Level of acuity, severity and intensity of care of adults and older adults admitted to the Intensive Care Unit.

OBJECTIVE: To characterize the level of acuity, severity and intensity of care of adults and older adults admitted to Intensive Care Units and to identify the predictors of severity with their respective predictive capacity according to the age group. METHOD: A retrospective cohort based on the analysis of medical records of individuals admitted to eight adult intensive care units in the city of São Paulo. The clinical characteristics at admission in relation to severity profile and intensity of care were analyzed through association and correlation tests. The predictors were identified by linear regression and the predictive capacity through the ROC curve. RESULTS: Of the 781 cases (41.1% from older adults), 56.2% were males with a mean age of 54.1 ± 17.3 years. The burden of the disease, the organic dysfunction and the number of devices were the predictors associated with greater severity among adults and older adults, in which the organic dysfunction had the highest predictive capacity (80%) in both groups. CONCLUSION: Adults and older adults presented a similar profile of severity and intensity of care in admission to the Intensive Care Unit. Organic dysfunction was the factor with the best ability to predict severity in adults and older adults.

Haemodialysis, nutritional disorders and hypoglycaemia in critical care.

This study aimed to determine hypoglycemia incidence and associated factors in critically ill patients. It looked at a retrospective cohort with 106 critically ill adult patients with 48 hours of glycaemic control and 72 hours of follow up. The dependent variable, hypoglycaemia (≤70 mg/dl), was assessed with respect to independent variables: age, diet, insulin, catecholamines, haemodialysis, nursing workload and the Simplified Acute Physiology Score. Statistical analysis was performed using Student's t-test, Fisher's exact test and logistic regression at 5% significance level. Incidence of hypoglycaemia was 14.2%. Hypoglycaemia was higher in the group of patients on catecholamines (p=0.040), with higher glycaemic variability (p<0.001) and death in the intensive care unit (p=0.008). Risk factors were identified as absence of oral diet (OR 5.11; 95% CI 1.04-25.10) and haemodialysis (OR 4.28; 95% CI 1.16-15.76). Patients on haemodialysis and with no oral diet should have their glycaemic control intensified in order to prevent and/or manage hypoglycaemic episodes.

Aging as a predictor of nursing workload in Intensive Care Unit: results from a Brazilian Sample.

OBJECTIVE: Verify if aging is an independent predictor of NW in ICU, according to age groups, and its predictive value as a determinant of NW in ICU. METHODS: Study was conducted from 2012 to 2016. A convenience sample composed by patients (age ≥ 18) admitted to nine ICU belonging to a Brazilian hospital, was analyzed. Age was assumed as an independent variable and NW (measured by the Nursing Activities Score - NAS) as dependent. Linear regression model and ROC curve were used for the analysis. RESULTS: 890 participants (361 older people), mostly males (58.1%). The mean NAS score was higher among older participants in comparison to adults (p=0.004) but not within categories of aging (p=0.697). Age was responsible for 0.6% of NAS score. Each year of age increases NAS score in 0.081 points (p=0.015). However, age was not a good predictor of NAS score (AUC = 0.394; p=0.320). CONCLUSION: The care of older people in ICU is associated with an increase in NW, compared to adults. Aging can be considered an associated factor but not a good predictor of NW in ICU. OBJETIVO: Verificar si el envejecimiento es un predictor independiente de la Carga de Trabajo de Enfermería (CTE) en la Unidad de Cuidados Intensivos (UCI), según grupos etarios y su valor predictivo como determinante de la CTE en la UCI. MÉTODOS: Se analizó una muestra de conveniencia compuesta por pacientes (edad ≥ 18) ingresados en nueve UCI pertenecientes a un hospital brasileño. La edad se asumió como variable independiente y como variable dependiente la carga de trabajo de enfermería -medida por el sistema Nursing Activities Score (NAS) de puntuación de actividades de enfermería. Para el análisis, se utilizaron el modelo de regresión lineal y la curva ROC. RESULTADOS: 890 participantes (361 adultos mayores), en su mayoría varones (58,1%). La puntuación NAS promedio fue mayor entre los participantes adultos mayores en comparación con los adultos (p=0,004), pero no en las categorías de envejecimiento (p=0,697). La edad fue responsable del 0,6% de la puntuación NAS. Cada año de edad aumenta la puntuación NAS en 0,081 puntos (p=0,015). Sin embargo, la edad no resultó un buen predictor de la puntuación NAS (AbC=0,394; p=0,320). CONCLUSIÓN: El cuidado de los adultos mayores en UCI se asocia con un aumento de la CTE en comparación con los adultos. El envejecimiento puede considerarse un factor asociado, pero no un buen predictor de la CTE en UCI.

Patient safety in organizational culture as perceived by leaderships of hospital institutions with different types of administration.

OBJECTIVE: To identify the perceptions of leaderships toward patient safety culture dimensions in the routine of hospitals with different administrative profiles: government, social and private organizations, and make correlations among participating institutions regarding dimensions of patient safety culture used. METHOD: A quantitative cross-sectional study that used the Self Assessment Questionnaire 30 translated into Portuguese. The data were processed by analysis of variance (ANOVA) in addition to descriptive statistics, with statistical significance set at p-value ≤ 0.05. RESULTS: According to the participants' perceptions, the significant dimensions of patient safety culture were 'patient safety climate' and 'organizational learning', with 81% explanatory power. Mean scores showed that among private organizations, higher values were attributed to statements; however, the correlation between dimensions was stronger among government hospitals. CONCLUSION: Different hospital organizations present distinct values for each dimension of patient safety culture and their investigation enables professionals to identify which dimensions need to be introduced or improved to increase patient safety. OBJETIVO: Identificar percepções das lideranças sobre as dimensões da cultura de segurança do paciente no cotidiano de hospitais de diferentes perfis administrativos: públicos, organizações sociais e privados, e realizar correlação entre as instituições participantes, de acordo com as dimensões da cultura de segurança do paciente utilizadas. MÉTODO: Estudo transversal de aspecto quantitativo obtido por meio da aplicação do instrumento Self Assessment Questionnaire 30, traduzido para a língua portuguesa. Os dados foram tratados com análise de variância (ANOVA), além das estatísticas descritivas, considerando como de significância estatística valores de p-valor ≤ 0,05. RESULTADOS: Segundo a percepção dos participantes do estudo, as dimensões significativas para a cultura de segurança do paciente foram Ambiente de Segurança do Paciente e Aprendizado Organizacional, com poder explicativo de 81%. A média de respostas obtidas evidenciou que nas organizações privadas houve maiores valores atribuídos às questões, porém a correlação entre as dimensões foi mais forte nas organizações públicas. CONCLUSÃO: As dimensões da cultura de segurança do paciente têm valores distintos nas diferentes organizações hospitalares e a sua investigação possibilita identificar quais necessitam ser introduzidas ou aprimoradas para maior segurança do paciente.

Nursing workload for cancer patients under palliative care.

OBJECTIVE: To verify the nursing workload required by cancer patients undergoing palliative care and possible associations between the demographic and clinical characteristics of the patients and the nursing workload. METHOD: This is a quantitative, cross-sectional, prospective study developed in the Connective Bone Tissue (TOC) clinics of Unit II of the Brazilian National Cancer Institute José Alencar Gomes da Silva with patients undergoing palliative care. RESULTS: Analysis of 197 measures of the Nursing Activities Score (NAS) revealed a mean score of 43.09% and an association between the performance status of patients undergoing palliative care and the mean NAS scores. The results of the study point to the need to resize the team of the unit. CONCLUSION: The NAS has proven to be a useful tool in oncologic clinical units for patients undergoing palliative care. OBJETIVO: Verificar a carga de trabalho de enfermagem requerida por pacientes com câncer sob cuidados paliativos e possíveis associações entre as características demográficas e clínicas dos pacientes e a carga de trabalho de enfermagem. MÉTODO: Trata-se de um estudo de abordagem quantitativa, transversal, prospectivo, desenvolvido na clínica de Tecido Ósseo Conectivo (TOC) da Unidade II do Instituto Nacional de Câncer José Alencar Gomes da Silva, com pacientes em cuidados paliativos. RESULTADOS: A análise de 197 medidas do Nursing Activities Score (NAS) revelou um escore médio de 43,09% e uma associação entre a performance status de pacientes em cuidados paliativos com os valores médios do NAS. Os resultados do estudo apontam para a necessidade de redimensionamento da equipe da Unidade. CONCLUSÃO: O NAS mostrou-se um instrumento passível de utilização em unidades clínicas oncológicas, com pacientes em cuidados paliativos.

The use of the Nursing Activities Score in clinical settings: an integrative review.

Objective analyze how studies have approached the results obtained from the application of the Nursing Activities Score (NAS) based on Donabedian's model of healthcare organization and delivery. Method CINAHL and PubMed databases were searched for papers published between 2003 and March 2015. Results 36 articles that met the inclusion criteria were reviewed and double-coded by three independent coders and analyzed based on the three elements of Donabedian's health care quality framework: structure, process and outcome. The most frequently addressed, but not always tested, variables were those that fell into the structure category. Conclusion variables that fell into the process category were used less frequently. Beside NAS, the most frequently used variables in the outcome category were mortality and length of stay. However, no study used a quality framework for healthcare or NAS to evaluate costs, and it is recommended that further research should explore this approach.

Stress, coping and burnout among Intensive Care Unit nursing staff: associated factors. / Estresse, coping e burnout da Equipe de Enfermagem de Unidades de Terapia Intensiva: fatores associados.

Objective To investigate emotional stress, coping and burnout among nursing staff and their association with biosocial factors and characteristics of work in Intensive Care Units (ICU). Method This was a cross-sectional study, conducted in eight ICUs at a teaching hospital in the city of São Paulo, Brazil, in October 2012. Biosocial data and information about the professionals' work was gathered, and they were given the Scale of Occupational Stress, Scale of Occupational Coping, List of Signs and Symptoms of Stress and the Maslach Burnout Inventory. Results The study sample consisted of 287 subjects, predominately women, with partners and children. Most professionals presented moderate stress levels and control as a coping strategy (74.47% and 79.93%, respectively), and burnout was present among 12.54%. Factors associated with stress were related to working conditions. The most prevalent protective factors were having a partner, working in the clinical ICU and liking work, while adequate amount of sleep was a protective factor for burnout. Conclusion Control of the working environment and adequate sleep are decisive and protective factors in dealing with situations of occupational stress.

Patient safety in Intensive Care Units: development of a research project. / Segurança do paciente em Unidades de Terapia Intensiva: desenvolvimento de um projeto de pesquisa.

OBJECTIVE: To describe our experience in the many processes involved in the development of a Project on Research into Intensive Care Unit Patient Safety. METHOD: Mixed design study: historic cohort study of the collection of data on patients and on adverse events/incidents and transversal design on the collection of data on a nursing team. The data were collected over a period of 90 days in 2012 at the Instituto Central do Hospital das Clínicas da Faculdade de Medicina of the Universidade de São Paulo (ICHC-FMUSP)and the University Hospital of the Universidade de São Paulo HU-USP).Procedures carried out: This study involved a number of stages: application of the Nursing Activities Score (NAS) at the ICHC-FMUSP, creation of a database system, hospital record inputs, monitor training, patient data extraction and load, collection of data during duty shift changes, and records. Final considerations : Training, researcher commitment, and collaboration with IT (Information Technology) professionals were crucial to the quality of the results obtained and of scientific production achieved. We hope that our report will serve to guide and encourage researchers to carry out complex surveys contributing to improve nursing and health knowledge.

Pattern of nursing interventions performed on trauma victims according to the Nursing Activities Score. / Padrão de intervenções de enfermagem realizadas em vítimas de trauma segundo o Nursing Activities Score.

Objective To identify the pattern of nursing interventions performed on trauma victims in the Intensive Care Unit (ICU). Method Prospective study performed in the ICU of a hospital in São Paulo, Brazil. Nursing interventions were identified using the Nursing Activities Score (NAS). Results The sample consisted of 200 patients, most of them male, with a mean age of 40.7, victims of transport accidents. The NAS mean was 71.3%. The pattern of nursing interventions identified included monitoring and titration, laboratory investigations, medication (with the exception of vasoactive drugs), hygiene procedures, caring for drains, mobilization and positioning, support and care of relatives and patient, administrative and managerial tasks, respiratory support, care of artificial airways, treatment for improving lung function, and quantitative urine output measurement. The monitoring and mobilization interventions required care beyond what is normally required by ICU patients. Conclusion The results of this study provide important contributions to plan training activities and to size ICU nursing team.

Nursing workload in hematopoietic stem cell transplantation: a cohort study. / Carga de trabalho de enfermagem em transplante de células-tronco hematopoiéticas: estudo de coorte.

Objective Measure nursing workload required by patients submitted to autologous and allogeneic hematopoietic stem cell transplantation (HSCT) and analyze the Nursing Activities Score (NAS) of the nursing team during the hospitalization period for HSCT. Method A prospective cohort study conducted from January 2013 to April 2014 with 62 patients hospitalized in the HSCT unit of a university hospital in Campinas, São Paulo, Brazil. The workload was measured through NAS and data analysis was through chi-square test or Fisher's exact test, Mann-Whitney test and Spearman's correlation coefficient; with 5% significance level. Results Mean nursing workload was 67.3% (SD of 8.2) in autologous HSCT patients and 72.4% (SD of 13.0) in allogeneic HSCT patients (p=0.1380).Monitoring and titration showed, in more than 50% of the time, patients demanded intensified care, requiring two hours or more in a nursing shift for reasons of safety, severity or therapy. Conclusion The nursing workload and the NAS items with the highest scores reflect the magnitude, complexity and specificity of care required by patients submitted to HSCT.

Nursing workload: is it a predictor of healthcare associated infection in intensive care unit? / Carga de trabalho de enfermagem: preditor de infecção relacionada à assistência à saúde na terapia intensiva?

Objective To analyze the influence of nursing workload on the occurrence of healthcare associated infection (HAI) in patients in the intensive care unit (ICU), according to type of treatment. Method Retrospective cohort study developed in nine ICUs in São Paulo, Brazil, from September to December 2012. Nursing workload was measured by the Nursing Activities Score (NAS). The Student's t and Fisher's exact tests and logistic regressions were used in the analyses. Results The sample was composed of 835 patients (54.3±17.3 years; 57.5% male), of which 12.5% acquired HAI in the ICU. The NAS of the patients admitted for clinical treatment was 71.3±10.9, and for surgery 71.6±9.2. Length of stay in ICU and severity were predictive factors for occurrence of HAI in patients admitted to the unit for clinical or surgical treatment, and male sex only for surgical patients. When considering the admissions independent of type of treatment, in addition to the variables mentioned above, index of comorbidities also remained in the regression model. The NAS was not a predictive factor of HAI. Conclusion Nursing workload did not influence occurrence of HAI in the patients included in this study.

Nursing Activities Score: an updated guideline for its application in the Intensive Care Unit.

Objective To describe nursing workload in Intensive Care Units (ICU) in different countries according to the scores obtained with Nursing Activities Score (NAS) and to verify the agreement among countries on the NAS guideline interpretation. Method This cross-sectional study considered 1-day measure of NAS (November 2012) obtained from 758 patients in 19 ICUs of seven countries (Norway, the Netherlands, Spain, Poland, Egypt, Greece and Brazil). The Delphi technique was used in expertise meetings and consensus. Results The NAS score was 72.8% in average, ranging from 44.5% (Spain) to 101.8% (Norway). The mean NAS score from Poland, Greece and Egypt was 83.0%, 64.6% and 57.1%, respectively. The NAS score was similar in Brazil (54.0%) and in the Netherlands (51.0%). There were doubts in the understanding of five out 23 items of the NAS (21.7%) which were discussed until researchers' consensus. Conclusion NAS score were different in the seven countries. Future studies must verify if the fine standardization of the guideline can have a impact on differences in the NAS results.

[Intraoperative nursing in bariatric surgery: integrative review]. / Enfermagem transoperatória nas cirurgias de redução de peso: revisão integrativa da literatura.

Integrative review of scientific literature study to identify and analyze the production of knowledge about clinical advances in security needs of patients during the intraoperative period of bariatric surgery. It was based on 12 selected studies in electronic databases, with descriptors previously defined. Except for two studies, the specific content of this production was composed of the general context of perioperative care. The studies highlight the possible state of the art of nursing activities on these needs, which are well established, including recommendations by several guidelines. However, they are fundamentally based on the science of traditional clinical practice through the development of rational judgments issued by experts. It concludes for the relevance of primary studies to evaluate the impact and resolution of the identified resources to answer those needs, as well as improving or generating other innovative features and identification of new needs.

[The use of severity indexes to estimate the risk of death in Intensive Care]. / Desempenho de índices de gravidade para estimar risco de morte em Unidades de Terapia Intensiva.

UNLABELLED: The Simplified Acute Physiology Score II (SAPS II) and Logistic Organ Dysfunction System (LODS) are instruments used to classify Intensive Care Unit (ICU) inpatients according to the severity of their condition and risk of death, and evaluate the quality of nursing care. The objective of this study is to evaluate and compare the performance of SAPS II and LODS to predict the mortality of patients admitted to the ICU. The participants were 600 patients from four ICUs located in São Paulo, Brazil. Receiver Operator Characteristic (ROC) curves were used to compare the performance of the indexes. RESULTS: The areas under the ROC curves of LODS (0.69) and SAPS II (0.71) indicated moderate discriminatory capacity to identify death or survival. No statistically significant differences were found between these areas (p=0.26). In conclusion, there was equivalence between SAPS II and LODS to estimate the risk of death of ICU patients.

[Nursing allocation and adverse events/incidents in intensive care units]. / Alocação da equipe de enfermagem e ocorrência de eventos adversos/incidentes em unidade de terapia intensiva.

Patient safety is a challenge for the quality in health care system. This study aimed to analyze the appropriateness of the allocation of nursing staff according to the hours of care required by patients and to identify the relationship between this allocation and adverse events/incidents (EA/I). This research was observational, descriptive and prospective, developed in Clinics ICU located in the 4th floor and 6th floor at a university hospital, in São Paulo, Brazil, from 01/11/07 to 10/12/07, with 46 patients. In the 4th floor and 6th floor ICU, respectively, 43,3% and 10.3% of allocations were inadequate (p=0.000). There was a difference in the frequency of EA/I between the adequate and inadequate allocation of nursing staff in the 4th floor and 6th floor ICU, p=0.0004 and p=0.000, respectively. It was concluded that the greater the difference between available and required hours of care in nursing allocations, the lower the frequency of EA/I.

Patient safety culture and incidents recorded during nursing shift changes in intensive care units. / Cultura de segurança do paciente e incidentes registrados durante as passagens de plantão de enfermagem em unidades de terapia intensiva.

OBJECTIVE: To analyze the association of patient safety culture perceived by nursing professionals with incidents recorded during nursing shifts in intensive care units. METHODS: This was a cross-sectional study that investigated patient safety culture measured by the Hospital Survey on Patient Safety Culture instrument. Descriptive statistics, chi-square tests, Student's t-test and multiple linear regression models were analyzed considering a significance level of 5%. RESULTS: The study reported a mean of 3.1 (standard deviation of 0.4) for the culture of patient safety in the perception of nursing professionals and 480 incidents with and without damage recorded during the nursing shifts. The variables patient safety culture with a difference between means of 0.543 (95%CI 0.022 - 1.065; p < 0.05) and nursing assistants with a difference between means of -0.133 (95%CI -0.192 - -0.074; p < 0.05) were associated with the incidents recorded during the nursing shifts. Further, nursing assistants had a lower tendency to record incidents than did the nurses. CONCLUSION: The strengthening of the patient safety culture and the aspects tangential to the nursing professionals represent a possible target for interventions to encourage the recording of incidents during the nursing shift shifts and improve patient safety.

OBJETIVO: Analisar a associação da cultura de segurança do paciente na percepção dos profissionais de enfermagem com os incidentes registrados durante as passagens de plantão de enfermagem nas unidades de terapia intensiva. MÉTODOS: Estudo transversal que investigou a cultura de segurança do paciente medida pelo instrumento Hospital Survey on Patient Safety Culture. Estatísticas descritivas, teste do qui-quadrado, teste t de Student e modelo de regressão linear múltiplo foram analisados considerando o nível de significância de 5%. RESULTADOS: O estudo relatou média de 3,1 (desvio-padrão de 0,4) para a cultura de segurança do paciente na percepção dos profissionais de enfermagem e 480 incidentes com e sem danos registrados nas passagens de plantão de enfermagem. As variáveis cultura de segurança do paciente com diferença entre médias de 0,543 (IC95% 0,022 - 1,065; p < 0,05) e técnicos de enfermagem com diferença entre médias de -0,133 (IC95% -0,192 - -0,074; p < 0,05) foram associadas aos incidentes registrados nas passagens de plantão de enfermagem, considerando ainda que os técnicos de enfermagem apresentaram menor tendência de registro que os enfermeiros. CONCLUSÃO: O fortalecimento da cultura de segurança do paciente e dos aspectos tangentes aos profissionais de enfermagem representam uma possibilidade real de intervenção para favorecer os incidentes registrados durante as passagens de plantão de enfermagem nas unidades de terapia intensiva deste estudo.

[Adverse events at the Intensive Care Unit: nurses' perception about the culture of no-punishment]. / Eventos adversos em Unidade de Terapia Intensiva: percepção dos enfermeiros sobre a cultura não punitiva.

UNLABELLED: The safety culture of Intensive Care Units (ICU) recommends following the no-punishment approach when adverse events (AE) occur. It is, however, questionable if nurses perceive those AE. OBJECTIVES: to characterize AE report systems; to verify AE frequency and consequences to the professionals; and to verify the nurses' level of confidence to report AE. This descriptive study involved 70 ICU nurses, who answered a questionnaire in 2007, followed by descriptive analyses. Most nurses (70.0%) reported the existence of an AE notification system at their place of work. The frequency of AE was reported as sometimes and several times by 51.4% and 28.6% of the sample, respectively. For 74.3% of nurses, punishment happens sometimes and always, mainly through verbal notice (49.0%). Most nurses (74.3%) reported feeling confident and completely confident to report AE. In conclusion, punishment still exists in the Units.

In(compatibility) of intravenous drugs in critical units: adult cohort.

OBJECTIVES: To analyze potential (in)compatibilities of intravenous drugs based on the scheduling prepared by the nursing team. METHODS: historic cohort (retrospective) with 110 adults in critical units. Intravenous medications were identified concomitantly, whose pairs were analyzed for (in) compatibility using the screening system Trissel's™ 2 Compatibility IV-Micromedex 2.0. Parametric and non-parametric statistic were used according to the nature of the variable. RESULTS: 565 pairs of drugs were identified. Of these, 44.9% were compatible; and 8.8%, potentially incompatible. Most potentially incompatible pairs involved substances with alkaline pH such as phenytoin (32%) and sodium bicarbonate (8%) and weak acids such as midazolam (12%) and dobutamine (6%), which could result in precipitate formation. CONCLUSIONS: almost half of the mixtures simultaneously administrated was compatible, which indirectly reflects in the organized work between the nursing team and the clinical pharmaceutic in the discussions and decisions related to time scheduling.

Patient destination after discharge from intensive care units: wards or intermediate care units?

This study characterizes patients hospitalized in Intensive Care Units (ICUs) of hospitals that have intermediate units (IU) regarding their demographic and clinical data and identifies factors related to discharge from these units. This prospective longitudinal study involved 600 adult patients hospitalized in general ICUs in four hospitals in São Paulo, SP, Brazil. Demographic and clinical characteristics were similar to those found in other studies addressing patients hospitalized in ICUs. Factors associated with discharge from ICU to IU were: age > or = 60 years, diseases related to the nervous, circulatory or respiratory systems, originated from the IU, and Simplified Acute Physiologic Score II (SAPS II), Logistic Organ Dysfunction (LODS) and Nursing Activities Scores (NAS) at admission and discharge from the ICU. Age and risk of death at admission in the ICU, according to SAPS II, stood out as indicators of discharge to IUs in the Multiple Logistic Regression analysis.