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paradas cardiorrespiratorias y ocasionalmente&#44; estimando su repercusi&#243;n en mortalidad e ingresos<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo de esta carta cient&#237;fica es&#44; a partir del registro de actividad de nuestro SRR&#44; analizar la magnitud pron&#243;stica de varias definiciones de alerta tard&#237;a &#40;AT&#41; para ingresar en SMI y justificar su c&#225;lculo como indicador de calidad que identifique situaciones de mejora y desviaciones de la pr&#225;ctica estandarizada&#46; Pertenece a un hospital de nivel terciario&#44; con dos sedes que suman 800 camas &#40;35 de SMI&#41;&#44; 41&#46;500 ingresos anuales &#40;2&#46;000 en SMI&#41; y 200&#46;000 estancias&#46; Se implementa desde el 2012 en cualquier &#225;rea hospitalaria &#40;excepto SMI&#44; pediatr&#237;a y quir&#243;fano&#41;&#46; Se activa mediante la evaluaci&#243;n cl&#237;nica de enfermer&#237;a y el registro en la historia cl&#237;nica informatizada de valores fuera de rango de constantes vitales que sobreimpresionan en pantalla un mensaje de situaci&#243;n de riesgo y sugiere avisar al m&#233;dico responsable&#44; para activar al intensivista si lo cree indicado&#46; Si el primero no se localiza&#44; o en sospecha de extrema gravedad&#44; enfermer&#237;a avisa al intensivista&#46; Todas las valoraciones de intensivos se registran prospectivamente en una base de datos que incluye&#58; variables demogr&#225;ficas&#44; pluripatolog&#237;a &#40;dos o m&#225;s de hipertensi&#243;n&#44; diabetes&#44; enfermedad pulmonar cr&#243;nica&#44; insuficiencia renal&#44; hep&#225;tica o cardiaca&#44; neoplasia y portar traqueotom&#237;a&#41;&#44; criterio de alerta &#40;cardiocirculatorio&#44; respiratorio&#44; neurol&#243;gico&#44; v&#237;a a&#233;rea&#44; aviso por parada cardiorrespiratoria&#44; sensaci&#243;n subjetiva de gravedad de la enfermera o del m&#233;dico responsable&#41;&#44; servicio de aviso&#44; turno de trabajo y puntuaci&#243;n en la escala de paciente en riesgo&#46; Si ingresan&#44; se anota&#44; adem&#225;s&#44; estancia&#44; mortalidad en SMI&#44; APACHE<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> de 24 horas&#44; si desarrolla disfunci&#243;n multiorg&#225;nica &#40;SDMO&#41; y si es AT&#46; Seleccionamos para el an&#225;lisis tres per&#237;odos seg&#250;n evolucion&#243; nuestro SRR&#58; en el primero &#40;P1&#41;&#44; entre enero y junio de 2013&#44; usamos la escala de riesgo &#40;EPAR&#41; de Goldhill<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> con datos de una sede &#40;280 camas&#44; 17 de SMI&#41;&#59; en el segundo &#40;P2&#41;&#44; entre marzo y noviembre de 2014&#44; y el tercero &#40;P3&#41;&#44; entre mayo y junio de 2018&#44; se incluyeron las dos sedes y la escala VIEWs<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&#46; En P3 a&#241;adimos las alertas de urgencias&#46; Definimos el SDMO como la afectaci&#243;n de dos o m&#225;s &#243;rganos con puntuaci&#243;n mayor de dos en la escala SOFA<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> y la AT en P1 como EPAR<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> &#62; 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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">P1&#58; primer per&#237;odo&#46; P2&#58; segundo per&#237;odo&#46; P3&#58; tercer per&#237;odo&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AT&#58; alerta tard&#237;a&#46; p&#58; nivel de significaci&#243;n&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Md&#58; mediana&#46; RI&#58; rango intercuart&#237;lico&#46; &#37;&#58; Porcentaje&#46; Pluripat&#58; pluripatol&#243;gicos&#46; H&#58; hombres&#46; SDMO&#58; s&#237;ndrome de disfunci&#243;n multiorg&#225;nica&#46; APACHE&#58; <span class="elsevierStyleItalic">Acute Physiology and Chronic Health Evaluation II</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46; <span class="elsevierStyleItalic">Score</span>&#58; puntuaci&#243;n en escala de riesgo&#46; PCR&#58; parada cardiorrespiratoria&#46;</p>"
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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CARTA CIENTÍFICA
Alerta tardía a los sistemas de respuesta rápida: propuesta de un nuevo indicador de calidad
Delayed alert to rapid response systems: proposal of a new quality indicator
S. Castaño Ávila
Autor para correspondencia
sergio.castanoavila@osakidetza.eus

Autor para correspondencia.
, F. Fonseca San Miguel, J.A. Urturi Matos, M. Iturbe Rementería, C. Pérez Lejonagoitia, S. Iribarren Diarasarri
Servicio de Medicina Intensiva, Hospital Universitario Araba, Vitoria-Gasteiz, País Vasco, España
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        "titulo" => "Delayed alert to rapid response systems&#58; proposal of a new quality indicator"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Cada hora de retraso para ingresar en el Servicio de Medicina Intensiva &#40;SMI&#41; del paciente que lo necesita&#44; incrementa un 1&#44;5&#37; su mortalidad intra-SMI y un 1&#37; la hospitalaria<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a>&#46; Para anticipar la detecci&#243;n y el tratamiento de pacientes con agravamiento cl&#237;nico significativo&#44; se han desarrollado ligados a los SMI&#44; los sistemas de respuesta r&#225;pida &#40;SRR&#41;&#46; Aunque la calidad asistencial centra la atenci&#243;n sanitaria&#44; la Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Urgencias Coronarias &#40;SEMICYUC&#41; no tiene indicadores de calidad relacionados con su actividad<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a>&#44; que se monitoriza contando activaciones&#44; paradas cardiorrespiratorias y ocasionalmente&#44; estimando su repercusi&#243;n en mortalidad e ingresos<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#44;4</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">El objetivo de esta carta cient&#237;fica es&#44; a partir del registro de actividad de nuestro SRR&#44; analizar la magnitud pron&#243;stica de varias definiciones de alerta tard&#237;a &#40;AT&#41; para ingresar en SMI y justificar su c&#225;lculo como indicador de calidad que identifique situaciones de mejora y desviaciones de la pr&#225;ctica estandarizada&#46; Pertenece a un hospital de nivel terciario&#44; con dos sedes que suman 800 camas &#40;35 de SMI&#41;&#44; 41&#46;500 ingresos anuales &#40;2&#46;000 en SMI&#41; y 200&#46;000 estancias&#46; Se implementa desde el 2012 en cualquier &#225;rea hospitalaria &#40;excepto SMI&#44; pediatr&#237;a y quir&#243;fano&#41;&#46; Se activa mediante la evaluaci&#243;n cl&#237;nica de enfermer&#237;a y el registro en la historia cl&#237;nica informatizada de valores fuera de rango de constantes vitales que sobreimpresionan en pantalla un mensaje de situaci&#243;n de riesgo y sugiere avisar al m&#233;dico responsable&#44; para activar al intensivista si lo cree indicado&#46; Si el primero no se localiza&#44; o en sospecha de extrema gravedad&#44; enfermer&#237;a avisa al intensivista&#46; Todas las valoraciones de intensivos se registran prospectivamente en una base de datos que incluye&#58; variables demogr&#225;ficas&#44; pluripatolog&#237;a &#40;dos o m&#225;s de hipertensi&#243;n&#44; diabetes&#44; enfermedad pulmonar cr&#243;nica&#44; insuficiencia renal&#44; hep&#225;tica o cardiaca&#44; neoplasia y portar traqueotom&#237;a&#41;&#44; criterio de alerta &#40;cardiocirculatorio&#44; respiratorio&#44; neurol&#243;gico&#44; v&#237;a a&#233;rea&#44; aviso por parada cardiorrespiratoria&#44; sensaci&#243;n subjetiva de gravedad de la enfermera o del m&#233;dico responsable&#41;&#44; servicio de aviso&#44; turno de trabajo y puntuaci&#243;n en la escala de paciente en riesgo&#46; Si ingresan&#44; se anota&#44; adem&#225;s&#44; estancia&#44; mortalidad en SMI&#44; APACHE<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> de 24 horas&#44; si desarrolla disfunci&#243;n multiorg&#225;nica &#40;SDMO&#41; y si es AT&#46; Seleccionamos para el an&#225;lisis tres per&#237;odos seg&#250;n evolucion&#243; nuestro SRR&#58; en el primero &#40;P1&#41;&#44; entre enero y junio de 2013&#44; usamos la escala de riesgo &#40;EPAR&#41; de Goldhill<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> con datos de una sede &#40;280 camas&#44; 17 de SMI&#41;&#59; en el segundo &#40;P2&#41;&#44; entre marzo y noviembre de 2014&#44; y el tercero &#40;P3&#41;&#44; entre mayo y junio de 2018&#44; se incluyeron las dos sedes y la escala VIEWs<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&#46; En P3 a&#241;adimos las alertas de urgencias&#46; Definimos el SDMO como la afectaci&#243;n de dos o m&#225;s &#243;rganos con puntuaci&#243;n mayor de dos en la escala SOFA<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> y la AT en P1 como EPAR<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> &#62; 3 o &#8805; 2 en la valoraci&#243;n de la presi&#243;n arterial sist&#243;lica o la pulsioximetr&#237;a en alg&#250;n momento de los tres turnos de trabajo previos al del ingreso en SMI&#46; En P2 y P3 definimos AT con VIEWs<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> &#62; 7 en alguno de los tres turnos previos al del ingreso en SMI&#44; y si proced&#237;an de urgencias&#44; si hab&#237;an estado m&#225;s de cinco horas previamente&#46; Se compararon las AT con el resto con el test de Fisher&#44; &#967;<span class="elsevierStyleSup">2</span>&#44; U de Mann-Whitney&#44; y la odds ratio &#40;OR&#41; con p &#60; 0&#44;05&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Analizamos 244 alertas de P1&#44; 544 de P2 y 343 de P3&#46; El promedio diario de alertas fue de 0&#44;81&#44; 1&#44;87 y 2&#44;85 en cada per&#237;odo&#44; y el porcentaje de AT 13&#44;52&#44; 6&#44;3 y 6&#44;9&#37;&#46; La <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a> resume diferencias de pacientes con AT al ingreso y el resto&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">La OR de fallecimiento de pacientes con AT en P1 fue 2&#44;39 &#40;IC 95&#37; 0&#44;62-6&#44;98&#41;&#44; 4&#44;14 &#40;IC95&#37; 1&#44;84-9&#44;31&#41; en P2 y 4&#44;25 &#40;1&#44;37-13&#44;2&#41; en P3&#44; y la de SDMO de 6&#44;86 &#40;IC 2&#44;39-19&#44;71&#41; en P1 y 6&#44;14 &#40;IC 95&#37; 2&#44;5-15&#44;08&#41; en P3&#46; En resumen&#44; la AT multiplica la probabilidad de fallecer y de desarrollar SDMO&#46; El c&#225;lculo de su porcentaje facilita la comparativa de per&#237;odos y hospitales y monitoriza la calidad del brazo aferente &#40;detecci&#243;n&#41; de los SRR&#46; Establecer est&#225;ndares del indicador resulta complejo por la falta de literatura&#59; con la existente&#44; la trayectoria de implementaci&#243;n de los protocolos actuales y nuestros resultados&#44; parece deseable que el porcentaje sea menor del 20&#37;&#44; es decir&#44; que el 80&#37; de las alertas no tengan retraso<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">9&#44;10</span></a>&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicto de intereses</span><p id="par0025" class="elsevierStylePara elsevierViewall">Los autores declaran no tener ning&#250;n conflicto de intereses&#46;</p></span></span>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">P1&#58; primer per&#237;odo&#46; P2&#58; segundo per&#237;odo&#46; P3&#58; tercer per&#237;odo&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AT&#58; alerta tard&#237;a&#46; p&#58; nivel de significaci&#243;n&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Md&#58; mediana&#46; RI&#58; rango intercuart&#237;lico&#46; &#37;&#58; Porcentaje&#46; Pluripat&#58; pluripatol&#243;gicos&#46; H&#58; hombres&#46; SDMO&#58; s&#237;ndrome de disfunci&#243;n multiorg&#225;nica&#46; APACHE&#58; <span class="elsevierStyleItalic">Acute Physiology and Chronic Health Evaluation II</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a>&#46; <span class="elsevierStyleItalic">Score</span>&#58; puntuaci&#243;n en escala de riesgo&#46; PCR&#58; parada cardiorrespiratoria&#46;</p>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Criterio &#40;n&#41;</span>CardiocirculatorioSubjetivo m&#233;dicoNeurol&#243;gicoRespiratorioV&#237;a a&#233;reaPCRSubjetivo Enfermera&nbsp;\t\t\t\t\t\t\n
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