[Discussion groups as an approach to assess knowledge, attitudes and practices of hand hygiene among the adult intensive care unit professionals from a referral hospital]. / Grupos de discusión como abordaje para valorar conocimiento, actitudes y prácticas de higiene de manos en profesionales de la unidad de cuidados intensivos de adultos de un hospital de referencia.

OBJECTIVES: The adherence to hand hygiene practices among the adult Intensive Care Unit (ICU) professionals in this hospital has not improved substantially in the last years, regardless of the theoretical training sessions conducted. A study was made of the knowledge, attitudes, and practices of the ICU personnel in this field. METHODS: Several small discussion groups with ICU staff organised by preventive medicine professionals were scheduled in March 2018. Semi-structured questions on hand hygiene and use of gloves were included. The points discussed were listed into strengths and weaknesses. Knowledge was then assessed using an anonymous questionnaire, after the sessions. RESULTS: Thirteen 60-minute sessions were carried out with 157 participants from all professional categories (82% from ICU, median=11 participants / session). The majority perceived hand hygiene as a priority issue of personal responsibility for patient safety. They identified factors that limit their ability to improve their adherence. Certain habits have more to do with personal preferences than with theoretical knowledge or technical indications. CONCLUSIONS: The discussion groups have helped to make a diagnosis of the situation that will be useful to strengthen those areas of improvement that have been identified. If we aim for a cultural change, and eliminate incorrect habits, it seems more useful to carry out adequate continuing education as part of the daily routine of professionals.

Nosocomial infection in an intensive-care unit: identification of risk factors.

OBJECTIVE: To identify risk factors predictive of nosocomial infection in an intensive-care unit (ICU) and to identify patients with a higher risk of nosocomial infection using a predictive model of nosocomial infection in our ICU. DESIGN: Prospective study; daily concurrent surveillance of intensive-care-unit patients. SETTING/PATIENTS: All patients admitted for at least 24 hours to the ICU of a tertiary-level hospital from February to November 1994 were followed daily. METHODS: Variables measuring extrinsic and intrinsic risk factors for nosocomial infection were collected on each patient during their ICU stay, and the Cox Proportional Hazards multivariable technique was used to identify the variables significantly associated with infection. RESULTS: The population studied consisted of 944 patients. The main risk factors identified were intrinsic; the significant extrinsic risk factors identified were head of the bed in a horizontal (< 30 degrees) position (this variable presented the highest increase of the infection hazard ratio) and the use of sedative medication. Patients presenting the highest risk scores using the predictive model are those with the highest risk of nosocomial infection. CONCLUSIONS: The important preventive measures derived from our results are that underlying conditions suffered by the patient at the ICU admission should be corrected promptly, the depression of the patient's level of consciousness with sedatives should be monitored carefully, and the horizontal position of the head of the bed should be avoided totally. Patients with a high risk of infection can be the target of special preventive measures.

Comparison of different methodological approaches to identify risk factors of nosocomial infection in intensive care units.

OBJECTIVE: Comparison of statistical methods and measurement scales to identify nosocomial infection risk factors in intensive care units (ICU). DESIGN: Prospective study in 558 patients admitted to the ICU of a referral hospital between February and November 1994. METHODS: Analysis using three logistic regression models, three standard Cox regression models, and two Cox regression models with time-dependent extrinsic factors. Different scales were used to measure exposures to risk factors (dichotomous, ordinal, quantitative, and time-dependent variables). RESULTS: The most appropriate models were those that measured exposure using dichotomous variables. Models using ordinal or quantitative variables estimated biased coefficients and/or failed to comply with the statistical assumptions underlying the analyses. The Cox regression model with quantitative time-dependent variables met all the statistical assumptions, obtained a precise assessment of risk by exposure time, and estimated unbiased coefficients. CONCLUSIONS: The Cox regression analysis with quantitative time-dependent variables is the most valid alternative for assessing the risk of nosocomial infection per day of exposure to an extrinsic risk factor in the ICU.

[The estimation of the cost of nosocomial infection in an intensive care unit]. / Estimación del coste de la infección nosocomial en una unidad de medicina intensiva.

BACKGROUND: Nosocomial infection (NI) represents an increase of hospital morbidity and mortality. The data available concerning the hospital expenses due to the prolongation of hospital stay associated to NI are fundamentally derived from American studies. The aim of this study was to evaluate the direct cost of nosocomial infection in an intensive medicine unit (IMU). METHODS: A study of cases and paired controls was carried out with a cohort study made up of 88 cases and 88 controls paired by age and severity (APACHE II grading). Previously identified confusion factors were controlled in the analysis. RESULTS: The mean stay in the IMU for infected patients was 17.2 days and for non infected patients 6.8 days. When these stays were adjusted by the variables associated with both NI and in the IMU this became 14.2 days for infected patients and 9.9 days for uninfected patients. The prolongation of stay in the IMU due to NI was 4.3 days. The extra cost for the hospital due to infection acquired by a patient's during stay in the IMU was estimated as 239,441 pesetas. CONCLUSIONS: The methodology used was considered as valid for estimating the prolongation of stay in intensive medicine units attributed to nosocomial infection. The high economic expense which nosocomial infection represents emphasizes the justification for measures of control of this entity.

[Risk factors for pneumonia, bacteremia, and urinary tract infection in an intensive care unit]. / Factores de riesgo de neumonía, bacteriemia e infección urinaria en una unidad de cuidados intensivos.

BACKGROUND: To identify nosocomial infection risk factors in an intensive care unit and construct a predictive model that will enable future risk-adjusted comparisons of infection incidences. PATIENTS AND METHODS: Prospective surveillance of pneumonia, bacteremia and urinary tract infections in intensive care unit patients. All patients (n = 944) admitted to the intensive care unit for at least 24 h were followed daily in a tertiary level hospital. Variables measuring extrinsic as well as intrinsic risk factors for nosocomial infections were collected from each patient during their intensive care unit stay and the Cox proportional hazards multivariable technique was applied to identify the variables mostly associated with infection in our hospital. RESULTS: The main risk factors identified for pneumonias were intrinsic. The hazard ratios (HR) of two extrinsic risk factors were noteworthy: mechanical ventilation (HR = 7.51; 95% CI = 2.95-19.13) and sedation (HR = 2.01; 95% CI = 1.14-3.56). The extrinsic factors associated with bacteremias were, the sum of extrinsic risk factors (HR = 1.52; 95% CI = 1.17-1.97) and having a tracheostomy (HR = 3.61; 95% CI = 1.99-6.56). The urinary tract infections were negatively associated with the administration of antibiotics prior to infection onset (HR = 0.41; 95% CI = 0.21-0.78) and the male sex (HR = 0.40; 95% CI = 0.22-0.75). Conversely, urinary tract infections were positively associated with the presence of cancer (HR = 2.70; 95% CI = 1.03-7.11) and the APACHE II index (for every 5 units of increase of the APACHE II index, HR = 1.39; 95% CI = 1.09-1.79). CONCLUSIONS: The most important risk factors identified for pneumonias and urinary tract infections in intensive care unit patients were endogenous, whereas they were exogenous for bacteremias.

[Accidental pricking by a needle in a third-level hospital: associated factors]. / Pinchazos accidentales con aguja en un hospital de tercer nivel: factores asociados.

The needlestick injuries are the most frequent accidents among hospital staff. The aim of this study is to identify some factors associated with accidents caused by needlestick injuries at hospitals, so as to measure the risk that they present. A case-control study has been made, the subject of which is the nurses working at "Reina Sofía" Hospital in Córdoba and within the period June 30, 1990 and June 30, 1991. A more significant factor in relation to needlestick injuries was the recapping of the needle after being used. The risk of injury being 3.95, 7.68 an 17.85 times higher between those who recapped sometimes, frequently and always, respectively, versus those who had never recapped needles. Professional experiences resulted in being a protector factor against the needlestick injuries (OR = 0.93; 95% CI = 0.89; 0.97;) it's estimated that the risk injuring is less than half among personnel having ten years of experience. Knowing these risk factors is important for the development of specific prevention programs. Nevertheless, it is still important to identify other risk factors.

[Influence of nosocomial infection on mortality in an intensive care unit]. / Influencia de la infección nosocomial sobre la mortalidad en una Unidad de Cuidados Intensivos.

OBJECTIVE: To evaluate the association between nosocomial infections (NI) and the mortality of Intensive Care Unit (ICU) patients, adjusting for the effect on mortality of other predictive variables. METHODS: Prospective study on 944 concurrent patients admitted for at least 24 hours in the ICU of a tertiary level hospital between February and November of 1994. The association between NI (diagnosed using CDC criteria) and mortality was studied using multivariable logistic regression. RESULTS: The cummulative incidence of mortality in the ICU was 11.2% (CI95% = 9.9-12.5). This incidence was significantly higher in infected patients with a crude mortality relative risk of 2.2 (CI95% = 1.5-3.1). In the multivariable analysis, the effect of NI (global, pneumonias, of the urinary tract and bacteriemias) on adjusted mortality depended on the patient's Acute Pysiology and Chronic Health Evaluation II (APACHE II) score. With low APACHE II scores, NI was associated with an increased mortality risk. Conversely, with higher APACHE II scores, the relevance of NI as a determinant of mortality decreased and prognosis was mainly associated with the patient's severity of illness. CONCLUSIONS: The association between NI and mortality, adjusting for other prognostic factors for mortality, is confirmed.

[Estimation of cost associated with incorrect surgical prophylaxis in a third level hospital center]. / Estimación del coste asociado a la profilaxis quirúrgica en un centro hospitalario de tercer nivel.

BACKGROUND: The constant increase of pharmaceutical costs is of great concern to the administrators of the Spanish National Health Service. Antibiotics administered as prophilaxis prior to surgery, play an important role in this increase. The compliance of physicians with protocols for chemoprophylaxis is therefore an important factor in the control of these pharmaceutical costs. The degree of compliance with the pre-established protocols of prophylaxis prior to surgery are examined in a tertiary level hospital during 1992 and the extra costs due to the lack of compliance with these protocols are estimated using a sample of 371 subjects. The object of this study is to describe the degree of the fulfillment of the protocols of surgical chemoprophylaxis in a tertiary level hospital and to estimate the minimum additional cost due to the wrong chemoprophylaxis. METHODS: A descriptive study was made of the surgical prophylaxis using a sample of 371 subjects. The cost was estimated from the price of the antibiotics administered. RESULTS: A total of 267 (71.9% IC95% = 67.3-76.5) subjects had received incorrect prophylaxis. The most important causes of incorrect prophylaxis were the wrong antibiotic choice and the excessive duration of their administration. The incorrect prophylaxis was responsible for an additional cost of 1,117,287 ptas. The application of these estimates to the entire 1992 surgical population, at our center, would yield an estimated additional cost of 39,409,965 pesetas. CONCLUSIONS: Our health services would have substantial savings if protocols for prophylaxis prior to surgery were strictly followed by physicians.

[Factors associated with accidents caused by percutaneous exposure in nursing staff at a tertiary level hospital]. / Factores asociados a los accidentes por exposición percutánea en personal de enfermería de un hospital de tercer nivel.

BACKGROUND: Accidents resulting from percutaneous exposure account for approximately one third of all accidents suffered at work by health workers in hospitals. Their importance lies in the illnesses caused by pathogens that can be transmitted in this way (hepatitis B, hepatitis C, HIV virus). The aims are to describe accidents of this type notified in a tertiary level hospital, identify factors associated with these accidents in nursing staff and build a predictive model for the individual risk of having an accident. METHODS: A descriptive study of a retrospective cohort made up of all the people who notified having suffered an accident between 1-1-93 and 30-6-96. A study of cases and controls in nursing staff during the period 1-1-95 to 30-6-96, analysed through multiple logistical regression. RESULTS: The cumulative incidence of cases of accidents in one year was 0.078 for male and female nurses. In 57.3% of cases, disposable or pre-loaded syringes were involved. The cumulative incidence of cases in one year was greater for intravenous catheterisation (8.5% per 100,000). The risk of having an accident, adjusted on account of confusing variables, was greater for female and male nurses (OR = 3.22; I.C.95% = 1.96-5.27), or workers in the Haemodialysis Unit (OR = 35.21; I.C.95% = 3.74-331.16) and for those employed on a temporary contract (OR = 4.50; I.C.95% = 2.24-9.04). CONCLUSIONS: Accidents resulting from percutaneous exposure at this hospital are more frequent among nursing staff and are basically caused by any type of hollow needles. Factors associated with these accidents were identified, allowing specific prevention programmes to be targeted at those workers at greater risk. The model obtained is valid to estimate the degree of individual accident probability for the subjects studied.

Underlying illness severity and outcome of nosocomial pneumonia: prospective cohort study in intensive care unit.

BACKGROUND: Previous studies have suggested that the final outcome of a patient with nosocomial pneumonia (NP) may depend on the patient's illness severity upon admission to the intensive care unit (ICU). AIM: To investigate the relationship between developing NP during hospitalization in an adult ICU and the risk of death with special focus on illness severity at admission in the unit. METHODS: A prospective cohort study was performed among all patients admitted for at least 24h to the ICU of a university reference hospital in Spain from 2006 to 2009. A stratified univariate study was performed according to the patients' illness severity at admission, estimated using the Acute Physiology And Chronic Health Evaluation (APACHE) II index. To determine whether the NP was independently associated with increased mortality in ICU, a multivariate logistic regression analysis was carried out, adjusting for potential confounders. RESULTS: In all, 4427 patients were studied, of whom 233 acquired NP while admitted. Patients who developed NP had a 2.6 higher risk (95% confidence interval: 2.1-3.0) of dying compared with those who did not develop NP. When stratified by the APACHE II index, the significant association remained at each stratum, although the strength of the association decreased as the value of the index increased. In the multivariate analysis, NP was independently associated with death in the ICU. The interaction between NP and the APACHE II index, with a negative coefficient, was also significant. CONCLUSIONS: Developing NP while admitted to the ICU was independently associated with increased mortality. However, the strength of the association decreased as the severity of patient illness upon admission to the ICU increased, not influencing death of patients with severe APACHE II values.

Neumonía nosocomial y mutirresistencias en una unidad de cuidados intensivos de adultos de un hospital de tercer nivel / Pneumonia nosocomial and multiresistances in adult in a tertiary referral hospital

OBJETIVO: Determinar la incidencia y etiología de la Neumonía Nosocomial (NN) en la Unidad de Cuidados Intensivos (UCI) de adultos del Hospital Universitario Reina Sofía (HURS) de Córdoba. METODOLOGÍA: El Servicio de Medicina Preventiva del HURS elaboró un estudio epidemiológico observacional de cohortes prospectivo de los pacientes ingresados en la UCI de adultos entre 2006 y 2009. Se calcularon las siguientes medidas de incidencia: Incidencia Acumulada (IA) de pacientes infectados con NN, IA de neumonías y densidad de incidencia de neumonías asociadas a ventilación mecánica. Se procedió a realizar una estadística descriptiva con cálculos de frecuencias. RESULTADOS: Hubo 233 pacientes con NN (IA de pacientes con NN=5,3/100 pacientes ingresados). El 96,6% de los pacientes con NN habían estado sometidos a ventilación mecánica (VM)previa. La tasa de incidencia de NN asociada VM fue de 15,7/1000 días de ventilación. Se solicitaron cultivos en todas las NN. El microorganismo más frecuente causante de NN fue Acinetobacter spp. (41,7% de los aislamientos), seguido de P.aeruginosa (8%), S. aureus y C. albicans, ambos aislados en un 7,1% de los cultivos. El 40% de las NN fueron provocadas por microorganismos multirresistentes, destacando el A. baumannii (82,6%) seguido de S. aureus meticilin resistente (9,7%). Destaca la emergencia de Stenothropomonas maltophilia (3,9%). CONCLUSIÓN: Las cifras de incidencia de NN en la UCI han disminuido en la última década, pero siguen siendo superiores a las de otros estudios. Los microorganismos más frecuentemente involucrados en la neumonía han sido los gramnegativos, y de ellos en primer lugar A. baumannii. Prácticamente la totalidad de los aislamientos de este microorganismo fueron multirresistentes

OBJECTIVE: To determine the incidence and etiology of Nosocomial pneumonia (NP) in adult ICU of Reina Sofia University Hospital (RSUH) of Córdoba. METHODOLOGY: The Department of Preventive Medicine of RSUH conducted a prospective cohort study for admitted patients at adults’ ICU from 2006 to 2009. The following incidence rates were calculated: accumulated incidence (AI) rate of patients with NP and incidence density of pneumonia associated with mechanical ventilation. We conducted a descriptive statistical analysis with calculation of the frequencies. RESULTS: There were registered 233 patients with NP (AI of NP of admitted patients 5.3/100). About 96.6% of patients with NP were previously subjected to mechanical ventilation (MV). The incidence rate of NP associated MV was 15.7/1000 days of ventilation. Culture was requested to all cases with NP. The most frequent microorganism of NP was Acinetobacter spp. (41.7% of cultures) followed by P.aeruginosa (8%). S.aureus and C.albicans were isolated in 7% of cultures. About 40% of NP were caused by multidrug-resistant microorganisms, like A.baumannii (82.6%) followed by methicillin resistant S. aureus (9.7%). Also we noted the emergence of Stenothropomonas maltophilia (3.9%). CONCLUSION: Incidence rates of NP in the ICU have declined in the last decade, although our rates are still higher than the reported in other studies. The microorganisms most frequently involved in NP were gram negative, of which the most frequent was A.baumannii. Nearly all isolated microorganisms were multidrug-resistant

El tabaco: la epidemia del siglo veinte / No disponible

El tabaquismo es sin duda la gran epidemia del siglo veinte. En principio, el hábito tabáquico no se consideró nocivo y es a partir de la introducción de tabaco en las raciones de los soldados en la Primera Guerra Mundial cuando su consumo experimenta un crecimiento exponencial en toda Europa. Son varias las especialidades que abarcan las enfermedades relacionadas con el abuso del tabaco. En los últimos 50 años se ha acumulado gran número de evidencias de gran consistencia científica que avalan el hecho de que el tabaco está directamente relacionado con el incremento de una amplia variedad de neoplasias. Asimismo existen suficientes pruebas que demuestran que el consumo de tabaco incrementa el riesgo cardiovascular y los procesos respiratorios crónicos. En 1999 se ha estimado que la mortalidad mundial esperada como consecuencia del tabaquismo alcanzará la cifra de 520 millones de adultos durante la primera mitad del siglo veintiuno y que se vería reducida en 180 millones si se lograra la mitad de los adultos fumadores dejaran de fumar durante ese período. En los últimos años se ha demostrado que el consumo ocasional de tabaco conduce a un consumo crónico y que la mayoría de los fumadores crónicos cumplen criterios de “dependencia del tabaco” enfermedad que ha sido enumerada por la OMS. Es importante instaurar algún tipo de tratamiento de deshabituación tabáquica a los pacientes fumadores. Las investigaciones recientes han abarcado tanto estrategias para la prevención del consumo como para el abandono del mismo (AU)

Smoking is certainly the grand epidemic of the 20th century. At the beginning, smoking was not considered as an harmful habit. The introduction of tobacco in the food ration of the first world war solders resulted in its wide consumption all over Europe. Various medical specialties attribute many diseases to tobacco abuse. Over the last 50 years, consistent scientific evidences, of large number, have proved that smoking is directly associated with increased risk of various neoplasm’s. At the same time, sufficient data demonstrates that tobacco consumption increases the risk of cardiovascular and chronic respiratory disease. In 1999, it was estimated that the expected world mortality during the first half of the 21st century because of smoking could reach 520 millions adults and it could be reduced to 180 millions if half of smokers give demonstrated that occasional tobacco consumption leads to chronic consumption and the mayor part of smokers satisfy the recognized and listed by the WHO. It is important to facilitate treatments for smokers to help them to give up smoking. The recent investigations have offered various strategies for prevention of tobacco consumption and its giving up (AU)