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1.
J Cardiothorac Vasc Anesth ; 33(5): 1430-1439, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30600204

RESUMO

The authors aimed to identify interventions documented by randomized controlled trials (RCTs) that reduce mortality in adult critically ill and perioperative patients, followed by a survey of clinicians' opinions and routine practices to understand the clinicians' response to such evidence. The authors performed a comprehensive literature review to identify all topics reported to reduce mortality in perioperative and critical care settings according to at least 2 RCTs or to a multicenter RCT or to a single-center RCT plus guidelines. The authors generated position statements that were voted on online by physicians worldwide for agreement, use, and willingness to include in international guidelines. From 262 RCT manuscripts reporting mortality differences in the perioperative and critically ill settings, the authors selected 27 drugs, techniques, and strategies (66 RCTs, most frequently published by the New England Journal of Medicine [13 papers], Lancet [7], and Journal of the American Medical Association [5]) with an agreement ≥67% from over 250 physicians (46 countries). Noninvasive ventilation was the intervention supported by the largest number of RCTs (n = 13). The concordance between agreement and use (a positive answer both to "do you agree" and "do you use") showed differences between Western and other countries and between anesthesiologists and intensive care unit physicians. The authors identified 27 clinical interventions with randomized evidence of survival benefit and strong clinician support in support of their potential life-saving properties in perioperative and critically ill patients with noninvasive ventilation having the highest level of support. However, clinician views appear affected by specialty and geographical location.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/mortalidade , Internet , Médicos , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Inquéritos e Questionários , Cuidados Críticos/tendências , Estado Terminal/terapia , Humanos , Unidades de Terapia Intensiva/tendências , Internet/tendências , Mortalidade/tendências , Médicos/tendências
2.
Int J Clin Pharm ; 41(1): 179-188, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30552623

RESUMO

Background Drug-related problems are mostly preventable or predictable circumstances that may impact on health outcomes. Clinical pharmacy activities such as medication therapy management can identify and solve these problems, with potential to improve medication safety and effectiveness. Objective To evaluate ability of medication therapy management service to detect drug-related problems and prevent adverse drug events. This study also aimed to assess the risk factors for drugrelated problem occurrence. Setting Medical intensive care unit of a public tertiary hospital in Brazil. Methods Patients were evaluated by a clinical pharmacist, who provided medication therapy management service. Detected drug-related problems were categorized according to the Pharmaceutical Care Network Europe methodology and analyzed in multinomial regression to identify risk factors. Main outcome measure Potential risk factors for drug-related problem occurrence. Results The proposed medication therapy management service allowed detection of 170 drug-related problems that had potential to reach patients causing harm and other 50 unavoidable adverse events. Drug-related problems identified were more often associated with antibacterial use, caused by improper combinations or inadequate drug dosage. These problems required interventions that were accepted by the multidisciplinary team, resulting in more than 85% adherence and total problem solving. Main risk factors identified were previous diagnosis of kidney injury (OR = 8.38), use of midazolam (OR = 7.96), furosemide (OR = 5.87) and vancomycin (OR = 4.82). Conclusion Medication therapy management proved to be an effective method not only for drug-related problem detection, but also for adverse drug event prevention, contributing to improve patient safety.


Assuntos
Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/prevenção & controle , Unidades de Terapia Intensiva/tendências , Erros de Medicação/prevenção & controle , Erros de Medicação/tendências , Conduta do Tratamento Medicamentoso/tendências , Serviço de Farmácia Hospitalar/tendências , Idoso , Idoso de 80 Anos ou mais , Efeitos Colaterais e Reações Adversas Relacionados a Medicamentos/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Farmacêuticos/tendências , Serviço de Farmácia Hospitalar/métodos
3.
Biomed J ; 41(5): 321-327, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-30580796

RESUMO

BACKGROUND: Patients with polytrauma are expected to have a higher risk of mortality than the summation of expected mortality for their individual injuries. This study was designed to investigate the outcome of polytrauma patients, diagnosed by abbreviated injury scale (AIS) ≥ 3 for at least two body regions, at a level I trauma center. METHODS: Detailed data of 694 polytrauma patients and 2104 non-polytrauma patients with an overall Injury Severity Score (ISS) ≥ 16 and hospitalized between January 1, 2009, and December 31, 2014 for treatment of all traumatic injuries, were retrieved from the Trauma Registry System. Two-sided Fisher exact or Pearson chi-square tests were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann-Whitney U-test was used to compare non-normally distributed data. Propensity-score matching in a 1:1 ratio was performed using NCSS software with logistic regression to evaluate the effect of polytrauma on in-hospital mortality. RESULTS: There was no significant difference in short-term mortality between polytrauma and non-polytrauma patients, regardless of whether the comparison was made among the total patients (11.4% vs. 11.0%, respectively; p = 0.795) or among the selected propensity score-matched groups of patients following controlled covariates including sex, age, systolic blood pressure, co-morbidities, Glasgow Coma Scale scores, injury region based on AIS. CONCLUSIONS: Polytrauma defined by AIS ≥3 for at least two body regions failed to recognize a significant difference in short-term mortality among trauma patients.


Assuntos
Comorbidade/tendências , Mortalidade Hospitalar/tendências , Unidades de Terapia Intensiva/tendências , Centros de Traumatologia/tendências , Escala Resumida de Ferimentos , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros/estatística & dados numéricos
4.
Respir Res ; 19(1): 245, 2018 Dec 07.
Artigo em Inglês | MEDLINE | ID: mdl-30526610

RESUMO

BACKGROUND: Host-associated microbial communities have important roles in tissue homeostasis and overall health. Severe perturbations can occur within these microbial communities during critical illness due to underlying diseases and clinical interventions, potentially influencing patient outcomes. We sought to profile the microbial composition of critically ill mechanically ventilated patients, and to determine whether microbial diversity is associated with illness severity and mortality. METHODS: We conducted a prospective, observational study of mechanically ventilated critically ill patients with a high incidence of pneumonia in 2 intensive care units (ICUs) in Hamilton, Canada, nested within a randomized trial for the prevention of healthcare-associated infections. The microbial profiles of specimens from 3 anatomical sites (respiratory, and upper and lower gastrointestinal tracts) were characterized using 16S ribosomal RNA gene sequencing. RESULTS: We collected 65 specimens from 34 ICU patients enrolled in the trial (29 endotracheal aspirates, 26 gastric aspirates and 10 stool specimens). Specimens were collected at a median time of 3 days (lower respiratory tract and gastric aspirates; interquartile range [IQR] 2-4) and 6 days (stool; IQR 4.25-6.75) following ICU admission. We observed a loss of biogeographical distinction between the lower respiratory tract and gastrointestinal tract microbiota during critical illness. Moreover, microbial diversity in the respiratory tract was inversely correlated with APACHE II score (r = - 0.46, p = 0.013) and was associated with hospital mortality (Median Shannon index: Discharged alive; 1.964 vs. Deceased; 1.348, p = 0.045). CONCLUSIONS: The composition of the host-associated microbial communities is severely perturbed during critical illness. Reduced microbial diversity reflects high illness severity and is associated with mortality. Microbial diversity may be a biomarker of prognostic value in mechanically ventilated patients. TRIAL REGISTRATION: ClinicalTrials.gov ID NCT01782755 . Registered February 4 2013.


Assuntos
Disbiose/microbiologia , Disbiose/mortalidade , Fenômenos Microbiológicos , Respiração Artificial/efeitos adversos , Respiração Artificial/mortalidade , Idoso , Estado Terminal/epidemiologia , Estado Terminal/terapia , Disbiose/etiologia , Feminino , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos
6.
Respir Res ; 19(1): 139, 2018 07 27.
Artigo em Inglês | MEDLINE | ID: mdl-30049266

RESUMO

BACKGROUND: Probiotics could prevent Pseudomonas aeruginosa colonization in lower respiratory tract (LRT) and reduced P. aeruginosa ventilator-associated pneumonia (VAP) rate. Recent studies also suggested that probiotics could improve lung inflammation in mice infected with P. aeruginosa. It seems that microbiota regulation may be a potential therapy for P. aeruginosa VAP patients. However, we know less about the LRT microbial composition and its correlation with prognosis in P. aeruginosa VAP patients. This study aimed to characterize LRT microbiota in P. aeruginosa VAP patients and explore the relationship between microbiota and patient prognosis. METHODS: Deep endotracheal secretions were sampled from subjects via intubation. Communities were identified by 16S ribosomal RNA gene sequencing. The relationship between microbiota and the prognosis of P. aeruginosa VAP patients were evaluated. Clinical pulmonary infection score and the survival of intensive care unit were both the indicators of patient prognosis. RESULTS: In this study, the LRT microbial composition of P. aeruginosa VAP patients was significantly different from non-infected intubation patients, and showed significant individual differences, forming two clusters. According to the predominant phylum of each cluster, these two clusters were named Pro cluster and Fir-Bac cluster respectively. Patients from Pro cluster were dominated by Proteobacteria (adj.P < 0.001), while those from Fir-Bac cluster were dominated by Firmicutes, and Bacteroidetes (both adj.P < 0.001). These two varied clusters (Pro and Fir-Bac cluster) were associated with the patients' primary disease (χ2-test, P < 0.0001). The primary disease of the Pro cluster mainly included gastrointestinal disease (63%), and the Fir-Bac cluster was predominantly respiratory disease (89%). During the two-week dynamic observation period, despite the use of antibiotics, the dominant genera and Shannon diversity of the LRT microbiota did not change significantly in patients with P. aeruginosa VAP. In prognostic analysis, we found a significant negative correlation between Lactobacillus and clinical pulmonary infection score on the day of diagnosis (P = 0.014); but we found no significant difference of microbial composition between survivors and non-survivors. CONCLUSIONS: LRT microbial composition was diversified among P. aeruginosa VAP patients, forming two clusters which were associated with the primary diseases of the patients.


Assuntos
Pneumonia Associada à Ventilação Mecânica/diagnóstico , Pneumonia Associada à Ventilação Mecânica/microbiologia , Infecções por Pseudomonas/diagnóstico , Pseudomonas aeruginosa/isolamento & purificação , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Pneumonia Associada à Ventilação Mecânica/epidemiologia , Estudos Prospectivos , Infecções por Pseudomonas/epidemiologia , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/epidemiologia
7.
JAMA ; 320(3): 264-271, 2018 07 17.
Artigo em Inglês | MEDLINE | ID: mdl-29946682

RESUMO

Importance: End-of-life care costs are high and decedents often experience poor quality of care. Numerous factors influence changes in site of death, health care transitions, and burdensome patterns of care. Objective: To describe changes in site of death and patterns of care among Medicare decedents. Design, Setting, and Participants: Retrospective cohort study among a 20% random sample of 1 361 870 decedents who had Medicare fee-for-service (2000, 2005, 2009, 2011, and 2015) and a 100% sample of 871 845 decedents who had Medicare Advantage (2011 and 2015) and received care at an acute care hospital, at home or in the community, at a hospice inpatient care unit, or at a nursing home. Exposures: Secular changes between 2000 and 2015. Main Outcomes and Measures: Medicare administrative data were used to determine site of death, place of care, health care transitions, which are changes in location of care, and burdensome patterns of care. Burdensome patterns of care were based on health care transitions during the last 3 days of life and multiple hospitalizations for infections or dehydration during the last 120 days of life. Results: The site of death and patterns of care were studied among 1 361 870 decedents who had Medicare fee-for-service (mean [SD] age, 82.8 [8.4] years; 58.7% female) and 871 845 decedents who had Medicare Advantage (mean [SD] age, 82.1 [8.5] years; 54.0% female). Among Medicare fee-for-service decedents, the proportion of deaths that occurred in an acute care hospital decreased from 32.6% (95% CI, 32.4%-32.8%) in 2000 to 19.8% (95% CI, 19.6%-20.0%) in 2015, and deaths in a home or community setting that included assisted living facilities increased from 30.7% (95% CI, 30.6%-30.9%) in 2000 to 40.1% (95% CI, 39.9%-30.3% ) in 2015. Use of the intensive care unit during the last 30 days of life among Medicare fee-for-service decedents increased from 24.3% (95% CI, 24.1%-24.4%) in 2000 and then stabilized between 2009 and 2015 at 29.0% (95% CI, 28.8%-29.2%). Among Medicare fee-for-service decedents, health care transitions during the last 3 days of life increased from 10.3% (95% CI, 10.1%-10.4%) in 2000 to a high of 14.2% (95% CI, 14.0%-14.3%) in 2009 and then decreased to 10.8% (95% CI, 10.6%-10.9%) in 2015. The number of decedents enrolled in Medicare Advantage during the last 90 days of life increased from 358 600 in 2011 to 513 245 in 2015. Among decedents with Medicare Advantage, similar patterns in the rates for site of death, place of care, and health care transitions were observed. Conclusions and Relevance: Among Medicare fee-for-service beneficiaries who died in 2015 compared with 2000, there was a lower likelihood of dying in an acute care hospital, an increase and then stabilization of intensive care unit use during the last month of life, and an increase and then decline in health care transitions during the last 3 days of life.


Assuntos
Unidades de Terapia Intensiva , Medicare , Assistência Terminal , Idoso , Idoso de 80 Anos ou mais , Moradias Assistidas/estatística & dados numéricos , Continuidade da Assistência ao Paciente/tendências , Morte , Planos de Pagamento por Serviço Prestado , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Unidades de Terapia Intensiva/tendências , Masculino , Medicare Part C/estatística & dados numéricos , Medicare Part C/tendências , Casas de Saúde/estatística & dados numéricos , Estudos Retrospectivos , Estados Unidos
8.
Medicine (Baltimore) ; 97(26): e11124, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-29952954

RESUMO

This retrospective cohort study investigated the outcomes of patients with unplanned intensive care unit (ICU) readmission.All of the patients readmitted to ICU within 48 hours between 2010 and 2016 were enrolled.A total of 99 patients early readmitted to ICU were identified and their mean age of the patients was 68.8 ± 14.8 years. Respiratory failure was the most common cause of ICU readmission (n = 48, 48.5%), followed by acute myocardial ischemia or worsening heart failure (n = 25, 25.3%), sepsis (n = 22, 22.2%), gastrointestinal disease (n = 16, 16.2%), and neurologic disease (n = 11, 11.1%). The median length of stay in the ICU and hospital was 7 (IQR, 4-11.5) and 32 (IQR, 15.5-48.5) days, respectively. A total of 34 patients died during the hospital stay and the rate of in-hospital mortality was 34.3%. Patients with higher APACHE II scores (adjusted odds ratio [OR], 1.17; 95% CI, 1.02-1.33), underlying malignancy (adjusted OR, 4.70; 95% CI, 1.19-18.57), and cardiovascular organ dysfunction (adjusted OR, 5.14; 95% CI, 1.24-21.38) were more likely to die.The mortality rate of ICU readmission patients was high, especially for those with higher APACHE II score, underlying malignancy and cardiovascular organ dysfunction.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Prognóstico , APACHE , Idoso , Idoso de 80 Anos ou mais , Feminino , Gastroenteropatias/epidemiologia , Gastroenteropatias/mortalidade , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva/tendências , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Isquemia Miocárdica/epidemiologia , Isquemia Miocárdica/mortalidade , Neoplasias/epidemiologia , Neoplasias/mortalidade , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/mortalidade , Avaliação de Resultados (Cuidados de Saúde) , Readmissão do Paciente/tendências , Insuficiência Respiratória/epidemiologia , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Fatores de Risco , Sepse/epidemiologia , Sepse/mortalidade , Índice de Gravidade de Doença
9.
Rev. pesqui. cuid. fundam. (Online) ; 10(2): 326-333, abr.-jun. 2018.
Artigo em Inglês, Português | LILACS | ID: biblio-908447

RESUMO

Objetivo: sistematizar estudos indexados no Scielo e Medline, sobre humanização em Unidade de Terapia Intensiva. Método: Qualitativo, de revisão bibliográfica sistemática. Utilizado estudos nas bases Scielo e Medline, indexados de julho de 1990 a agosto de 2015, com os descritores: ‘humanização’ e ‘unidades de terapia intensiva’. Os critérios de inclusão foram: artigos publicados até agosto de 2015, que faziam referência à humanização em UTI e de exclusão, os artigos de revisão bibliográfica. Resultados: Foram analisados 21 artigos. Chegou-se as categorias: Caracterização dos estudos analisados; ‘Não somos máquina, humano é que somos’; e ‘Atores(as) e fatores envolvidos no processo de humanização em saúde’. Conclusão: A humanização em UTI ainda é um desafio, a Enfermagem é uma das áreas que se ocupa com esta prática, o entendimento de que a humanização envolve assistência, os processos e condições de trabalho, vários são os atores producentes e que há interferentes na sua produção.


Objective: the aim is to systematize studies indexed in Medline and Scielo on humanization in Intensive Care Unit. Method: A qualitative study with a systematic literature review. It was used studies from Scielo and Medline databases indexed from July 1990 to August 2015, with the key words: ‘humanization’ and ‘intensive care unit’. Inclusion criteria were: articles published until August 2015, which referred to the humanization in the ICU and exclusion: bibliographic review articles. Results: It was analyzed 21 articles. It has come up some categories: Characterization of the studies analyzed; ‘We are not machines, human is what we are’; and ‘Actors and factors involved in health humanization process’. Conclusion: Humanization in ICU is still a challenge, nursing is one of the areas that deals with this practice, the understanding that the humanization involves care, the processes and working conditions, there are several actors who produce and there are interferents in their production.


Objetivo: sistematizar estudios vinculados en Scielo y Medline, acerca de humanización en Unidad de Cuidados Intensivos. Método: Cualitativo, de revisión bibliográfica sistemática. Utilizado estudios en las bases Scielo y Medline, vinculados de julio de 1990 a agosto de 2015, con los descriptores: ‘humanización’ y ‘unidade de cuidados intensivos’. Los criterios de inclusión fueron: artículos publicados hasta agosto de 2015, que hacían referencia a humanización en UCI y de exclusión, los artículos de revisión bibliográficos. Resultados: Fueron analizados 21 artículos. Se ha encontrado las categorías: Caracterización de los estudios analizados; ‘No somos máquina, humano es lo que somos’; y ‘Actores(as) y hechos involucrados en el proceso de humanización en salud’. Conclusión: La humanización en UCI aún es un desafío, la Enfermería es una de las áreas de que se ocupa con esta práctica, el entendimiento de que la humanización requiere asistencia, los procesos y condiciones de trabajo, varios son los actores productivos y hay interferentes en su producción.


Assuntos
Masculino , Feminino , Humanos , Humanização da Assistência , Unidades de Terapia Intensiva/tendências , Literatura de Revisão como Assunto , Sistema Único de Saúde , Brasil
10.
Biomed Res Int ; 2018: 9438046, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-29750174

RESUMO

Background and Aim: Long hospital days in intensive care unit (ICU) due to life-threatening diseases are increasing in the world. The primary goal in ICU is to decrease length of stay in order to improve the quality of medical care and reduce cost. The aim of our study is to identify and categorize the factors associated with prolonged stays in ICU. Materials and Method: We retrospectively analyzed 3925 patients. We obtained the patients' demographic, clinical, diagnostic, and physiologic variables; mortality; lengths of stay by examining the intensive care unit database records. Results: The mean age of the study was 61.6 ± 18.9 years. The average length of stay in intensive care unit was 10.2 ± 25.2 days. The most common cause of hospitalization was because of multiple diseases (19.5%). The length of stay was positively correlated with urea, creatinine, and sodium. It was negatively correlated with uric acid and hematocrit levels. Length of stay was significantly higher in patients not operated on than in patients operated on (p < 0.001). Conclusion: Our study showed a significantly increased length of stay in patients with cardiovascular system diseases, multiple diseases, nervous system diseases, and cerebrovascular diseases. Moreover we showed that when urea, creatinine, and sodium values increase, in parallel the length of stay increases.


Assuntos
Unidades de Terapia Intensiva/tendências , Tempo de Internação/tendências , Feminino , Mortalidade Hospitalar/tendências , Humanos , Masculino , Pessoa de Meia-Idade , Admissão do Paciente/tendências , Estudos Retrospectivos , Fatores de Risco
11.
Rev. pesqui. cuid. fundam. (Online) ; 10(2): 326-333, abr.-jun. 2018.
Artigo em Inglês, Português | BDENF - Enfermagem | ID: bde-32793

RESUMO

Objetivo: Sistematizar estudos indexados no Scielo e Medline, sobre humanização em Unidade de Terapia Intensiva. Método: Qualitativo, de revisão bibliográfica sistemática. Utilizado estudos nas bases Scielo e Medline, indexados de julho de 1990 a agosto de 2015, com os descritores: ‘humanização’ e ‘unidades de terapia intensiva’. Os critérios de inclusão foram: artigos publicados até agosto de 2015, que faziam referência à humanização em UTI e de exclusão, os artigos de revisão bibliográfica. Resultados: Foram analisados 21 artigos. Chegou-se as categorias: Caracterização dos estudos analisados; ‘Não somos máquina, humano é que somos’; e ‘Atores(as) e fatores envolvidos no processo de humanização em saúde’. Conclusão: A humanização em UTI ainda é um desafio, a Enfermagem é uma das áreas que se ocupa com esta prática, o entendimento de que a humanização envolve assistência, os processos e condições de trabalho, vários são os atores producentes e que há interferentes na sua produção.(AU)


Objective: The aim is to systematize studies indexed in Medline and Scielo on humanization in Intensive Care Unit. Method: A qualitative study with a systematic literature review. It was used studies from Scielo and Medline databases indexed from July 1990 to August 2015, with the key words: ‘humanization’ and ‘intensive care unit’. Inclusion criteria were: articles published until August 2015, which referred to the humanization in the ICU and exclusion: bibliographic review articles. Results: It was analyzed 21 articles. It has come up some categories: Characterization of the studies analyzed; ‘We are not machines, human is what we are’; and ‘Actors and factors involved in health humanization process’. Conclusion: Humanization in ICU is still a challenge, nursing is one of the areas that deals with this practice, the understanding that the humanization involves care, the processes and working conditions, there are several actors who produce and there are interferents in their production.(AU)


Objetivo: Sistematizar estudios vinculados en Scielo y Medline, acerca de humanización en Unidad de Cuidados Intensivos. Método: Cualitativo, de revisión bibliográfica sistemática. Utilizado estudios en las bases Scielo y Medline, vinculados de julio de 1990 a agosto de 2015, con los descriptores: ‘humanización’ y ‘unidade de cuidados intensivos’. Los criterios de inclusión fueron: artículos publicados hasta agosto de 2015, que hacían referencia a humanización en UCI y de exclusión, los artículos de revisión bibliográficos. Resultados: Fueron analizados 21 artículos. Se ha encontrado las categorías: Caracterización de los estudios analizados; ‘No somos máquina, humano es lo que somos’; y ‘Actores(as) y hechos involucrados en el proceso de humanización en salud’. Conclusión: La humanización en UCI aún es un desafío, la Enfermería es una de las áreas de que se ocupa con esta práctica, el entendimiento de que la humanización requiere asistencia, los procesos y condiciones de trabajo, varios son los actores productivos y hay interferentes en su producción.(AU)


Assuntos
Humanos , Masculino , Feminino , Unidades de Terapia Intensiva/tendências , Humanização da Assistência , Sistema Único de Saúde , Literatura de Revisão como Assunto , Brasil
12.
Nutr Clin Pract ; 33(2): 185-190, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29532504

RESUMO

Clinical simulation training provides a realistic environment for students and healthcare professionals to strengthen and broaden skills and abilities. This type of learning experience creates a controlled environment in which learners may attain new skills or further develop skills that positively impact patient outcomes. Although few studies exist regarding the use of clinical simulation training and nutrition support practitioners, preliminary data following a small-bowel feeding tube (SBFT) insertion workshop for intensive care unit registered nurses and registered dietitian nutritionists showed potential use in this realm. The purpose of this paper is to provide a basic overview of clinical simulation learning, review literature related to clinical simulation in healthcare, and discuss the recent implementation of a SBFT insertion workshop incorporating clinical simulation learning.


Assuntos
Nutrição Enteral/instrumentação , Intubação Gastrointestinal/métodos , Treinamento por Simulação , Nutrição Enteral/enfermagem , Nutrição Enteral/tendências , Humanos , Unidades de Terapia Intensiva/tendências , Intestino Delgado , Intubação Gastrointestinal/enfermagem , Intubação Gastrointestinal/tendências , Nutricionistas/educação , Treinamento por Simulação/tendências , Terminologia como Assunto , Fatores de Tempo , Recursos Humanos
14.
BMJ Open ; 8(1): e019357, 2018 01 30.
Artigo em Inglês | MEDLINE | ID: mdl-29382680

RESUMO

OBJECTIVE: There has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED). DESIGN, SETTING AND PARTICIPANTS: Observational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012. OUTCOMES MEASURES: Billing intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling. RESULTS: High-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (-0.68% per year; 95% CI -0.71% to -0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R2 of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148). CONCLUSIONS: Increases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.


Assuntos
Codificação Clínica/tendências , Serviço Hospitalar de Emergência/tendências , Preços Hospitalares/tendências , Hospitalização/economia , Unidades de Terapia Intensiva/tendências , Medicare/economia , Idoso , Idoso de 80 Anos ou mais , Serviço Hospitalar de Emergência/economia , Honorários Médicos , Feminino , Humanos , Unidades de Terapia Intensiva/economia , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Sensibilidade e Especificidade , Estados Unidos
15.
Exp Clin Transplant ; 16(1): 116-118, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29409439

RESUMO

OBJECTIVES: Substantial numbers of patients after hematopoietic stem cell transplant need critical care. In Japan, however, data regarding the availability of an intensive care unit and intensivists at hospitals performing hematopoietic stem cell transplant are lacking. We aimed to investigate this issue using data from the 2014 Hematopoietic Cell Transplantation in Japan Annual Report of Nationwide Survey. MATERIALS AND METHODS: We examined whether hospitals have intensive care unit facilities and whether these hospitals are authorized by the Japanese Society of Intensive Care Medicine to provide intensivist training. The number of hematopoietic cell transplantations at each hospital was collected from the Transplant Registry Unified Management Program by the Japanese Data Center for Hematopoietic Cell Transplantation. RESULTS: Among 236 hospitals that perform hematopoietic stem cell transplants, 106 hospitals did not have intensive care units certified by the Japanese Society of Intensive Care Medicine. In patients who receive hematopoietic stem cell transplants with the highest mortality rate, 947 allogeneic transplants were performed at hospitals without this certification and 73 were performed at hospitals without intensive care units. CONCLUSIONS: We found that a considerable number of hematopoietic stem cell transplants are performed at hospitals with insufficient availability of critical care facilities or physicians.


Assuntos
Acesso aos Serviços de Saúde/tendências , Transplante de Células-Tronco Hematopoéticas/tendências , Hospitais/tendências , Unidades de Terapia Intensiva/tendências , Certificação/tendências , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde/normas , Transplante de Células-Tronco Hematopoéticas/efeitos adversos , Transplante de Células-Tronco Hematopoéticas/mortalidade , Transplante de Células-Tronco Hematopoéticas/normas , Hospitais/normas , Humanos , Unidades de Terapia Intensiva/normas , Japão , Segurança do Paciente , Sistema de Registros , Medição de Risco , Resultado do Tratamento
16.
Curr Opin Anaesthesiol ; 31(2): 136-143, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29351143

RESUMO

PURPOSE OF REVIEW: The narrative review aims to summarize the relevant studies from the last 2 years and provide contextual information to understand findings. RECENT FINDINGS: Recent ICU studies have provided insight in the pathophysiology and time course of catabolism, anabolic resistance, and metabolic and endocrine derangements interacting with the provision of calories and proteins.Early provision of high protein intake and caloric overfeeding may confer harm. Refeeding syndrome warrants caloric restriction and to identify patients at risk phosphate monitoring is mandatory.Infectious complications of parenteral nutrition are associated with overfeeding. In recent studies enteral nutrition is no longer superior over parenteral nutrition.Previously reported benefits of glutamine, selenium, and fish oil seem to have vanished in recent studies; however, studies on vitamin C, thiamine, and corticosteroid combinations show promising results. SUMMARY: Studies from the last 2 years will have marked impact on future nutritional support strategies and practice guidelines for critical care nutrition as they challenge several old-fashioned concepts.


Assuntos
Cuidados Críticos/tendências , Estado Terminal/terapia , Unidades de Terapia Intensiva/tendências , Apoio Nutricional/tendências , Síndrome da Realimentação/etiologia , Restrição Calórica/efeitos adversos , Restrição Calórica/métodos , Cuidados Críticos/métodos , Cuidados Críticos/normas , Estado Terminal/mortalidade , Suplementos Nutricionais , Metabolismo Energético/fisiologia , Humanos , Unidades de Terapia Intensiva/normas , Apoio Nutricional/efeitos adversos , Apoio Nutricional/métodos , Apoio Nutricional/normas , Fosfatos/sangue , Guias de Prática Clínica como Assunto , Síndrome da Realimentação/sangue , Síndrome da Realimentação/fisiopatologia , Resultado do Tratamento
17.
Curr Opin Anaesthesiol ; 31(2): 144-150, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29351145

RESUMO

PURPOSE OF REVIEW: To examine the benefits of early mobilization and summarize the results of most recent clinical studies examining early mobilization in critically ill patients followed by a presentation of recent developments in the field. RECENT FINDINGS: Early mobilization of ICU patients, defined as mobilization within 72 h of ICU admission, is still uncommon. In medical and surgical critically ill patients, mobilization is well tolerated even in intubated patients. In neurocritical care, evidence to support early mobilization is either lacking (aneurysmal subarachnoid hemorrhage), or the results are inconsistent (e.g. stroke). Successful implementation of early mobilization requires a cultural change; preferably based on an interprofessional approach with clearly defined responsibilities and including a mobilization scoring system. Although the evidence for the majority of the technical tools is still limited, the use of a bed cycle ergometer and a treadmill with strap system has been promising in smaller trials. SUMMARY: Early mobilization is well tolerated and feasible, resulting in improved outcomes in surgical and medical ICU patients. Implementation of early mobilization can be challenging and may need a cultural change anchored in an interprofessional approach and integrated in a patient-centered bundle. Scoring systems should be integrated to define daily goals and used to verify patients' achievements or identify barriers immediately.


Assuntos
Cuidados Críticos/métodos , Estado Terminal/terapia , Deambulação Precoce/métodos , Medicina Baseada em Evidências/métodos , Unidades de Terapia Intensiva/normas , Cuidados Críticos/normas , Deambulação Precoce/normas , Deambulação Precoce/tendências , Medicina Baseada em Evidências/normas , Medicina Baseada em Evidências/tendências , Estudos de Viabilidade , Implementação de Plano de Saúde , Humanos , Unidades de Terapia Intensiva/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto , Padrão de Cuidado , Fatores de Tempo
18.
Ir J Med Sci ; 187(3): 585-591, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29330753

RESUMO

BACKGROUND: Transfer of critically ill patients within the hospital is commonly associated with adverse incidents, but, despite this, no standardised training exists on how to carry out this task. Very little information is published in the literature on the learning needs of staff undertaking these transfers, and this limits our ability to provide a focused and appropriate educational intervention. AIMS: This study aimed to explore the organisational, environmental and individual issues that increase risk to patients during intrahospital transport (IHT) and to explore the potential educational solutions to these issues as articulated by these practitioners. METHODS: This qualitative descriptive study was conducted in an Irish tertiary hospital critical care unit. Semi-structured interviews were conducted on critical care practitioners until data saturation was achieved. After manual transcription of the data, they were then analysed to identify themes. RESULTS: Two themes emerged: challenges related to intrahospital transport and plans to improve intrahospital transport. CONCLUSIONS: Organisational, communication and individual issues need to be considered when addressing problems associated with IHT. A multifaceted approach is needed, with a focus on organisational solutions in the form of checklists as well as educational interventions such as interprofessional education initiatives. Further studies on implementation of educational initiatives will add to the findings we report here.


Assuntos
Cuidados Críticos/psicologia , Estado Terminal/terapia , Unidades de Terapia Intensiva/tendências , Transferência de Pacientes/métodos , Adulto , Cuidados Críticos/normas , Feminino , Humanos , Masculino
19.
Intensive Crit Care Nurs ; 45: 58-65, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29331633

RESUMO

OBJECTIVE: To better understand how local policies influence organ donation rates. RESEARCH METHODOLOGY/DESIGN: We conducted a document analysis of our ICU organ donation policies, protocols and order sets. We used a systematic search of our institution's policy library to identify documents related to organ donation. We used Mindnode software to create a publication timeline, basic statistics to describe document characteristics, and qualitative content analysis to extract document themes. SETTING: Documents were retrieved from Hamilton Health Sciences, an academic hospital system with a high volume of organ donation, from database inception to October 2015. FINDINGS: We retrieved 12 active organ donation documents, including six protocols, two policies, two order sets, and two unclassified documents, a majority (75%) after the introduction of donation after circulatory death in 2006. Four major themes emerged: organ donation process, quality of care, patient and family-centred care, and the role of the institution. These themes indicate areas where documented institutional standards may be beneficial. CONCLUSION: Further research is necessary to determine the relationship of local policies, protocols, and order sets to actual organ donation practices, and to identify barriers and facilitators to improving donation rates.


Assuntos
Unidades de Terapia Intensiva/tendências , Política Organizacional , Obtenção de Tecidos e Órgãos/métodos , Humanos , Unidades de Terapia Intensiva/organização & administração , Assistência Centrada no Paciente/métodos , Pesquisa Qualitativa , Qualidade da Assistência à Saúde/organização & administração , Qualidade da Assistência à Saúde/normas , Obtenção de Tecidos e Órgãos/legislação & jurisprudência , Obtenção de Tecidos e Órgãos/tendências
20.
J Cardiothorac Vasc Anesth ; 32(1): 197-204, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-28666929

RESUMO

OBJECTIVES: To describe tissue oxygen saturation (StO2) in response to a vascular occlusion test using thenar eminence and forearm near-infrared spectroscopy (NIRS) and the association with volume responsiveness after cardiac surgery. DESIGN: Single-center, prospective, observational cohort study. SETTING: Cardiothoracic intensive care unit. PARTICIPANTS: Seventy-six post-cardiac surgical adults. INTERVENTIONS: Immediately before and 10 minutes after a 250-to-500 mL fluid bolus, StO2 was measured in response to a vascular occlusion test to calculate tissue deoxygenation (Rdes) and reoxygenation (Rres) rates. Concurrently, systemic hemodynamic, metabolic, and blood gas variables were collected. MEASUREMENTS AND MAIN RESULTS: A total of 203 boluses were captured using thenar NIRS and 141 boluses using forearm NIRS. Approximately 25% of boluses increased cardiac output by ≥15% (volume responders). Thenar and forearm Rdes decreased in responders, but increased (thenar) or remained unchanged (forearm) in nonresponders. A logistic regression model of the association among StO2, Rdes and Rres, and volume responsiveness was significant for thenar measurements (p = 0.001) with an area under the receiver operating characteristic of 0.69 (95% confidence interval: 0.62-0.75). It also was significant (p = 0.02) for forearm measurements, with an area under the receiver operating characteristic of 0.71 (0.62-0.79). Rdes was an independent variable in both instances (odds ratio 0.31 [0.14-0.69], thenar; odds ratio 0.60 [0.45-0.80], forearm). Thenar and forearm NIRS variables were correlated poorly with cardiac output, stroke volume, systemic oxygen delivery and consumption index, mixed venous, and central venous oxygen saturation (Spearman׳s coefficients, r = 0.17-0.46, p < 0.002). CONCLUSION: In post-cardiac surgical patients, thenar and forearm NIRS variables were associated with volume responsiveness although not achieving precision necessary for clinical management.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Hidratação/métodos , Unidades de Terapia Intensiva , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Idoso , Determinação do Volume Sanguíneo/métodos , Determinação do Volume Sanguíneo/tendências , Procedimentos Cirúrgicos Cardíacos/tendências , Estudos de Coortes , Feminino , Hidratação/tendências , Hemodinâmica/fisiologia , Humanos , Unidades de Terapia Intensiva/tendências , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Espectroscopia de Luz Próxima ao Infravermelho/tendências
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