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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Millions of surgical operations involving different levels of risk are performed each year throughout the world&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Ten percent of these operations imply a high risk of complications&#44; representing 80&#37; of all postoperative deaths&#44; or three million fatalities each year&#46; Furthermore&#44; many survivors discharged from hospital experience adverse events that leave functional sequelae and shorten long-term survival&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The demographic data of surgical patients show them to be progressively older and with increased comorbidities &#8211; a situation that can have a significant negative impact upon the surgical outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Quality postoperative care&#44; understood as a global process&#44; is essential in order to improve the surgical outcomes&#46; It includes adequate preoperative evaluation&#44; optimization of coexisting medical disease&#44; clinical practice referred to the surgical procedure&#44; surgical checklists&#44; advanced hemodynamic monitoring during surgery&#44; the management of acute pain&#44; early admission to the Intensive Care Unit &#40;ICU&#41; in high risk cases&#44; effective monitoring of vital signs after conventional hospital discharge&#44; rapid response teams for dealing with situations of clinical deterioration&#44; adequate rehabilitation and the joint planning of hospital discharge with primary care&#46; Data recording and the auditing of outcomes are key elements for improving quality&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The European Surgical Outcomes Study &#40;EuSOS&#41;&#44; an international initiative conducted in 28 European countries with the participation of 498 hospitals and 46&#44;539 patients with the purpose of assessing the outcomes of non-cardiac surgery in Europe&#44; recorded a higher than expected mortality rate &#40;4&#37;&#41;&#46; In this study only 5&#37; of the patients were admitted to the ICU on a scheduled or elective basis&#46; Emergency admission to the ICU was associated to greater mortality than elective admission&#46; Surprisingly&#44; most of the patients that died &#40;73&#37;&#41; were never admitted to the ICU after surgery&#44; and of those who were admitted to the ICU&#44; 43&#37; died after being discharged to the hospital ward&#46; These findings suggest that there is a deficient assignment of critical care resources&#44; as well as failure to rescue surgical patients that suffer worsening in the ward&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this number of Medicina Intensiva&#44; de Nadal et al&#46; present the results of an <span class="elsevierStyleItalic">ad hoc</span> analysis of the EuSOS&#46; The aim of the study was to evaluate patient age as an independent factor conditioning admission to the ICU after non-cardiac surgery in Spain&#44; as well as to explore the factors associated to elderly patient admission to the ICU and in-hospital mortality&#46; A total of 5412 patients were included&#44; of which 677 &#40;12&#46;5&#37;&#41; were admitted to the ICU after surgery&#46; The main findings of the study were that elderly patients &#40;over 80 years of age&#41; were more likely to enter the ICU after surgery&#44; though this was not associated to increased postoperative mortality after 60 days&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> Likewise in this study&#44; most of the patients that died &#40;69&#37;&#41; had never been admitted to the ICU&#46; With regard to the possible factors underlying lesser elderly patient admission to the ICU&#44; the authors cited a certain inaccuracy in the definition of the evaluated resources&#59; an important percentage of patients with hip fractures &#40;commonly not considered for elective admission to intensive care&#41;&#59; and the possibility that such patients may have been subject to limitation of life support measures or had undergone palliative oncological surgery &#8211; though these circumstances were not supported by the epidemiological characteristics of the series&#46; The main limitations of the study were failure to consider the concept of frailty&#59; no evaluation of postoperative adverse events except mortality&#59; no consideration of organizational models or resources in the hospital ward&#59; and failure to consider long-term mortality&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Elective admission of high risk surgical patients to the ICU has been questioned by some studies&#44; probably in relation to the different organization models &#40;open and closed ICUs&#41; and the availability of resources &#40;beds and intensive care professionals&#41; found in different countries&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In Spain&#44; where over 70&#37; of all critical care beds are assigned to Departments of Intensive Care Medicine &#40;DICMs&#41;&#44; high risk surgical patients are more often admitted to the ICU than in other countries &#40;12&#46;5&#37; versus 8&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study questions whether elderly patients experience limited access to the ICU&#44; and whether this has an impact upon the outcomes&#46; Recent guides have established that chronological age should not be the criterion deciding where the patient is to be admitted&#59; rather&#44; the applicable criteria are comorbidity&#44; seriousness of the disease&#44; previous performance status&#44; and patient preferences&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of intensive care medicine is to offer patients quality care adapted to their needs and provided in the safest way possible &#8211; guaranteeing adequacy&#44; sustainability&#44; ethics and respect for personal autonomy&#46; Extended Departments of Intensive Care Medicine and the ICU without walls model address the need for a broader and more balanced approach in critical patients&#44; classifying them according to the care needed&#44; rather than to the place of admission&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Guaranteeing improved outcomes in surgical patients requires DICMs to oversee care throughout the process&#46; The creation of rapid response teams and the ICU without walls model &#40;teamwork involving different professionals and the automatic detection of severity&#44; integrating clinical and laboratory test data&#41; improve the outcomes and avoid unnecessary admissions of patients with established limitation of care measures&#46; Innovation in management through industry-derived tools such as Lean techniques &#40;based on reducing process variability and suppressing those elements which lack added value&#41;&#44; and coordinated and multidisciplinary work result in improved patient care&#44; with better outcomes&#44; efficiency&#44; patient safety and satisfaction on the part of the professionals&#46; Such strategies have been shown to reduce delays in discharge from the ICU to the hospital ward&#44; and this in turn can reduce the number of elective surgical patient admissions canceled due to a lack of ICU beds&#44; as well as reduce unscheduled discharges that pose an increased risk for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Lastly&#44; DICMs can contribute value to the surgical process in chronic critical patients through follow-up in the ward after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The evaluation of these integrated management models through specific registries is necessary in order to ensure that surgical patients receive safe&#44; effective and efficient care&#46;</p></span>"
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Editorial
Intensive medicine services. How to add value to the surgical process?
Servicios de medicina intensiva. ¿Cómo aportar valor al proceso quirúrgico?
M.C. Martín Delgadoa,
Corresponding author
mcmartindelgado@gmail.com

Corresponding author.
, F. Gordo Vidalb
a Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain
b Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada, Madrid, Spain
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understood as a global process&#44; is essential in order to improve the surgical outcomes&#46; It includes adequate preoperative evaluation&#44; optimization of coexisting medical disease&#44; clinical practice referred to the surgical procedure&#44; surgical checklists&#44; advanced hemodynamic monitoring during surgery&#44; the management of acute pain&#44; early admission to the Intensive Care Unit &#40;ICU&#41; in high risk cases&#44; effective monitoring of vital signs after conventional hospital discharge&#44; rapid response teams for dealing with situations of clinical deterioration&#44; adequate rehabilitation and the joint planning of hospital discharge with primary care&#46; Data recording and the auditing of outcomes are key elements for improving quality&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The European Surgical Outcomes Study &#40;EuSOS&#41;&#44; an international initiative conducted in 28 European countries with the participation of 498 hospitals and 46&#44;539 patients with the purpose of assessing the outcomes of non-cardiac surgery in Europe&#44; recorded a higher than expected mortality rate &#40;4&#37;&#41;&#46; In this study only 5&#37; of the patients were admitted to the ICU on a scheduled or elective basis&#46; Emergency admission to the ICU was associated to greater mortality than elective admission&#46; Surprisingly&#44; most of the patients that died &#40;73&#37;&#41; were never admitted to the ICU after surgery&#44; and of those who were admitted to the ICU&#44; 43&#37; died after being discharged to the hospital ward&#46; These findings suggest that there is a deficient assignment of critical care resources&#44; as well as failure to rescue surgical patients that suffer worsening in the ward&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In this number of Medicina Intensiva&#44; de Nadal et al&#46; present the results of an <span class="elsevierStyleItalic">ad hoc</span> analysis of the EuSOS&#46; The aim of the study was to evaluate patient age as an independent factor conditioning admission to the ICU after non-cardiac surgery in Spain&#44; 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though these circumstances were not supported by the epidemiological characteristics of the series&#46; The main limitations of the study were failure to consider the concept of frailty&#59; no evaluation of postoperative adverse events except mortality&#59; no consideration of organizational models or resources in the hospital ward&#59; and failure to consider long-term mortality&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Elective admission of high risk surgical patients to the ICU has been questioned by some studies&#44; probably in relation to the different organization models &#40;open and closed ICUs&#41; and the availability of resources &#40;beds and intensive care professionals&#41; found in different countries&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In Spain&#44; where over 70&#37; of all critical care beds are assigned to Departments of Intensive Care Medicine &#40;DICMs&#41;&#44; high risk surgical patients are more often admitted to the ICU than in other countries &#40;12&#46;5&#37; versus 8&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The study questions whether elderly patients experience limited access to the ICU&#44; and whether this has an impact upon the outcomes&#46; Recent guides have established that chronological age should not be the criterion deciding where the patient is to be admitted&#59; rather&#44; the applicable criteria are comorbidity&#44; seriousness of the disease&#44; previous performance status&#44; and patient preferences&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The aim of intensive care medicine is to offer patients quality care adapted to their needs and provided in the safest way possible &#8211; guaranteeing adequacy&#44; sustainability&#44; ethics and respect for personal autonomy&#46; Extended Departments of Intensive Care Medicine and the ICU without walls model address the need for a broader and more balanced approach in critical patients&#44; classifying them according to the care needed&#44; rather than to the place of admission&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Guaranteeing improved outcomes in surgical patients requires DICMs to oversee care throughout the process&#46; The creation of rapid response teams and the ICU without walls model &#40;teamwork involving different professionals and the automatic detection of severity&#44; integrating clinical and laboratory test data&#41; improve the outcomes and avoid unnecessary admissions of patients with established limitation of care measures&#46; Innovation in management through industry-derived tools such as Lean techniques &#40;based on reducing process variability and suppressing those elements which lack added value&#41;&#44; and coordinated and multidisciplinary work result in improved patient care&#44; with better outcomes&#44; efficiency&#44; patient safety and satisfaction on the part of the professionals&#46; Such strategies have been shown to reduce delays in discharge from the ICU to the hospital ward&#44; and this in turn can reduce the number of elective surgical patient admissions canceled due to a lack of ICU beds&#44; as well as reduce unscheduled discharges that pose an increased risk for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Lastly&#44; DICMs can contribute value to the surgical process in chronic critical patients through follow-up in the ward after discharge&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The evaluation of these integrated management models through specific registries is necessary in order to ensure that surgical patients receive safe&#44; effective and efficient care&#46;</p></span>"
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