Correlation of inflammatory and cardiovascular biomarkers with pneumonia severity scores.

PURPOSE: To assess the correlation of procalcitonin (PCT), C-reactive protein (CRP), neopterin, mid-regional pro-atrial natriuretic peptide (MR-proANP), and mid-regional pro-adrenomedullin (MR-proADM) with severity risk scores: severe CAP (SCAP) and SMART-COP in patients with community-acquired pneumonia (CAP), as well as short term prognosis and to determine the correlation with mortality risk scores. METHODS: Eighty-five patients with a final diagnosis of pneumonia were consecutively included during a two month period. Epidemiological, clinical, microbiological, and radiological data were recorded. Patients were stratified according to the PSI, CURB-65, SCAP and SMART-COP. Complications were defined as respiratory failure/shock, need of ICU, and death. Plasma samples were collected at admission. RESULTS: MR-proANP and MR-proADM showed significantly higher levels in high risk SCAP group in comparison to low risk. When considering SMART-COP none of the biomarkers showed statistical differences. MR-proADM levels were high in patients with high risk of needing intensive respiratory or vasopressor support according to SMRT-CO. Neopterin and MR-proADM were significantly higher in patients that developed complications. PCT and MR-proADM showed significantly higher levels in cases of a definite bacterial diagnosis in comparison to probable bacterial, and unknown origin. MR-proANP and MR-proADM levels increased statistically according to PSI and CURB-65. CONCLUSIONS: Biomarker levels are higher in pneumonia patients with a poorer prognosis according to SCAP and SMART-COP indexes, and to the development of complications.

[Prediction of bacteremia in patients with suspicion of infection in emergency room]. / Predicción de bacteriemia en los pacientes con sospecha de infección en urgencias.

BACKGROUND AND OBJECTIVES: To evaluate the relationship between some clinical and analytical data and the presence of bacteremia in order to establish a clinical decision rule. PATIENTS AND METHODS: All the patients with blood cultures obtained from the emergency room in a two months period were analyzed. Patients were randomly assigned to derivation or validation sets. A logistic regression of the significant values in the univariate analysis was performed and a score obtained. The prevalence of bacteraemia for every score was calculated. The diagnostic efficacy curves and the performance of the predictive model were calculated. RESULTS: 412 patients were enrolled. The blood cultures were positive in 12.8% of them. The significant values in the univariate analysis were Charlson index ≥2 and PCT > 0.4ng/ml. Four groups of increasing risk of bacteraemia were designed, from 0 to 35% in the derivation set and from 2.9% to 27.2% in the validation set. In the diagnostic efficacy curve, the AUC was 0.8 in the derivation set and 0.74 in the validation set. The model presented a negative predictive value of 95.2% in the derivation set and 95.3% in the validation set. CONCLUSIONS: A model that includes Charlson index and PCT makes possible to define a group of patients with a very low risk of bacteremia.

Hospital-acquired legionnaires disease in a university hospital: impact of the copper-silver ionization system.

We evaluated the impact of the copper-silver ionization system in a hospital where hyperendemic nosocomial legionellosis and was present and all previous disinfection measures had failed. After implementation of the copper-silver ionization system, environmental colonization with Legionella species decreased significantly, and the incidence of nosocomial legionellosis decreased dramatically, from 2.45 to 0.18 cases per 1000 patient discharges.

[Bacteremia in outpatients: a 10-year period follow-up]. / Bacteriemia en pacientes no hospitalizados: tendencias evolutivas en los últimos 10 años.

BACKGROUND AND OBJECTIVE: To know the incidence of bacteremia in outpatients (BO), their clinical and epidemiological characteristics and evolution. PATIENTS AND METHOD: We have analyzed the percentage of positive blood cultures and BO in a 10 year period. We have collected year, month, age, gender, first diagnosis, risk factors for bacteremia, microrganism, final diagnosis and diagnosis concordance. The bacteremia was classified by origin in: urinary tract infection, respiratory, abdominal, venous catheter (IVC), skin, endocarditis, bacteremia without an apparent focus (BWAF) and miscellaneous. We have compared the characteristics of the patients with and without diagnosis concordance. RESULTS: We have collected 283 episodes. The percentage of positive blood culture remained wi-thout changes and the percentage of BO tended to decrease. The most prevalent bacteria was Escherichia coli (56.5%) and the most frequent origin was urinary (59.7%) and BWAF (19.7%). There was no concordance between diagnoses in 37.1%. 30.3% of patients were admitted. Urinary tract infection was detected in 93.5% of the cases, IVC in 6.2% and BWAF in 0%. With regard to the risk factors of bacteremia, human immunodeficiency infection tended to decrease and neoplasm to increase during the study period. CONCLUSIONS: In our experience, BO tends to decrease. The management of urinary infection seems adequate, and IVC could be improved. The main challenge is the cases of BWAF.

Diagnostic errors in emergency departments. / El error diagnóstico en urgencias.

Diagnostic errors have to be recognised as a possible adverse event inherent to clinical activity and incorporate them as another quality indicator. Different sources of information report their frequency, although they may still be underestimated. Contrary to what one could expect, in most cases, it does not occur in infrequent diseases. Causes can be complex and multifactorial, with individual cognitive aspects, as well as the health system. These errors can have an important clinical and socioeconomic impact. It is necessary to learn from diagnostic errors in order to develop an accurate and reliable system with a high standard of quality.

[Diagnosis mistake in the emergency room: relation to main symptom at admission, reasons and clinical implications]. / Error diagnóstico en urgencias: relación con el motivo de consulta, mecanismos y trascendencia clínica.

BACKGROUND AND OBJECTIVE: We intended to analyze the relation between the main symptom at hospital admission and the diagnosis mistake, assessing the reasons and clinical implications. PATIENTS AND METHOD: We analyzed hospitalized patients from the emergency room to the medical wards. We collected: age, sex, time, main symptom at admission, diagnosis at admission and final diagnosis, days of hospitalization and mortality. We established two groups: patients with a concordant diagnosis and patients with a wrong diagnosis, and we compared the characteristics of them. In each case of a wrong diagnosis, we analyzed the reason of the mistake and the clinical consequences. RESULTS: We found a wrong diagnosis in 42 (6.2%) cases. Fever, as main symptom at admission, had a significant higher rate of mistake than other symptoms. No differences were found in the other variables analyzed. Most frequently omitted diagnosis were infectious diseases, pulmonary embolism and heart failure. Main causes of mistake were a deficient clinical evaluation and X-ray interpretation. The mistake implied a delay in the specific treatment in 42.8% cases. CONCLUSIONS: Diagnostic mistakes in the emergency room are more frequent in patients attending with fever. They are mostly related to deficient clinical evaluation or wrong interpretation of X-ray findings. Although these mistakes usually lead to a delay in the treatment, no increase in the days of hospitalization or mortality is observed.

[On hospital emergency department crowding]. / La saturación en los servicios de urgencias hospitalarios.

EN: Recent years have seen a range of measures deployed to curb crowding in hospital emergency departments, but as episodes of overcrowding continue to occur the discussion of causes and possible solutions remains open. The problem is universal, and efforts to revamp health care systems as a result of current socioeconomic circumstances have put emergency services in the spotlight. Consensus was recently achieved on criteria that define emergency department overcrowding. The causes are diverse and include both external factors and internal ones, in the form of attributes specific to a department. The factors that have the most impact, however, involve hospital organization, mainly the availability of beds and the difficulty of assigning them to emergency patients requiring admission. Crowding is associated with decreases in most health care quality indicators, as departments see increases in the number of patients waiting, the time until initial processing, and the time until a physician or nurse intervenes. Crowding is also associated with risk for more unsatisfactory clinical outcomes. This situation leads to dissatisfaction all around-of patients, families, and staff-as aspects such as dignity, comfort, and privacy deteriorate. Proposals to remedy the problem include assuring that the staff and structural resources of a facility meet minimum standards and are all working properly, facilitating access to complementary tests, and providing observation areas and short-stay units. The response of hospitals to the situation in emergency departments should include alternatives to conventional admission, through means for rapid diagnosis, day hospitals, and home hospitalization as well as by offering a clear response in cases where admission is needed, granting easier access to beds that are in fact available. For its part, the health system overall, should improve the care of patients with chronic diseases, so that fewer admissions are required. It is also essential to search for ways to bring the supply of necessary social and health care services more in step with demand.

ES: En los últimos años hemos asistido al despliegue de diferentes medidas de desarrollo de los SUH, pero a pesar de ello los episodios de saturación siguen sucediéndose y el debate en cuanto a sus causas y posibles soluciones sigue abierto. Se trata de un problema universal y en el momento actual las circunstancias socioeconómicas comportan un replanteamiento del sistema sanitario, en el que los SUH tendrán un papel crucial. Recientemente se han consensuado los criterios concretos que definen una situación de saturación en los SUH. Las causas de la saturación son diversas e implican aspectos tanto externos a los SUH como intrínsecos a la propia unidad. Pero los más determinantes son propios de la dinámica hospitalaria, fundamentalmente la dificultad en adjudicación de cama para ingreso y en su disponibilidad real. Esta saturación se asocia a un descenso de la mayoría de indicadores de calidad. Así mismo, se incrementan el número de pacientes que esperan ser atendidos, el tiempo de espera para el inicio de la asistencia y el tiempo de actuación médico-enfermería. Además conlleva un alto riesgo de peores resultados clínicos. Esta situación conduce a la insatisfacción de pacientes, familiares y personal sanitario y a deterioro de aspectos como la dignidad, la comodidad o la confidencialidad. Las propuestas de mejora pasan por asegurar unos mínimos recursos estructurales y de personal, y agilizar algunas exploraciones complementarias, así como implementar áreas de observación y unidades de corta estancia. La respuesta de los centros a los SUH debería incluir alternativas a la hospitalización convencional con dispositivos de diagnóstico rápido, hospitales de día y hospitalización domiciliaria, así como acciones de respuesta bien definidas a las necesidades de ingreso hospitalario, con agilización de la disponibilidad real de camas. El sistema sanitario por su parte debería mejorar el control de los pacientes crónicos para reducir las necesidades de ingreso, y adecuar la oferta a las necesidades reales de atención sociosanitaria.

[Hospital emergency rooms]. / Urgencias hospitalarias.

Overuse of hospital emergency rooms (HERs) is parallel to their controversy. To understand this problem, some concepts should be first clarified. In HERs, there are some intrinsic aspects which are directly related to the emergency itself and thus cannot be modified (intermittent patient flow, need to prioritize, difficulty to achieve a rapid diagnosis, influence of time on treatment, value of clinical follow up, patient's expectations, impact of HER on the overall hospital working dynamics). On the other hand, there are some extrinsic aspects which indeed are not related to HER itself but are rather historically associated with it (precarious structure, delay on admission, lack of privacy, inadequate triage of cases, lack of professionalization); these latter aspects may be potentially modified and should be reconsidered.

[Diagnostic concordance between emergency room and hospitalization in medical patients]. / Estudio de la concordancia diagnóstica entre el área médica de urgencias y la de hospitalización en un hospital general.

BACKGROUND: The purpose of this study was to know the concordance of diagnosis between emergency rooms amd hospitalization wards and to analyze the mistake index, the epidemiological characteristics and the main reasons for the mistakes. PATIENTS AND METHOD: We analyzed hospitalized patients and used a three-level concordance: exact diagnosis (A), syndromical concordance (B) and mistake (C). We compared age, sex, time and days of hospitalization between the groups A+B and C. We also analyzed the causes of mistakes in group C. RESULTS: We found 88.1% of patients in level A, 7.3% in level B and 4.6% in level C. There were no significant differences in the variables analyzed. Main mistakes were a deficient clinical evaluation (50%) and X-ray interpretation (28.6%). CONCLUSIONS: Concordance of diagnoses was the rule, with less than 5% mistakes. There is no clinical or epidemiological pattern for the mistake. The most frequent cause for it was a deficient clinical evaluation.

[Indications and diagnosis efficiency of lumbar puncture in emergencies]. / Indicaciones y rendimiento diagnóstico de la punción lumbar en urgencias.

BACKGROUND: To know the frequency, indications and diagnosis efficiency of lumbar puncture (LP) in the Emergency Department (ED) when suspecting a central nervous system (CNS) infection. PATIENTS AND METHOD: We analyzed all the LP performed over a 2-year period in the ED. We compared the clinical characteristics of patients with and without CNS infection. We also reviewed all the cases of CNS infection diagnosed in the hospital in the same period. RESULTS: A LP was performed in 0.4% of emergencies. In 76% of cases, it was performed because of CNS infection suspicion, which was confirmed in 30% of cases. Fever, headache, nuchal rigidity and chronical otitis were all clinical variables associated with CNS infection. An 80% of CNS infections that were not diagnosed in the ED corresponded to HIV-infected patients. CONCLUSIONS: Lumbar puncture is frequently performed in the ED, mostly for suspicion of CNS infection, which is eventually confirmed in one third of cases. CNS infection cases which have not been suspected in the ED usually correspond to a subacute meningitis in a HIV-infected patient.