Aportaciones de la medicina preventiva y salud pública a la seguridad del paciente

La esencia de la Salud Pública es la vigilancia. Detrás da cada avance científico de la medicina hay una observación, un análisis y una toma de decisiones consecuencia de éste. La Salud Pública persigue proteger a la población minimizando los riesgos que amenazan su salud, mientras que la Medicina Preventiva intenta identificar los grupos de población que son especialmente vulnerables a riesgos específicos, para desarrollar estrategias concretas a ellos destinadas. Ambas utilizan la observación sistemática y continuada de la frecuencia, distribución y determinantes de los eventos de salud y sus tendencias

Calidad percibida del cuidado hospitalario

ResumenFundamentoSERVQUAL ha sido introducido en el sector sanitario como alternativa a las encuestas de satisfacción del paciente. SERVQUAL es uno de los cuestionarios más utilizados para medir la calidad percibida por los clientes de empresas de servicios dentro del denominado paradigma de la desconfirmación (diferencia entre expectativa y percepción del servicio). Pese a su pretendida utilidad no se ha estudiado la estructura, validez y fiabilidad de este cuestionario en el medio hospitalario de nuestro país.MétodosEste trabajo se diseñó con tres objetivos: 1) analizar la estructura factorial del SERVQUAL; 2) determinar la capacidad predictiva de las diferentes puntuaciones que de él pueden obtenerse (escala de percepciones, de expectativas, y diferencia entre expectativas y percepciones); 3) validar una versión del SERVQUAL adaptada al medio hospita lario (a la que denominamos SERVQHOS). Se diseñó un estudio descriptivo basado en encuestas con análisis multi-variante de los datos. Se entrevistó a 826 sujetos que habían sido atendidos en los hospitales de Alicante, Elche y Elda de la provincia de Alicante.ResultadosLa estructura factorial en cinco dimensiones del SERVQUAL no pudo ser confirmada. La escala de percepciones reunió mayor capacidad predictiva que la derivada de la puntuación de la diferencia entre expectativas y percepciones. Se identificaron cuatro factores en SERVQHOS (56% de varianza explicada). Alfa de Cronbach de 0,87, coeficiente Spearman-Brown 0,77. La escala de percepciones SERVQHOS mostró una mayor capacidad predictiva que las puntuaciones derivadas de la diferencia entre expectativas y percepciones con respecto a los criterios «satisfacción del paciente» (55% de varianza explicada) y «¿es recomendable el hospital?» (76,36% de clasificaciones correctas con respecto a los niveles de respuesta del criterio).ConclusionesEl empleo de SERVQUAL requiere de un proceso de validación previo. En este sentido, SERVQHOS ha demostrado índices psicométricos adecuados, si bien algunos de los problemas metodológicos atribuidos a las mediciones basadas en SERVQUAL han quedado patentes, la principal que el valor predictivo de la escala de percepciones de la experiencia del servicio fue superior al de la magnitud de la diferencia entre expectativas y percepciones.SummaryIntroductionSERVQUAL has been introduced in the healthcare sector as an alternative to the patient satisfaction measures. SERVQUAL is one of the most used questionnaires to measure the customers’ perceived quality. It is based on the disconfirmation paradigm (expectations-minus-perceptions). However, the structure, validity and reliability of this questionnaire have not been assessed in the Spanish hospital context.MethodsThree main targets defined in this study: 1) analyze the SERVQUAL's factorial solution, 2) determine which of its scales (perceptions, expectations, and expectations-minus-perceptions) has higher predictive efficiency, and 3) develop a new version for hospital setting (which was called SERVQHOS). A descriptive study based on surveys with multivariate analysis of data was conducted. Eight-hundred-twenty-six subjects were interviewed. All were attended in the Alicante's, Elche's, or Elda's hospital.ResultsA five-factor solution of the SERVQUAL was not corroborated. The perceptions scale obtained a higher predictive efficiency than expectations and expectations-minus-perceptions scales. Four factors were identified using SERVQHOS (56% explained variance). Perceptions-SERVQHOS gathered a greater predictive capacity that the scores derived from the difference among expectations and perceptions. This result was obtained in both criteria: patient satisfaction (55% explained variance) and whether the respondents would recommend the hospital (76,36% right classifications with respect to response levels of the criterion).ConclusionsBefore using SERVQUAL is highly recommended to realize a validation procedure of this questionnaire. SERVQHOS has shown adequate reliability and validity. However, there were some methodological problems using it. The most important inconvenience was that perceptions' scores showed greater predictive capacity than expectations-minus-perceptions

Inappropriate hospital admission as a risk factor for the subsequent development of adverse events: a cross-sectional study

Background: All health overuse implies an unnecessary risk of patients suffering adverse events (AEs). However, this hypothesis has not been corroborated by direct estimates for inappropriate hospital admission (IHA). The objectives of the study were the following: (1) to analyze the association between IHA and the development of subsequent AEs; (2) to explore the distinct clinical and economic implications of AEs subsequent IHA compared to appropriate admissions. Methods: An observational cross-sectional study was conducted on hospitalized patients in May 2019 in a high-complexity hospital in Madrid, Spain. The Appropriateness Evaluation Protocol was used to measure IHA, and the methodologies of the Harvard Medical Practice Study and the European Point Prevalence Survey of Healthcare-associated Infections were used to detect and characterize AEs. The association between IHA and the subsequent. Results: A total of 558 patients in the hospital ward were studied. IHA increased the risk of subsequent occurrence of AEs (OR [95% CI]: 3.54 [1.87 to 6.69], versus appropriate) and doubled the mean AEs per patient (coefficient [95% CI]: 0.19 [0.08 to 0.30] increase, versus appropriate) after adjusting for confounders. IHA was a predictive variable of subsequent AEs and the number of AEs per patient. AEs developed after IHA were associated with scheduled admissions (78.9% of AEs, versus 27.9% after appropriate admissions; p < 0.001). Compared with AEs developed after appropriate admissions, AEs after IHA added 2.4 additional days of stay in the intensive care unit and incurred an extra cost of €166,324.9 for the studied sample. Conclusions: Patients with IHA have a higher risk of subsequent occurrence of AE. Due to the multifactorial nature of AEs, IHA is a possible contributing factor. AEs developed after IHA are associated with scheduled admissions, prolonged ICU stays, and resulted in significant cost overruns. © 2023, BioMed Central Ltd., part of Springer Nature

Seguridad del paciente en atención primaria de salud : magnitud del problema

La seguridad del paciente (SP) ha preocupado desde siempre a los profesionales sanitarios en todos los escenarios de la práctica clínica. Es importante asumir una taxonomía común para hablar de SP y conocer cuales son las amenazas mediante el estudio de los eventos adversos (EA). El estudio APEAS mostró una prevalencia de EA de un 11,18‰, de los cuales un 47,8% estaban relacionados con la medicación. Al analizar la gravedad e impacto de los mismos pudo observarse que la mayor parte eran leves y se resolvían en el propio centro de salud. La causalidad de los EA es compleja. La medicación prescrita es un factor causal esencial en casi la mitad de los EA, junto con factores como la comunicación, la gestión y los cuidados. Aplicando el conocimiento disponible, el 70% de los EA que aparecen en el primer nivel asistencial fueron valorados por los propios profesionales como evitables. En el primer nivel asistencial confluyen varios factores diferenciales en relación con la SP que podrían incrementar el riesgo de aparición de EA e incidentes relacionados con la SP: la elevada presión asistencial, la hiperfrecuentación, la ambulatorización de cuidados y seguimientos, la deficiente continuidad asistencial y escasa comunicación entre atención primaria y especializada, la medicalización incontrolada y desmedida de procesos banales, al igual que la generalización de pruebas diagnósticas y tratamientos sin evidencia razonable de efectividad son una amenaza para la SP. El hecho de que los incidentes relacionados con la SP y los EA sean un problema común y en gran parte evitable, sitúa la mejora de la SP en el primer nivel asistencial como una estrategia prioritaria, siendo conscientes de que se trata de un problema crónico que requiere perseverancia y tratamiento continuado

Inappropriate Hospital Admission According to Patient Intrinsic Risk Factors: an Epidemiological Approach

Background: Inappropriate hospital admissions compromise the efficiency of the health care system. This work analyzes, for the first time, the prevalence of inappropriate admission and its association with clinical and epidemiological patient characteristics. Objectives: To estimate the prevalence, associated risk factors, and economic impact of inappropriate hospital admissions. Design and Participants: This was a cross-sectional observational study of all hospitalized patients in a high complexity hospital of over 901 beds capacity in Spain. The prevalence of inappropriate admission and its causes, the association of inappropriateness with patients’ intrinsic risk factors (IRFs), and associated financial costs were analyzed with the Appropriateness Evaluation Protocol in a multivariate model. Main Measures and Key Results: A total of 593 patients were analyzed, and a prevalence of inappropriate admissions of 11.9% (95% CI: 9.5 to 14.9) was found. The highest number of IRFs for developing health care-related complications was associated with inappropriateness, which was more common among patients with 1 IRF (OR [95% CI]: 9.68 [3.6 to 26.2.] versus absence of IRFs) and among those with surgical admissions (OR [95% CI]: 1.89 [1.1 to 3.3] versus medical admissions). The prognosis of terminal disease reduced the risk (OR [95% CI]: 0.28 [0.1 to 0.9] versus a prognosis of full recovery based on baseline condition). Inappropriate admissions were responsible for 559 days of avoidable hospitalization, equivalent to €17,604.6 daily and €139,076.4 in total, mostly attributable to inappropriate emergency admissions (€96,805.3). Conclusions: The prevalence of inappropriate admissions is similar to the incidence found in previous studies and is a useful indicator in monitoring this kind of overuse. Patients with a moderate number of comorbidities were subject to a higher level of inappropriateness. Inappropriate admission had a substantial and avoidable financial impact

Adverse events: an expensive and avoidable hospital problem

Introduction: Adverse healthcare-related events (AE) entail reduced patient safety. Estimating their frequency, characteristics, avoidability and impact is a means to identify targets for improvement in the quality of care. Methods: This was a descriptive observational study conducted within the Patient Safety Incident Study in Hospitals in the Community of Madrid (ESHMAD). The study was conducted in a high-complexity hospital in May 2019 through a two-phase electronic medical record review: (1) AE screening and epidemiological and clinical data collection and (2) AE review and classification and analysis of their impact, avoidability, and associated costs. Results: A total of 636 patients were studied. The prevalence of AE was 12.4%. Death during the stay was associated with the presence of AE (OR [CI95%]: 2.15 [1.07 to 4.52]) versus absence and emergency admission (OR [CI95%]: 17.11[6.63 to 46.26]) versus scheduled. A total of 70.2% of the AEs were avoidable. Avoidable AEs were associated with the presence of pressure ulcers (OR [CI95%]: 2.77 [1.39 to 5.51]), central venous catheter (OR [CI95%]: 2.58 [1.33 to 5.00]) and impaired mobility (OR [CI95%]: 2.24[1.35 to 3.71]), versus absences. They were associated too with the stays in the intensive care unit (OR [CI95%]: 2.75 [1.07 to 7.06]) versus medical service. AEs were responsible for additional costs of €909,716.8 for extra days of stay and €12,461.9 per patient with AE. Conclusions: The prevalence of AEs was similar to that found in other studies. AEs led to worse patient outcomes and were associated with the patient’s death. Although avoidable AEs were less severe, their higher frequency produced a greater impact on the patient and healthcare system.Key messages Adverse events are one of the main problems in healthcare delivery and patients who suffer from at least one AE are double as likely to die during hospitalization. Avoidable adverse events are the most frequent in health care and they are a good target where achieve improvement areas that allow getting optimal patient safety and quality of care levels. Patients hospitalized in the ICU, with the previous presence of pressure ulcers, central venous catheter, or impaired mobility were associated with the development of avoidable AE, so optimal management of these patients would reduce the impact of AE

Risk analysis for patient safety in surgical departments: Cross-sectional design usefulness

(1) Background: Identifying and measuring adverse events (AE) is a priority for patient safety, which allows us to define and prioritise areas for improvement and evaluate and develop solutions to improve health care quality. The aim of this work was to determine the prevalence of AEs in surgical and medical-surgical departments and to know the health impact of these AEs. (2) Methods: A cross-sectional study determining the prevalence of AEs in surgical and medical-surgical departments was conducted and a comparison was made among both clinical areas. A total of 5228 patients were admitted in 58 hospitals in Argentina, Colombia, Costa Rica, Mexico, and Peru, within the Latin American Study of Adverse Events (IBEAS), led by the Spanish Ministry of Health, the Pan American Health Organization, and the WHO Patient Safety programme. (3) Results: The global prevalence of AEs was 10.7%. However, the prevalence of AEs in surgical departments was 11.9%, while in medical-surgical departments it was 8.9%. The causes of these AEs were associated with surgical procedures (38.6%) and nosocomial infections (35.4%). About 60.6% of the AEs extended hospital stays by 30.7 days on average and 25.8% led to readmission with an average hospitalisation of 15 days. About 22.4% resulted in death, disability, or surgical reintervention. (4) Conclusions: Surgical departments were associated with a higher risk of experiencing AEs

How Does Vaccination against SARS-CoV-2 Affect Hospitalized Patients with COVID-19?

Background: The development of effective COVID-19 vaccines has reduced the impact of COVID-19 on the general population. Our study aims to analyze how vaccination modifies the likelihood of death and length of stay in hospitalized patients with COVID-19; (2) Methods: A retrospective cohort study of 1927 hospitalized patients infected with COVID-19 was conducted. Information was gathered on vaccination status, hospitalization episode, and clinical profile of the patients. The effect of vaccination on mortality was analyzed using a multiple logistic regression model, and length of stay was analyzed using linear regression. The performance and fit of the models were evaluated; (3) Results: In hospitalized patients with COVID-19, the risk of dying during admission in vaccinated patients was half that of non-vaccinated (OR: 0.45; CI 95%: 0.25 to 0.84). In patients who were discharged due to improvement, the reduction in hospital stay in vaccinated patients was 3.17 days (CI 95%: 5.88 to 0.47); (4) Conclusions: Patients who, despite having been vaccinated, acquire the infection by SARS-CoV-2, have a significant reduction of the risk of death during admission and a reduction of hospital stay compared with unvaccinated patients

Prevalence, characteristics, and impact of adverse events in 34 Madrid hospitals. The ESHMAD study

Introduction: Adverse Events (AE) are one of the main problems in healthcare. Therefore, many policies have been developed worldwide to mitigate their im pact. The Patient Safety Incident Study in Hospitals in the Community of Madrid (ESHMAD) measures the results of them in the region. Methods: Cross-sectional study, conducted in May 2019, in hospitalised patients in 34 public hospitals using the Harvard Medical Practice Study methodology. A logistic regression model was carried out to study the association of the variables with the presence of AE, calibrated and adjusted by patient. Results: A total of 9975 patients were included, estimating a prevalence of AE of 11.9%. A higher risk of AE was observed in patients with surgical procedures (OR[CI95%]: 2.15[1.79 to 2.57], vs. absence), in Intensive Care Units (OR[CI95%]: 1.60[1.17 to 2.17], vs. Medical) and in hospitals of medium complexity (OR[CI95%]: 1.45[1.12 to 1.87], vs. low complexity). A 62.6% of AE increased the length of the stay or it was the cause of admission, and 46.9% of AE were considered prevent able. In 11.5% of patients with AE, they had contributed to their death. Conclusions: The prevalence of AE remains similar to the previously estimated one in studies developed with the same methodology. AE keep leading to longer hospital stays, contributing to patient's death, showing that it is necessary to put focus on patient safety again. A detailed analysis of these events has enabled the detection of specific areas for improvement according to the type of care, centre and patient

Higher incidence of adverse events in isolated patients compared with non-isolated patients: A cohort study

Objective To determine whether isolated patients admitted to hospital have a higher incidence of adverse events (AEs), to identify their nature, impact and preventability. Design Prospective cohort study with isolated and non-isolated patients. Setting One public university hospital in the Valencian Community (southeast Spain). Participants We consecutively collected 400 patients, 200 isolated and 200 non-isolated, age =18 years old, to match according to date of entry, admission department, sex, age (±5 years) and disease severity from April 2017 to October 2018. Exclusion criteria: patients age <18 years old and/or reverse isolation patients. Primary and secondary outcome measures The primary outcome as the AE, defined according to the National Study of Adverse Effects linked to Hospitalisation (Estudio Nacional Sobre los Efectos Adversos) criteria. Cumulative incidence rates and AE incidence density rates were calculated. Results The incidence of isolated patients with AEs 16.5% (95% CI 11.4% to 21.6%) compared with 9.5% (95% CI 5.4% to 13.6%) in non-isolated (p<0.03). The incidence density of patients with AEs among isolated patients was 11.8 per 1000?days/patient (95%?CI 7.8 to 15.9) compared with 4.3 per 1000?days/patient (95%?CI 2.4 to 6.3) among non-isolated patients (p<0.001). The incidence of AEs among isolated patients was 18.5% compared with 11% for non-isolated patients (p<0.09). Among the 37 AEs detected in 33 isolated patients, and the 22 AEs detected in 19 non-isolated patients, most corresponded to healthcare-associated infections (HAIs) for both isolated and non-isolated patients (48.6% vs 45.4%). There were significant differences with respect to the preventability of AEs, (67.6% among isolated patients compared with 52.6% among non-isolated patients). Conclusions AEs were significantly higher in isolated patients compared with non-isolated patients, more than half being preventable and with HAIs as the primary cause. It is essential to improve training and the safety culture of healthcare professionals relating to the care provided to this type of patient