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Aguilera B. Ethical allocation of scarce health care resources in the context of the COVID-19 crisis. Medwave 2020; 20:e7935. [DOI: 10.5867/medwave.2020.05.7935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/06/2020] [Indexed: 11/27/2022] Open
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González de Molina Ortiz FJ, Gordo Vidal F, Estella García A, Morrondo Valdeolmillos P, Fernández Ortega JF, Caballero López J, Pérez Villares PV, Ballesteros Sanz MA, de Haro López C, Sanchez-Izquierdo Riera JA, Serrano Lázaro A, Fuset Cabanes MP, Terceros Almanza LJ, Nuvials Casals X, Baldirà Martínez de Irujo J. "Do not do" recommendations of the working groups of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) for the management of critically ill patients. Med Intensiva 2018; 42:425-443. [PMID: 29789183 DOI: 10.1016/j.medin.2018.04.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/24/2018] [Accepted: 04/02/2018] [Indexed: 02/06/2023]
Abstract
The project "Commitment to Quality of Scientific Societies", promoted since 2013 by the Spanish Ministry of Health, seeks to reduce unnecessary health interventions that have not proven effective, have little or doubtful effectiveness, or are not cost-effective. The objective is to establish the "do not do" recommendations for the management of critically ill patients. A panel of experts from the 13 working groups (WGs) of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) was selected and nominated by virtue of clinical expertise and/or scientific experience to carry out the recommendations. Available scientific literature in the management of adult critically ill patients from 2000 to 2017 was extracted. The clinical evidence was discussed and summarized by the experts in the course of consensus finding of each WG, and was finally approved by the WGs after an extensive internal review process carried out during the first semester of 2017. A total of 65 recommendations were developed, of which 5 corresponded to each of the 13 WGs. These recommendations are based on the opinion of experts and scientific knowledge, and aim to reduce those treatments or procedures that do not add value to the care process; avoid the exposure of critical patients to potential risks; and improve the adequacy of health resources.
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Affiliation(s)
- F J González de Molina Ortiz
- Servicio de Medicina Intensiva, Hospital Universitario Mutua Terrassa, Barcelona, España; Servicio de Medicina Intensiva, Hospital Universitario Quirón Dexeus, Barcelona, España.
| | - F Gordo Vidal
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, España
| | - A Estella García
- Servicio de Medicina Intensiva, Hospital del SAS de Jerez, Jerez, Cádiz, España
| | - P Morrondo Valdeolmillos
- Servicio de Medicina Intensiva, Hospital Universitario Donostia, San Sebastián, Guipúzcoa, España
| | - J F Fernández Ortega
- Servicio de Medicina Intensiva, Complejo Hospitalario Carlos Haya, Málaga, España
| | - J Caballero López
- Servicio de Medicina Intensiva, Hospital Universitario Arnau de Vilanova, Lleida, España
| | - P V Pérez Villares
- Servicio de Medicina Intensiva, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M A Ballesteros Sanz
- Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, España
| | - C de Haro López
- Servicio de Medicina Intensiva, Corporació Sanitària Parc Taulí, Sabadell, Barcelona, España
| | | | - A Serrano Lázaro
- Servicio de Medicina Intensiva, Hospital Clínico Universitario, Valencia, España
| | - M P Fuset Cabanes
- Servicio de Medicina Intensiva, Hospital Universitari i Politècnic la Fe, Valencia, España
| | - L J Terceros Almanza
- Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre, Madrid, España
| | - X Nuvials Casals
- Servicio de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Barcelona, España
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Ruiz-Ramos J, Frasquet J, Romá E, Poveda-Andres JL, Salavert-Leti M, Castellanos A, Ramirez P. Cost-effectiveness analysis of implementing an antimicrobial stewardship program in critical care units. J Med Econ 2017; 20:652-659. [PMID: 28345481 DOI: 10.1080/13696998.2017.1311903] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIMS To evaluate the cost-effectiveness of antimicrobial stewardship (AS) program implementation focused on critical care units based on assumptions for the Spanish setting. MATERIALS AND METHODS A decision model comparing costs and outcomes of sepsis, community-acquired pneumonia, and nosocomial infections (including catheter-related bacteremia, urinary tract infection, and ventilator-associated pneumonia) in critical care units with or without an AS was designed. Model variables and costs, along with their distributions, were obtained from the literature. The study was performed from the Spanish National Health System (NHS) perspective, including only direct costs. The Incremental Cost-Effectiveness Ratio (ICER) was analysed regarding the ability of the program to reduce multi-drug resistant bacteria. Uncertainty in ICERs was evaluated with probabilistic sensitivity analyses. RESULTS In the short-term, implementing an AS reduces the consumption of antimicrobials with a net benefit of €71,738. In the long-term, the maintenance of the program involves an additional cost to the system of €107,569. Cost per avoided resistance was €7,342, and cost-per-life-years gained (LYG) was €9,788. Results from the probabilistic sensitivity analysis showed that there was a more than 90% likelihood that an AS would be cost-effective at a level of €8,000 per LYG. LIMITATIONS Wide variability of economic results obtained from the implementation of this type of AS program and short information on their impact on patient evolution and any resistance avoided. CONCLUSIONS Implementing an AS focusing on critical care patients is a long-term cost-effective tool. Implementation costs are amortized by reducing antimicrobial consumption to prevent infection by multidrug-resistant pathogens.
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Affiliation(s)
- Jesus Ruiz-Ramos
- a Intensive Care Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Juan Frasquet
- b Microbiology Department , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Eva Romá
- c Pharmacy Department , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | | | - Miguel Salavert-Leti
- d Infectious Disease Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Alvaro Castellanos
- a Intensive Care Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
| | - Paula Ramirez
- a Intensive Care Unit , Hospital Universitario y Politecnico La Fe , Valencia , Spain
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Innovation in the management of intensive care units: This is the right time. Med Intensiva 2016; 40:263-5. [PMID: 27262446 DOI: 10.1016/j.medin.2016.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/16/2016] [Accepted: 04/18/2016] [Indexed: 11/23/2022]
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Sirvent JM, Gil M, Alvarez T, Martin S, Vila N, Colomer M, March E, Loma-Osorio P, Metje T. Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit of a reference hospital. Med Intensiva 2015; 40:266-72. [PMID: 26560019 DOI: 10.1016/j.medin.2015.08.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/19/2015] [Accepted: 08/03/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To analyze whether the application of Lean techniques to improve the flow of critically ill patients in a health region with its epicenter in the intensive care unit (ICU) of a reference hospital. DESIGN Observational study with pre and post intervention analysis. SETTING ICU of a reference hospital. PATIENTS We design projects and a value stream map of flow and compared pre and post intervention. INTERVENTIONS We recorded demographic data, patient transfers by EMS for lack of beds and delay times in the discharge from ICU to ward. Multidisciplinary meetings and perform daily visual panel, with high priority ICU discharge. We promote temporary relocation of critically ill patients in other special areas of the hospital. We performed a professional satisfaction questionnaire with pre and post implementation of process. We make a statistical analysis of pre and post-intervention comparisons. RESULTS We planned for 2013 and progressively implemented in 2014. Analysis of patients entering the critical process flow 1) evaluate patients who must transfer for lack of beds, focusing on a diagnosis: pre 10/22 vs. 3/21 post (P=.045); 2) analysis of time delay in the discharge from the ICU to ward: 360.8±163.9minutes in the first period vs. 276.7±149.5 in the second (P=.036); and 3) personal professional satisfaction questionnaire, with 6.6±1.5 points pre vs. 7.5±1.1 in post (P=.001). Analysis of indicators such as the ICU acquired infections, length of ICU stay, the rate of re-admissions and mortality, with no significant differences between the two periods. CONCLUSIONS The application of Lean techniques in the critically ill process had a positive impact on improving patient flow within the health region, noting a decrease of transfers outside the region due to lack of beds, reduced delayed discharge from ICU to conventional ward and increased satisfaction of ICU professionals.
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Affiliation(s)
- J M Sirvent
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España.
| | - M Gil
- Actio-Consulting, Barcelona, España
| | - T Alvarez
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - S Martin
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - N Vila
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - M Colomer
- Servicio de Medicina Intensiva (UCI), Hospital Universitari de Girona Doctor Josep Trueta, Grupo de Microbiología e Infección, IDIBGI, CIBERES, Girona, España
| | - E March
- Secretaría Técnica, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - P Loma-Osorio
- Servicio de Cardiología, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
| | - T Metje
- Servicio de Anestesiología, Hospital Universitari de Girona Doctor Josep Trueta, Girona, España
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Lopera Betancur MA. Cuidados al final de la vida: una oportunidad para fortalecer el patrón emancipatorio de enfermería. AVANCES EN ENFERMERÍA 2015. [DOI: 10.15446/av.enferm.v33n1.37514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
<p class="MsoNormal"><span><span style="font-size: 10pt; line-height: 115%; font-family: Arial, sans-serif; background-position: initial initial; background-repeat: initial initial;">El objetivo es analizar parte de la situación que viven los pacientes con enfermedad en fase terminal en el marco del sistema de salud colombiano y el papel de las enfermeras.<br />La ley 100 de 1993 trajo cambios, uno de los cuales está relacionado con el cuidado a los enfermos terminales, el otro, con el papel de las enfermeras. Este artículo explora los conceptos de los cuidados paliativos y qué ha pasado en Colombia con este mecanismo legal y con el rol de la enfermera.</span></span></p><p class="MsoNormal"><span><span style="font-size: 10pt; line-height: 115%; font-family: Arial, sans-serif; background-position: initial initial; background-repeat: initial initial;">Conclusión: Las enfermeras pueden ser claves al aplicar el patrón de conocimiento emancipatorio, en el cuidado en la adversidad, la abogacía y el empoderamiento de los derechos<br />de los pacientes, así como en la definición de políticas.</span></span></p><div> </div>
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Fernandez R. Occupancy of the Departments of Intensive Care Medicine in Catalonia (Spain): A prospective, analytical cohort study. Med Intensiva 2015; 39:537-42. [PMID: 25573190 DOI: 10.1016/j.medin.2014.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 11/10/2014] [Accepted: 11/11/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Before deciding increases in the number or capacitance of Intensive Care Units (ICUs), or the regionalization of Units, it is essential to know their present effectiveness. OBJECTIVE To analyze the daily occupancy rate of ICUs in Catalonia (Spain) and the frequency of denied admission due to lack of capacity. DESIGN A prospective, observational multicenter study was carried out. PARTICIPANTS A total of 35 out of 40 ICUs of Catalonia (87%). INTERVENTIONS Daily registry. VARIABLES OF INTEREST Open beds and free beds, patients not discharged due to unavailability of ward beds, critically ill patients not admitted due to a lack of ICU beds, and rate of transfer to other ICUs. STATISTICAL ANALYSIS A descriptive cohort analysis was made. RESULTS Daily averages were 383 open ICU beds, 58 available beds (15%), and 16 patients not discharged due to unavailability of ward beds. Each day 6 patients on average were not admitted due to a lack of ICU beds, and one of them (16%) was transferred to another ICU. The mean occupancy rate was 83±19%, and a 100% occupancy rate was reported in 35% of the registries. A subanalysis of the 24 public hospitals demonstrated slightly higher occupancy (87±16%), with a 100% occupancy rate reported in 38% of the registries. CONCLUSIONS The mean occupancy rate of Catalonian ICUs may appear correct, but in some Units over-occupancy very often precludes early ICU treatment and even ICU admission for a significant number of critically ill patients.
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Affiliation(s)
- R Fernandez
- Servicio de Medicina Intensiva, Hospital Sant Joan de Déu, Fundació Althaia, CIBERES, Universitat Internacional de Catalunya, Manresa, España.
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Gordo F, Abella A. Intensive care unit without walls: seeking patient safety by improving the efficiency of the system. Med Intensiva 2014; 38:438-43. [PMID: 24661919 DOI: 10.1016/j.medin.2014.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 02/10/2014] [Indexed: 12/11/2022]
Abstract
The term "ICU without walls" refers to innovative management in Intensive Care, based on two key elements: (1) collaboration of all medical and nursing staff involved in patient care during hospitalization and (2) technological support for severity early detection protocols by identifying patients at risk of deterioration throughout the hospital, based on the assessment of vital signs and/or laboratory test values, with the clear aim of improving critical patient safety in the hospitalization process. At present, it can be affirmed that there is important work to be done in the detection of severity and early intervention in patients at risk of organ dysfunction. Such work must be adapted to the circumstances of each center and should include training in the detection of severity, multidisciplinary work in the complete patient clinical process, and the use of technological systems allowing intervention on the basis of monitored laboratory and physiological parameters, with effective and efficient use of the information generated. Not only must information be generated, but also efficient management of such information must also be achieved. It is necessary to improve our activity through innovation in management procedures that facilitate the work of the intensivist, in collaboration with other specialists, throughout the hospital environment. Innovation is furthermore required in the efficient management of the information generated in hospitals, through intelligent and directed usage of the new available technology.
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Affiliation(s)
- F Gordo
- Intensive Care Medicine, Hospital Universitario del Henares, Coslada, Madrid, Spain; Francisco de Vitoria University, Madrid, Spain.
| | - A Abella
- Intensive Care Medicine, Hospital Universitario del Henares, Coslada, Madrid, Spain
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Rubio O, Sánchez JM, Fernández R. [Life-sustaining treatment limitation criteria upon admission to the intensive care unit: results of a Spanish national multicenter survey]. Med Intensiva 2012; 37:333-8. [PMID: 22959596 DOI: 10.1016/j.medin.2012.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/15/2012] [Accepted: 06/16/2012] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the life-sustaining treatment limitation (LSTL) predisposition upon patient admission to the intensive care unit (ICU), the criteria upon which such predisposition is based, and whether these decisions are related to structural factors of the surveyed hospitals. DESIGN A descriptive multicenter study was made in 2010, involving the conduction of a survey in 90 hospitals, with a view to documenting the usual practice referred to LSTL upon admission in these centers. SETTING Spanish ICUs. INTERVENTION Opinion survey. MAIN VARIABLES OF INTEREST Type of hospital, number of hospital beds, ICU and semicritical patient beds, usual bed availability in the ICU, use of restrictive admission criteria, use of LSTL criteria upon admission, and type of criterion used to decide LSTL. RESULTS A total of 43 (48%) hospitals participated in the study, with LSTL being a common practice in these centers (93%). LSTL was fundamentally decided on the basis of the presence of prior severe chronic disease (95%), observation of previously declared patient will (95%), prior functional limitation (85%), and qualitative futility of care (82%). Frequent ICU bed availability (77% of the hospitals) and the use of restrictive criteria (79% of the hospitals) were also associated to patient admission with LSTL. CONCLUSIONS Admission to ICU with LSTL is a generalized practice in Spanish Hospitals. LSTL is decided based on physiological futility from an objective medical point of view, but also in observance of ethical and moral implications based on the qualitative futility of medical care.
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Affiliation(s)
- O Rubio
- Servicio de Medicina Intensiva, Hospital Sant Joan de Déu, Manresa, Barcelona, España.
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[The ritual of the lack of beds "upstream"]. Med Intensiva 2011; 35:589. [PMID: 21917359 DOI: 10.1016/j.medin.2011.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Accepted: 07/20/2011] [Indexed: 11/21/2022]
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