interventions using the BTS-IHI "Improvement Model", during 18 months. In the project, promoted by the Ministry of Health, Brazilian philanthropic hospitals certified for excellence (HE), those mostly private, certified as excellence and exempt from security contributions, regularly trained and monitored public hospitals in diagnostics, data collection and in developing cycles to improve quality and to prevent HAIs (bundles). In the analysis regarding the length of stay, mortality, the IDs of VAP, CLABSIs and CAUTIs over time, a Generalized Estimating Equation (GEE) model was applied for continuous variables, using the constant correlation (exchangeable) between assessments over time. The model estimated the average difference (ß coefficient of the model) of the measures analyzed during two periods: a period in the year 2017 (prior to implementing the project) and in the years 2018 and 2019 (during the project). RESULT: A mean monthly reduction of 0.427 in VAP ID (p = 0.002) with 33.8% decrease at the end of the period and 0.351 in CAUTI ID (p = 0.009) with 45% final decrease. The mean monthly reduction of 0.252 for CLABSIs was not significant (p = 0.068). Length of stay and mortality rates had no significant variation. CONCLUSIONS: Given the success in reducing VAP and CAUTIs in a few months of interventions, the achievement of the collaborative project is evident. This partnership among public hospitals/HE may be applied to other ICUs including countries with fewer resources.


Assuntos
Infecção Hospitalar/prevenção & controle , Hospitais/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Parcerias Público-Privadas/estatística & dados numéricos , Adulto , Brasil/epidemiologia , Infecções Relacionadas a Cateter/epidemiologia , Infecções Relacionadas a Cateter/prevenção & controle , Infecção Hospitalar/epidemiologia , Hospitais/normas , Humanos , Incidência , Unidades de Terapia Intensiva/normas , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Pneumonia Associada à Ventilação Mecânica/prevenção & controle , Parcerias Público-Privadas/organização & administração , Parcerias Público-Privadas/normas
2.
J Healthc Qual ; 43(1): 3-12, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33394838

RESUMO

INTRODUCTION: As the COVID-19 pandemic spread, patient care guidelines were published and elective surgeries postponed. However, trauma admissions are not scheduled and cannot be postponed. There is a paucity of information available on continuing trauma care during the pandemic. The study purpose was to describe multicenter trauma care process changes made during the COVID-19 pandemic. METHODS: This descriptive survey summarized the response to the COVID-19 pandemic at six Level I trauma centers. The survey was completed in 05/2020. Questions were asked about personal protective equipment, ventilators, intensive care unit (ICU) beds, and negative pressure rooms. Data were summarized as proportions. RESULTS: The survey took an average of 5 days. Sixty-seven percent reused N-95 respirators; 50% sanitized them with 25% using ultraviolet light. One hospital (17%) had regional resources impacted. Thirty-three percent created ventilator allocation protocols. Most hospitals (83%) designated more beds to the ICU; 50% of hospitals designated an ICU for COVID-19 patients. COVID-19 patients were isolated in negative pressure rooms at all hospitals. CONCLUSIONS: In response to the COVID-19 pandemic, Level I trauma centers created processes to provide optimal trauma patient care and still protect providers. Other centers can use the processes described to continue care of trauma patients during the COVID-19 pandemic.


Assuntos
/terapia , Cuidados Críticos/estatística & dados numéricos , Cuidados Críticos/normas , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/normas , Centros de Traumatologia/estatística & dados numéricos , Centros de Traumatologia/normas , Humanos , Pandemias , Guias de Prática Clínica como Assunto , Estados Unidos
3.
J Surg Res ; 260: 38-45, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33316758

RESUMO

BACKGROUND: Urgent guidance is needed on the safety for providers of percutaneous tracheostomy in patients diagnosed with COVID-19. The objective of the study was to demonstrate that percutaneous dilational tracheostomy (PDT) with a period of apnea in patients requiring prolonged mechanical ventilation due to COVID-19 is safe and can be performed for the usual indications in the intensive care unit. METHODS: This study involves an observational case series at a single-center medical intensive care unit at a level-1 trauma center in patients diagnosed with COVID-19 who were assessed for tracheostomy. Success of a modified technique included direct visualization of tracheal access by bronchoscopy and a blind dilation and tracheostomy insertion during a period of patient apnea to reduce aerosolization. Secondary outcomes include transmission rate of COVID-19 to providers and patient complications. RESULTS: From April 6th, 2020 to July 21st, 2020, 2030 patients were admitted to the hospital with COVID-19, 615 required intensive care unit care (30.3%), and 254 patients required mechanical ventilation (12.5%). The mortality rate for patients requiring mechanical ventilation was 29%. Eighteen patients were assessed for PDT, and 11 (61%) underwent the procedure. The majority had failed extubation at least once (72.7%), and the median duration of intubation before tracheostomy was 15 d (interquartile range 13-24). The median positive end-expiratory pressure at time of tracheostomy was 10.8. The median partial pressure of oxygen (PaO2)/FiO2 ratio on the day of tracheostomy was 142.8 (interquartile range 104.5-224.4). Two patients had bleeding complications. At 1-week follow-up, eight patients still required ventilator support (73%). At the most recent follow-up, eight patients (73%) have been liberated from the ventilator, one patient (9%) died as a result of respiratory/multiorgan failure, and two were discharged on the ventilator (18%). Average follow-up was 20 d. None of the surgeons performing PDT have symptoms of or have tested positive for COVID-19. CONCLUSIONS: and relevance: PDT for patients with COVID-19 is safe for health care workers and patients despite higher positive end-expiratory pressure requirements and should be performed for the same indications as other causes of respiratory failure.


Assuntos
Broncoscopia/efeitos adversos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Complicações Pós-Operatórias/epidemiologia , Respiração Artificial/efeitos adversos , Traqueostomia/efeitos adversos , Adulto , Idoso , Extubação/estatística & dados numéricos , Broncoscopia/instrumentação , Broncoscopia/métodos , Broncoscopia/normas , /mortalidade , /estatística & dados numéricos , Feminino , Seguimentos , Mortalidade Hospitalar , Humanos , Transmissão de Doença Infecciosa do Paciente para o Profissional/estatística & dados numéricos , Unidades de Terapia Intensiva/normas , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Estudos Retrospectivos , Índice de Gravidade de Doença , Fatores de Tempo , Traqueostomia/instrumentação , Traqueostomia/métodos , Traqueostomia/normas , Resultado do Tratamento
4.
PLoS One ; 15(10): e0239853, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33057435

RESUMO

BACKGROUND: Mobilization of intensive care patients is a multi-professional task. Aim of this study was to explore how different professions working at Intensive Care Units (ICU) estimate the mobility capacity using the ICU Mobility Score in 10 different scenarios. METHODS: Ten fictitious patient-scenarios and guideline-related knowledge were assessed using an online survey. Critical care team members in German-speaking countries were invited to participate. All datasets including professional data and at least one scenario were analyzed. Kruskal Wallis test was used for the individual scenarios, while a linear mixed-model was used over all responses. RESULTS: In total, 515 of 788 (65%) participants could be evaluated. Physicians (p = 0.001) and nurses (p = 0.002) selected a lower ICU Mobility Score (-0.7 95% CI -1.1 to -0.3 and -0.4 95% CI -0.7 to -0.2, respectively) than physical therapists, while other specialists did not (p = 0.81). Participants who classified themselves as experts or could define early mobilization in accordance to the "S2e guideline: positioning and early mobilisation in prophylaxis or therapy of pulmonary disorders" correctly selected higher mobilization levels (0.2 95% CI 0.0 to 0.4, p = 0.049 and 0.3 95% CI 0.1 to 0.5, p = 0.002, respectively). CONCLUSION: Different professions scored the mobilization capacity of patients differently, with nurses and physicians estimating significantly lower capacity than physical therapists. The exact knowledge of guidelines and recommendations, such as the definition of early mobilization, independently lead to a higher score. Interprofessional education, interprofessional rounds and mobilization activities could further enhance knowledge and practice of mobilization in the critical care team.


Assuntos
Deambulação Precoce/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Pessoal de Saúde/psicologia , Unidades de Terapia Intensiva/normas , Posicionamento do Paciente/normas , Adulto , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Pessoal de Saúde/normas , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Inquéritos e Questionários
5.
Med. intensiva (Madr., Ed. impr.) ; 44(7): 399-408, oct. 2020. graf, tab
Artigo em Inglês | IBECS | ID: ibc-197358

RESUMO

OBJECTIVE: To evaluate the relationship between antipseudomonal antibiotic consumption and each individual drug resistance rate in Pseudomonas aeruginosa strains causing ICU acquired invasive device-related infections (IDRI). DESIGN: A post hoc analysis was made of the data collected prospectively from the ENVIN-HELICS registry. SETTING: Intensive Care Units participating in the ENVIN-UCI registry between the years 2007 and 2016 (3-month registry each year). PATIENTS: Patients admitted for over 24h. MAIN VARIABLES: Annual linear and nonlinear trends of resistance rates of P. aeruginosa strains identified in IDRI and days of treatment of each antipseudomonal antibiotic family per 1000 occupied ICU bed days (DOT) were calculated. RESULTS: A total of 15,095 episodes of IDRI were diagnosed in 11,652 patients (6.2% out of a total of 187,100). Pseudomonas aeruginosa was identified in 2095 (13.6%) of 15,432 pathogens causing IDRI. Resistance increased significantly over the study period for piperacillin-tazobactam (P<0.001), imipenem (P=0.016), meropenem (P=0.004), ceftazidime (P=0.005) and cefepime (P=0.015), while variations in resistance rates for amikacin, ciprofloxacin, levofloxacin and colistin proved nonsignificant. A significant DOT decrease was observed for aminoglycosides (P<0.001), cephalosporins (P<0.001), quinolones (P<0.001) and carbapenems (P<0.001). CONCLUSIONS: No significant association was observed between consumption of each antipseudomonal antibiotic family and the respective resistance rates for P. aeruginosa strains identified in IDRI


OBJETIVO: Evaluar la relación entre el consumo de antibióticos antipseudomonales y la tasa de resistencia de cada fármaco individual en cepas de Pseudomonas aeruginosa aisladas en infecciones relacionadas con dispositivos invasivos (IDRI, por sus siglas en inglés) adquiridas en la unidad de cuidados intensivos (UCI). DISEÑO: Análisis post-hoc de los datos recopilados prospectivamente del registro ENVIN-HELICS. Ámbito: Las UCI que participaron en el registro ENVIN-UCI entre los años 2007-2016 (registro de 3 meses cada año). PACIENTES: Pacientes ingresados >24h. VARIABLES PRINCIPALES: Se calcularon las tendencias anuales lineales y no lineales de las tasas de resistencia de las cepas de P. aeruginosa identificadas en IDRI y los días de tratamiento de cada familia de antibióticos antipseudomonales por 1.000 días de cama ocupada en la UCI (DOT). RESULTADOS: Se diagnosticaron 15.095 episodios de IDRI en 11.652 pacientes (6,2% de 187.100). Se identificó P. aeruginosa en 2.095 (13,6%) de 15.432 patógenos que causaron IDRI. La resistencia aumentó significativamente durante el período de estudio para piperacilina-tazobactam (p < 0,001), imipenem (p = 0,016), meropenem (p = 0,004), ceftazidima (p = 0,005) y cefepima (p = 0,015), mientras que las variaciones en las tasas de resistencia de amikacina, ciprofloxacina, levofloxacina y colistina no fueron significativas. Se observó una disminución significativa de la DOT para aminoglucósidos (p < 0,001), cefalosporinas (p < 0,001), quinolonas (p < 0,001) y carbapenems (p < 0,001). CONCLUSIONES: No se encontró asociación significativa del consumo de cada familia de antibióticos antipseudomonales con sus respectivas tasas de resistencia para las cepas de P. aeruginosa identificadas en IDRI


Assuntos
Humanos , Farmacorresistência Bacteriana , Anti-Infecciosos/uso terapêutico , Unidades de Terapia Intensiva/normas , Pseudomonas aeruginosa/efeitos dos fármacos , Infecção Hospitalar/tratamento farmacológico , Unidades de Terapia Intensiva , Pseudomonas aeruginosa/isolamento & purificação , Infecção Hospitalar/microbiologia , Estudos Prospectivos
6.
S Afr Med J ; 110(7): 621-624, 2020 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-32880335

RESUMO

Infectious diseases pandemics have devastating health, social and economic consequences, especially in developing countries such as South Africa. Scarce medical resources must often be rationed effectively to contain the disease outbreak. In the case of COVID-19, even the best-resourced countries will have inadequate intensive care facilities for the large number of patients needing admission and ventilation. The scarcity of medical resources creates the need for national governments to establish admission criteria that are evidence-based and fair. Questions have been raised whether infection with HIV or tuberculosis (TB) may amplify the risk of adverse COVID-19 outcomes and therefore whether these conditions should be factored in when deciding on the rationing of intensive care facilities. In light of these questions, clinical evidence regarding inclusion of these infections as comorbidities relevant to intensive care unit admission triage criteria is investigated in the first of a two-part series of articles. There is currently no evidence to indicate that HIV or TB infection on their own predispose to an increased risk of infection with SARS-CoV-2 or worse outcomes for COVID-19. It is recommended that, as for other medical conditions, validated scoring systems for poor prognostic factors should be applied. A subsequent article examines the ethicolegal implications of limiting intensive care access of persons living with HIV or TB.


Assuntos
Infecções por Coronavirus , Infecções por HIV/epidemiologia , Alocação de Recursos para a Atenção à Saúde/métodos , Unidades de Terapia Intensiva , Pandemias , Pneumonia Viral , Triagem/organização & administração , Tuberculose/epidemiologia , Betacoronavirus/isolamento & purificação , Coinfecção , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Necessidades e Demandas de Serviços de Saúde/organização & administração , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/normas , Pandemias/economia , Seleção de Pacientes , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Prognóstico , Medição de Risco , África do Sul/epidemiologia
7.
S Afr Med J ; 110(7): 625-628, 2020 06 17.
Artigo em Inglês | MEDLINE | ID: mdl-32880336

RESUMO

The COVID-19 pandemic has brought discussions around the appropriate and fair rationing of scare resources to the forefront. This is of special importance in a country such as South Africa (SA), where scarce resources interface with high levels of need. A large proportion of the SA population has risk factors associated with worse COVID-19 outcomes. Many people are also potentially medically and socially vulnerable secondary to the high levels of infection with HIV and tuberculosis (TB) in the country. This is the second of two articles. The first examined the clinical evidence regarding the inclusion of HIV and TB as comorbidities relevant to intensive care unit (ICU) admission triage criteria. Given the fact that patients with HIV or TB may potentially be excluded from admission to an ICU on the basis of an assumption of lack of clinical suitability for critical care, in this article we explore the ethicolegal implications of limiting ICU access of persons living with HIV or TB. We argue that all allocation and rationing decisions must be in terms of SA law, which prohibits unfair discrimination. In addition, ethical decision-making demands accurate and evidence-based strategies for the fair distribution of limited resources. Rationing decisions and processes should be fair and based on visible and consistent criteria that can be subjected to objective scrutiny, with the ultimate aim of ensuring accountability, equity and fairness.


Assuntos
Infecções por Coronavirus , Infecções por HIV/epidemiologia , Alocação de Recursos para a Atenção à Saúde/métodos , Unidades de Terapia Intensiva , Pandemias , Seleção de Pacientes/ética , Pneumonia Viral , Alocação de Recursos , Triagem , Tuberculose/epidemiologia , Betacoronavirus/isolamento & purificação , Coinfecção , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Necessidades e Demandas de Serviços de Saúde/organização & administração , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/normas , Pandemias/economia , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia , Alocação de Recursos/ética , Alocação de Recursos/legislação & jurisprudência , África do Sul/epidemiologia , Triagem/economia , Triagem/ética , Triagem/legislação & jurisprudência
8.
Med. intensiva (Madr., Ed. impr.) ; 44(6): 325-332, ago.-sept. 2020. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-194811

RESUMO

OBJETIVO: Evaluar la capacidad de los modelos TRISS y PS14 para predecir la probabilidad de supervivencia en nuestro sistema de salud y población. DISEÑO: Desarrollamos un estudio observacional retrospectivo durante un periodo de 66 meses. ÁMBITO: El estudio se llevó a cabo en una UCI especializada en traumatología en un hospital urbano de alta complejidad. PACIENTES: Se incluyeron en el estudio los pacientes mayores de 14 años con traumatismo grave (definido como ISS ≥ 16 y/o RTS < 12). VARIABLES DE INTERÉS: Se calculó el estadístico W (diferencia entre la mortalidad -hospitalaria o a los 30 días para los modelos TRISS o PS14 respectivamente- calculada y observada por cada 100 pacientes) y su nivel de significación para cada modelo. Se realizó un análisis por subgrupos. La calibración y discriminación se evaluaron por medio del test de Hosmer-Lemeshoy y cinturón GiViTI y curvas ROC respectivamente. RESULTADOS: Se incluyeron 1.240 pacientes. La supervivencia global al alta fue de 81,9%. El estadístico W para los modelos TRISS, TRISS2010 y PS14 fue respectivamente +6,72 (p < 0,01), +1,48 (p = 0,08) y +2,74 (p < 0,01). El AUROC para los citados modelos fue respectivamente 0,915, 0,919 y 0,914, sin que se encontraran diferencias significativas entre ellos. Tanto el test de Hosmer-Lemeshow como el cinturón de calibración GiViTI mostraron escasa calibración en los 3 modelos. CONCLUSIONES: Estos modelos son una herramienta adecuada para la evaluación de la calidad asistencial en una UCI de traumatismo. En nuestro centro las tasas de supervivencia fueron mayores de lo predicho por los modelos


OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score ≥ 16 and/or Revised Trauma Score < 12) aged > 14 years were included. Variables of interest: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were +6.72 (P < .01), +1.48 (P = .08) and +2.74 (P < .01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P > .05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed


Assuntos
Humanos , Masculino , Feminino , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Garantia da Qualidade dos Cuidados de Saúde/métodos , Índices de Gravidade do Trauma , Ferimentos e Lesões/mortalidade , Taxa de Sobrevida , Estudos Retrospectivos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/normas , Intervalos de Confiança , Ferimentos e Lesões/classificação
9.
Ann. intensive care ; 118: 1-26, Sept. 07, 2020.
Artigo em Inglês | BIGG - guias GRADE | ID: biblio-1128263

RESUMO

The French Society of Intensive Care Medicine (SRLF), jointly with the French-Speaking Group of Paediatric Emer­ gency Rooms and Intensive Care Units (GFRUP) and the French-Speaking Association of Paediatric Surgical Inten­ sivists (ADARPEF), worked out guidelines for the management of central venous catheters (CVC), arterial catheters and dialysis catheters in intensive care unit. For adult patients: Using GRADE methodology, 36 recommendations for an improved catheter management were produced by the 22 experts. Recommendations regarding catheterrelated infections' prevention included the preferential use of subclavian central vein (GRADE 1), a one-step skin disinfection(GRADE 1) using 2% chlorhexidine (CHG)-alcohol (GRADE 1), and the implementation of a quality of care improvement program. Antiseptic- or antibiotic-impregnated CVC should likely not be used (GRADE 2, for children and adults). Catheter dressings should likely not be changed before the 7th day, except when the dressing gets detached, soiled or impregnated with blood (GRADE 2− adults). CHG dressings should likely be used (GRADE 2+). For adults and children, ultrasound guidance should be used to reduce mechanical complications in case of internal jugular access (GRADE 1), subclavian access (Grade 2) and femoral venous, arterial radial and femoral access (Expert opinion). For children, an ultrasound-guided supraclavicular approach of the brachiocephalic vein was recommended to reduce the number of attempts for cannulation and mechanical complications. Based on scarce publications on diagnostic and therapeutic strategies and on their experience (expert opinion), the panel proposed defnitions, and therapeutic strategies.


Assuntos
Humanos , Adulto , Controle de Infecções/métodos , Infecções Relacionadas a Cateter/diagnóstico , Infecções Relacionadas a Cateter/prevenção & controle , Infecções Relacionadas a Cateter/transmissão , Clorexidina/uso terapêutico , Medicina Baseada em Evidências , Unidades de Terapia Intensiva/normas
10.
Anesthesiology ; 133(5): 985-996, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32773686

RESUMO

Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.


Assuntos
Betacoronavirus , Simulação por Computador/normas , Infecções por Coronavirus/terapia , Análise do Modo e do Efeito de Falhas na Assistência à Saúde/normas , Equipe de Respostas Rápidas de Hospitais/normas , Unidades de Terapia Intensiva/normas , Pneumonia Viral/terapia , Boston/epidemiologia , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/métodos , Cuidados Críticos/normas , Análise do Modo e do Efeito de Falhas na Assistência à Saúde/métodos , Humanos , Pandemias , Pneumonia Viral/epidemiologia , Desenvolvimento de Programas/métodos , Desenvolvimento de Programas/normas , Melhoria de Qualidade/normas
11.
J Med Internet Res ; 22(9): e20143, 2020 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-32795997

RESUMO

BACKGROUND: The COVID-19 pandemic has necessitated a rapid increase of space in highly infectious disease intensive care units (ICUs). At Houston Methodist Hospital (HMH), a virtual intensive care unit (vICU) was used amid the COVID-19 outbreak. OBJECTIVE: The aim of this paper was to detail the novel adaptations and rapid expansion of the vICU that were applied to achieve patient-centric solutions while protecting staff and patients' families during the pandemic. METHODS: The planned vICU implementation was redirected to meet the emerging needs of conversion of COVID-19 ICUs, including alterations to staged rollout timing, virtual and in-person staffing, and scope of application. With the majority of the hospital critical care physician workforce redirected to rapidly expanded COVID-19 ICUs, the non-COVID-19 ICUs were managed by cardiovascular surgeons, cardiologists, neurosurgeons, and acute care surgeons. HMH expanded the vICU program to fill the newly depleted critical care expertise in the non-COVID-19 units to provide urgent, emergent, and code blue support to all ICUs. RESULTS: Virtual family visitation via the Consultant Bridge application, palliative care delivery, and specialist consultation for patients with COVID-19 exemplify the successful adaptation of the vICU implementation. Patients with COVID-19, who were isolated and separated from their families to prevent the spread of infection, were able to virtually see and hear their loved ones, which bolstered the mental and emotional status of those patients. Many families expressed gratitude for the ability to see and speak with their loved ones. The vICU also protected medical staff and specialists assigned to COVID-19 units, reducing exposure and conserving personal protective equipment. CONCLUSIONS: Telecritical care has been established as an advantageous mechanism for the delivery of critical care expertise during the expedited rollout of the vICU at Houston Methodist Hospital. Overall responses from patients, families, and physicians are in favor of continued vICU care; however, further research is required to examine the impact of innovative applications of telecritical care in the treatment of critically ill patients.


Assuntos
Infecções por Coronavirus/terapia , Assistência à Saúde/organização & administração , Unidades de Terapia Intensiva/organização & administração , Pneumonia Viral/terapia , Telemedicina/organização & administração , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Assistência à Saúde/métodos , Assistência à Saúde/normas , Feminino , Humanos , Unidades de Terapia Intensiva/normas , Masculino , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Telemedicina/métodos , Telemedicina/normas
12.
Intern Med J ; 50(9): 1146-1150, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32761863

RESUMO

The scale of the COVID-19 pandemic represents unprecedented challenges to healthcare systems. We describe a cohort of 18 critically ill COVID-19 patients - to our knowledge the highest number, in a single intensive care unit in Australia. We discuss the complex challenges and dynamic solutions that concern an intensive care unit pandemic response. Acting as the State's COVID-19 referral hospital, we provide local insights to consider alongside national guidelines.


Assuntos
Infecções por Coronavirus/epidemiologia , Unidades de Terapia Intensiva/organização & administração , Pneumonia Viral/epidemiologia , Idoso , Betacoronavirus , Comunicação , Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Planejamento em Desastres , Família/psicologia , Feminino , Humanos , Controle de Infecções/organização & administração , Unidades de Terapia Intensiva/normas , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Saúde do Trabalhador/normas , Pandemias , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Guias de Prática Clínica como Assunto , Encaminhamento e Consulta , Austrália do Sul/epidemiologia
13.
J Healthc Risk Manag ; 40(2): 28-33, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32734687

RESUMO

Many writers and organizations have postulated that health care facilities and providers may need to implement a "crisis standard of care" to deal with the exigent circumstances associated with the massive influx of patients infected with the novel coronavirus and suffering from COVID-19. There is a relative scarcity of critical resources, such as intensive care unit beds, emergency department beds, ventilators, personal protective equipment, and medications. Facilities can become overwhelmed. A crisis standard of care can act as a guidepost for rationing supplies and care, should that become necessary. However, that is not without danger. Health care facilities and providers should plan carefully and then act with due deliberation in implementing a crisis standard of care to mitigate or prevent future liability.


Assuntos
Infecções por Coronavirus , Serviço Hospitalar de Emergência/normas , Unidades de Terapia Intensiva/normas , Pandemias , Pneumonia Viral , Guias de Prática Clínica como Assunto , Gestão de Riscos/normas , Padrão de Cuidado/normas , Humanos
14.
J Cardiothorac Vasc Anesth ; 34(10): 2595-2603, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32620487

RESUMO

Cardiopulmonary resuscitation (CPR) in patients with severe acute respiratory syndrome coronavirus-2-associated disease (coronavirus disease 2019) poses a unique challenge to health- care providers due to the risk of viral aerosolization and disease transmission. This has caused some centers to modify existing CPR procedures, limit the duration of CPR, or consider avoiding CPR altogether. In this review, the authors propose a procedure for CPR in the intensive care unit that minimizes the number of personnel in the immediate vicinity of the patient and conserves the use of scarce personal protective equipment. Highlighting the low likelihood of successful resuscitation in high-risk patients may prompt patients to decline CPR. The authors recommend the preemptive placement of central venous lines in high-risk patients with intravenous tubing extensions that allow for medication delivery from outside the patients' rooms. During CPR, this practice can be used to deliver critical medications without delay. The use of a mechanical compression system for CPR further reduces the risk of infectious exposure to health- care providers. Extracorporeal membrane oxygenation should be reserved for patients with few comorbidities and a single failing organ system. Reliable teleconferencing tools are essential to facilitate communication between providers inside and outside the patients' rooms. General principles regarding the ethics and peri-resuscitative management of coronavirus 2019 patients also are discussed.


Assuntos
Betacoronavirus , Reanimação Cardiopulmonar/métodos , Infecções por Coronavirus/terapia , Cuidados Críticos/métodos , Parada Cardíaca/terapia , Unidades de Terapia Intensiva , Pneumonia Viral/terapia , Reanimação Cardiopulmonar/normas , Infecções por Coronavirus/epidemiologia , Cuidados Críticos/normas , Parada Cardíaca/epidemiologia , Humanos , Unidades de Terapia Intensiva/normas , Pandemias , Pneumonia Viral/epidemiologia , Fluxo de Trabalho
15.
Stroke Vasc Neurol ; 5(3): 242-249, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32641446

RESUMO

During the COVID-19 epidemic, the treatment of critically ill patients has been increasingly difficult and challenging. During the epidemic, some patients with neurological diseases also have COVID-19, which could be misdiagnosed and cause silent transmission and nosocomial infection. Such risk is high in a neurological intensive care unit (NCU). Therefore, prevention and control of epidemic in critically ill patients is of utmost importance. The principle of NCU care should include comprehensive screening and risk assessment, weighing risk against benefits and reducing the risk of COVID-19 transmission while treating patients as promptly as possible.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/prevenção & controle , Infecção Hospitalar/prevenção & controle , Controle de Infecções/normas , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Unidades de Terapia Intensiva/normas , Doenças do Sistema Nervoso/terapia , Neurologia/normas , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Consenso , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Estado Terminal , Infecção Hospitalar/diagnóstico , Infecção Hospitalar/transmissão , Infecção Hospitalar/virologia , Interações Hospedeiro-Patógeno , Humanos , Doenças do Sistema Nervoso/diagnóstico , Saúde do Trabalhador , Segurança do Paciente , Pneumonia Viral/diagnóstico , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Medição de Risco , Fatores de Risco , Resultado do Tratamento
16.
Rev Bras Enferm ; 73Suppl 2(Suppl 2): e20200316, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32609253

RESUMO

OBJECTIVE: to perform a situational diagnosis of the behavior of health professionals concerning hand hygiene practices in highly-complex sectors. METHODS: this quantitative and retrospective study was based on reports (2016 and 2017) of Adult and Pediatric ICUs of a Federal hospital in Rio de Janeiro. RESULTS: one thousand two hundred fifty-eight opportunities for hand hygiene were analysed. The chance of professionals sanitizing hands in Pediatric ICUs is 41.61% higher than in Adult ICUs. Concerning proper hand hygiene, the medical team had a 39.44% lower chance than the nursing team. Others had a 30.62% lower chance when compared to the nursing team. The moment "after contact with the patient" presented 4.5275 times the chance in relation "before contact with the patient". CONCLUSION: in front of hand hygiene recommendations to control COVID-19, diagnostic assessment and previous analysis of the behavior of professionals proved to be positive.


Assuntos
Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Fidelidade a Diretrizes/estatística & dados numéricos , Desinfecção das Mãos/normas , Pessoal de Saúde/educação , Unidades de Terapia Intensiva/normas , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto , Adulto , Brasil , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
17.
Anesth Analg ; 131(3): 669-676, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32520728

RESUMO

BACKGROUND: Protecting first-line health care providers against work-related coronavirus disease 2019 (COVID-19) infection at the onset of the pandemic has been a crucial challenge in the United States. Anesthesiologists in particular are considered at risk, since aerosol-generating procedures, such as intubation and extubation, have been shown to significantly increase the odds for respiratory infections during severe acute respiratory syndrome (SARS) outbreaks. This study assessed the incidence of COVID-19-like symptoms and the presence of COVID-19 antibodies after work-related COVID-19 exposures, among physicians working in a large academic hospital in New York City (NYC). METHODS: An e-mail survey was addressed to anesthesiologists and affiliated intensive care providers at Columbia University Irving Medical Center on April 15, 2020. The survey assessed 4 domains: (1) demographics and medical history, (2) community exposure to COVID-19 (eg, use of NYC subway), (3) work-related exposure to COVID-19, and (4) development of COVID-19-like symptoms after work exposure. The first 100 survey responders were invited to undergo a blood test to assess antibody status (presence of immunoglobulin M [IgM]/immunoglobulin G [IgG] specific to COVID-19). Work-related exposure was defined as any episode where the provider was not wearing adequate personal protective equipment (airborne or droplet/contact protection depending on the exposure type). Based on the clinical scenario, work exposure was categorized as high risk (eg, exposure during intubation) or low risk (eg, exposure during doffing). RESULTS: Two hundred and five health care providers were contacted and 105 completed the survey (51%); 91 completed the serological test. Sixty-one of the respondents (58%) reported at least 1 work-related exposure and 54% of the exposures were high risk. Among respondents reporting a work-related exposure, 16 (26.2%) reported postexposure COVID-19-like symptoms. The most frequent symptoms were myalgia (9 cases), diarrhea (8 cases), fever (7 cases), and sore throat (7 cases). COVID-19 antibodies were detected in 11 of the 91 tested respondents (12.1%), with no difference between respondents with (11.8%) or without (12.5%) a work-related exposure, including high-risk exposure. Compared with antibody-negative respondents, antibody-positive respondents were more likely to use NYC subway to commute to work and report COVID-19-like symptoms in the past 90 days. CONCLUSIONS: In the epicenter of the United States' pandemic and within 6-8 weeks of the COVID-19 outbreak, a small proportion of anesthesiologists and affiliated intensive care providers reported COVID-19-like symptoms after a work-related exposure and even fewer had detectable COVID-19 antibodies. The presence of COVID-19 antibodies appeared to be associated with community/environmental transmission rather than secondary to work-related exposures involving high-risk procedures.


Assuntos
Centros Médicos Acadêmicos/normas , Anestesiologistas/normas , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/sangue , Unidades de Terapia Intensiva/normas , Pneumonia Viral/sangue , Adulto , Técnicas de Laboratório Clínico , Estudos de Coortes , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Masculino , Cidade de Nova Iorque/epidemiologia , Exposição Ocupacional/prevenção & controle , Pandemias , Pneumonia Viral/diagnóstico , Pneumonia Viral/epidemiologia , Estudos Prospectivos
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