RESUMEN

BACKGROUND: The overburdening of the healthcare system during the coronavirus disease 19 (COVID-19) pandemic is driving the need to create new tools to improve the management of inter-hospital transport for patients with a severe COVID-19 infection. OBJECTIVE: The aim of this study was to analyse the usefulness of the application of a prioritization score (IHTCOVID-19) for inter-hospital transfer of patients with COVID-19 infection. METHODS: The study has a quasi-experimental design and was conducted on the Medical Emergency System, the pre-hospital emergency department of the public company belonging to the Autonomous Government of Catalonia that manages urgent healthcare in the region. Patients with a severe COVID-19 infection requiring inter-hospital transport were consecutively included. The pre-intervention period was from 1 to 31 March 2020, and the intervention period with the IHTCOVID-19 score was from 1 to 30 April 2020 (from 8 am to 8 pm). The prioritization score comprises four priority categories, with Priority 0 being the highest and Priority 3 being the lowest. Inter-hospital transfer (IHT) management times (alert-assignment time, resource management time and total central management time) and their variability were evaluated according to whether or not the IHTCOVID-19 score was applied. RESULTS: A total of 344 IHTs were included: 189 (54.9%) in the pre-intervention period and 155 (45.1%) in the post-intervention period. The majority of patients were male and the most frequent age range was between 50 and 70 years. According to the IHTCOVID-19 score, 12 (3.5%) transfers were classified as Priority 0, 66 (19.4%) as Priority 1, 247 (71.8%) as Priority 2 and 19 (5.6%) as Priority 3. Overall, with the application of the IHTCOVID-19 score, there was a significant reduction in total central management time [from 112.4 (inter-quartile range (IQR) 281.3) to 89.8 min (IQR 154.9); P = 0.012]. This significant reduction was observed in Priority 0 patients [286.2 (IQR 218.5) to 42.0 min (IQR 58); P = 0.018] and Priority 1 patients [130.3 (IQR 297.3) to 75.4 min (IQR 91.1); P = 0.034]. After applying the IHTCOVID-19 score, the average time of the process decreased by 22.6 min, and variability was reduced from 618.1 to 324.0 min. CONCLUSION: The application of the IHTCOVID-19 score in patients with a severe COVID-19 infection reduces IHT management times and variability.

Asunto(s)

COVID-19 , Anciano , COVID-19/epidemiología , Femenino , Hospitales , Humanos , Masculino , Persona de Mediana Edad , Administración del Tiempo

RESUMEN

OBJECTIVE: To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients. METHODS-DESIGN: A prospective randomized study was carried out. Setting: A 16-bed clinical-surgical ICU (July 2007-February 2009). Interventions: Patients were randomly assigned to one of two groups at the time CR-BSI was suspected. In the standard group, a standard strategy requiring catheter withdrawal was used to confirm or rule out CR-BSI. In the DTP group, DTP without catheter withdrawal was used to confirm or rule out CR-BSI. Measurements: clinical and microbiological data, CR-BSI rates, unnecessary catheter removals, and complications due to new puncture or to delays in catheter removal. RESULTS: Twenty-six patients were analyzed in each group. In the standard group, 6 of 37 suspected episodes of CR-BSI were confirmed and 5 colonizations were diagnosed. In the DTP group, 5 of 26 suspected episodes of CR-BSI were confirmed and four colonizations were diagnosed. In the standard group, all catheters (58/58, 100%) were removed at the time CR-BSA was suspected, whereas in the DTP group, only 13 catheters (13/41, 32%) were removed at diagnosis, and 10 due to persistent septic signs (10/41, 24%). In cases of confirmed CR-BSI, there were no differences between the two groups in the evolution of inflammatory parameters during the 48hours following the suspicion of CR-BSI. CONCLUSIONS: In critically ill patients with suspected CR-BSI, the DTP method makes it possible to keep the central venous catheter in place safely

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OBJETIVO: Evaluar la utilidad clínica y la seguridad de la diferencia del tiempo de positivización (DTP) de hemocultivos en el manejo de la sospecha de bacteriemia asociada a catéter (BAC) comparándola con un método estándar que incluye la retirada de catéter en los pacientes de cuidados intensivos. MÉTODOS-DISEÑO: Estudio prospectivo aleatorizado. ÁMBITO: UCI médico-quirúrgica de 16 camas (julio de 2007-febrero de 2009). Intervención: aleatorización en 2 ramas de los pacientes en el momento de la sospecha de BAC. GRUPO ESTÁNDAR: estrategia clásica que requiere la retirada de catéter para descartar o confirmar la BAC; grupo DTP: método DTP sin retirada de catéter que confirma o descarta la BAC. Variables: datos clínicos y microbiológicos, tasas de BAC, recambios innecesarios de catéteres, complicaciones debidas al recambio de catéter o al retraso en el recambio de catéter. RESULTADOS: Veintiséis pacientes fueron estudiados en cada grupo. En el grupo estándar 6 de los 37 episodios de sospecha de BAC fueron confirmados y 5 colonizaciones de catéter fueron diagnosticadas. En el grupo DTP 5 de los 26 episodios de BAC fueron confirmados y 4 colonizaciones diagnosticadas. En el grupo estándar todos los catéteres (58/58, 100%) se retiraron en el momento de la sospecha de BAC, mientras que en el grupo DTP solo 13 catéteres (13/41, 32%) se retiraron en el momento del diagnóstico y 10 por persistencia de signos inflamatorios (10/41, 24%). En los casos de BAC confirmada no se encontraron diferencias en la evolución de los parámetros inflamatorios en las 48 h que siguieron la sospecha de BAC. CONCLUSIONES: En los pacientes críticos con sospecha de BAC el método DTP permite mantener los catéteres venosos centrales de forma segura

Asunto(s)

Humanos , Infecciones Relacionadas con Catéteres/epidemiología , Cateterismo Venoso Central/efectos adversos , Bacteriemia/epidemiología , 24959/métodos , Cuidados Críticos , Cuidados Críticos , Pruebas de Sensibilidad Microbiana , Técnicas Microbiológicas

RESUMEN

OBJECTIVE: To evaluate the clinical usefulness and safety of the differential-time-to-positivity (DTP) method for managing the suspicion of catheter-related bloodstream infection (CR-BSI) in comparison with a standard method that includes catheter removal in critically ill patients. METHODS-DESIGN: A prospective randomized study was carried out. SETTING: A 16-bed clinical-surgical ICU (July 2007-February 2009). INTERVENTIONS: Patients were randomly assigned to one of two groups at the time CR-BSI was suspected. In the standard group, a standard strategy requiring catheter withdrawal was used to confirm or rule out CR-BSI. In the DTP group, DTP without catheter withdrawal was used to confirm or rule out CR-BSI. MEASUREMENTS: clinical and microbiological data, CR-BSI rates, unnecessary catheter removals, and complications due to new puncture or to delays in catheter removal. RESULTS: Twenty-six patients were analyzed in each group. In the standard group, 6 of 37 suspected episodes of CR-BSI were confirmed and 5 colonizations were diagnosed. In the DTP group, 5 of 26 suspected episodes of CR-BSI were confirmed and four colonizations were diagnosed. In the standard group, all catheters (58/58, 100%) were removed at the time CR-BSA was suspected, whereas in the DTP group, only 13 catheters (13/41, 32%) were removed at diagnosis, and 10 due to persistent septic signs (10/41, 24%). In cases of confirmed CR-BSI, there were no differences between the two groups in the evolution of inflammatory parameters during the 48hours following the suspicion of CR-BSI. CONCLUSIONS: In critically ill patients with suspected CR-BSI, the DTP method makes it possible to keep the central venous catheter in place safely.

Asunto(s)

Técnicas Bacteriológicas , Sangre/microbiología , Infecciones Relacionadas con Catéteres/diagnóstico , Cateterismo Venoso Central/efectos adversos , Catéteres de Permanencia/microbiología , Adulto , Anciano , Infecciones Relacionadas con Catéteres/sangre , Infecciones Relacionadas con Catéteres/microbiología , Remoción de Dispositivos , Enterobacter cloacae/aislamiento & purificación , Infecciones por Enterobacteriaceae/diagnóstico , Infecciones por Enterobacteriaceae/etiología , Infecciones por Enterobacteriaceae/microbiología , Femenino , Humanos , Unidades de Cuidados Intensivos , Tiempo de Internación/estadística & datos numéricos , Masculino , Staphylococcus aureus Resistente a Meticilina/aislamiento & purificación , Persona de Mediana Edad , Estudios Prospectivos , Infecciones por Pseudomonas/diagnóstico , Infecciones por Pseudomonas/etiología , Infecciones por Pseudomonas/microbiología , Infecciones Estafilocócicas/diagnóstico , Infecciones Estafilocócicas/etiología , Infecciones Estafilocócicas/microbiología , Factores de Tiempo , Resultado del Tratamiento , Procedimientos Innecesarios

RESUMEN

BACKGROUND: We compared the ability of noninvasive measurements of cardiac output (CO) and thoracic fluid content (TFC) and their change in response to orthostatic challenges to diagnose acute decompensate heart failure (ADHF) from non-ADHF causes of acute dyspnea in patients in the ED. METHODS: Forty-five patients > 44 years old presenting in the ED with dyspnea were studied. CO and TFC were monitored with a NICOM bioreactance device. CO and TFC were measured continuously while each patient was sitting, supine, and during a passive leg-raising maneuver (3 min each); the maximal values during each maneuver were reported. Orthostatic challenges were repeated 2 h into treatment. One patient was excluded because of intolerance to the supine position. Diagnoses obtained with the hemodynamic measurements were compared with ED diagnoses and with two expert physicians by chart review (used as gold standard diagnosis); both groups were blinded to CO and TFC values. Patient's treatment, ED disposition, hospital length of stay, and subjective dyspnea (Borg scale) were also recorded. RESULTS: Sixteen of 44 patients received a diagnosis of ADHF and 28 received a diagnosis of non-ADHF by the experts. Baseline TFC was higher in patients with ADHF (P = .001). Fifteen patients were treated for ADHF, and their Borg scale values decreased at 2 h (P < .05). TFC threshold of 78.8 had a receiver operator characteristic area under the curve of 0.81 (76% sensitivity, 71% specificity) for ADHF. Both ADHF and non-ADHF groups were similar in their increased CO from baseline to PLR and supine. Pre- and posttreatment measurements were similar. CONCLUSIONS: Baseline TFC can discriminate patients with ADHF from non-ADHF dyspnea in the ED.

Asunto(s)

Disnea/diagnóstico , Servicio de Urgencia en Hospital , Insuficiencia Cardíaca/diagnóstico , Monitoreo Fisiológico/instrumentación , Enfermedad Aguda , Adulto , Líquidos Corporales/metabolismo , Gasto Cardíaco , Disnea/fisiopatología , Femenino , Insuficiencia Cardíaca/fisiopatología , Hemodinámica , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Péptido Natriurético Encefálico/metabolismo , Postura/fisiología , Sensibilidad y Especificidad

RESUMEN

Recent interest in functional hemodynamic monitoring for the bedside assessment of cardiovascular insufficiency has heightened. Functional hemodynamic monitoring is the assessment of the dynamic interactions of hemodynamic variables in response to a defined perturbation. Accordingly, fluid responsiveness can be predicted in a quantities fashion by measuring as arterial pulse pressure variation and left ventricular stroke volume variation during positive pressure breathing or the change in cardiac output response to a passive leg raising maneuver. However, volume responsiveness, though important, reflects only part of the overall spectrum of functional physiological variables that can be measured to define physiologic state and monitor response to therapy. Dynamic tissue O2 saturation (StO2) responses to complete stop flow conditions, which can be created by measuring hand StO2 and occluding flow with a blood pressure cuff, assesses cardiovascular sufficiency and microcirculatory blood flow distribution. Furthermore, these measures can be made increasingly more sensitive and specific if coupled to other "traditional" measures of organ perfusion, such as blood lactate levels.