Eventos adversos y adecuación sanitaria en el ámbito hospitalario: frecuencia, causas e impacto

Introducción: La Calidad Asistencial se ve afectada por el nivel de inadecuación de la atención sanitaria, ya sea por infrautilización —asistencia insuficiente para pacientes que la necesitan—, como por sobreutilización —prestación de servicios sanitarios innecesarios con posibles daños en forma de evento adverso relacionado con la asistencia sanitaria (EA) para el paciente—. La sobreutilización en el ámbito hospitalario puede presentarse de diversas formas, siendo la admisión hospitalaria inadecuada una de las principales. Tanto para la medición de la admisión hospitalaria inadecuada como de los EA, se han empleado estrategias basadas en la revisión de la historia clínica, como son el Appropriateness Evaluation Protocol (AEP) y la metodología del Harvard Medical Practice Study (HMPS). Está globalmente aceptado que la inadecuación sanitaria implica un mayor riesgo de EA para el paciente. No obstante, esta hipótesis nunca ha sido corroborada para la admisión hospitalaria inadecuada mediante estimaciones directas. Esta Tesis Doctoral analiza la asociación entre las admisiones hospitalarias inadecuadas y el desarrollo posterior de EA en un hospital de alta complejidad, combinando, de forma pionera, las metodologías AEP y HMPS (ambas validadas), profundizando en su análisis epidemiológico inicial y estimando una medida de asociación directa a partir de la misma muestra. El presente proyecto se encuentra enmarcado dentro del Estudio sobre la Seguridad de los Pacientes en los Hospitales de la Comunidad de Madrid (ESHMAD). Objetivos: Los objetivos se dividieron en tres fases: 1) Conocer la prevalencia de EA, su asociación con el fallecimiento al final del episodio de hospitalización, los factores relacionados con los EA evitables y su impacto económico. 2) Estimar la prevalencia de admisiones hospitalarias inadecuadas, factores asociados, causas e impacto económico. 3) Analizar la asociación entre admisiones hospitalarias inadecuadas y el desarrollo posterior de EA, así como si la admisión hospitalaria inadecuada actuaba de variable predictora de EA. Metodología: La metodología de cada fase del estudio fue: 1) Estudio descriptivo observacional realizado dentro del ESHMAD y basado en la metodología del HMPS. Se desarrolló en un hospital de alta complejidad, en mayo de 2019, mediante revisión de historia clínica electrónica en dos fases: 1) Cribado de EA y recogida de datos epidemiológicos y clínicos de los pacientes; 2) Revisión y caracterización del EA y análisis de su impacto, evitabilidad y costes asociados. Se realizaron dos modelos multivariantes de regresión logística: 1) Modelo explicativo para estudiar la asociación entre el EA y el fallecimiento; 2) Modelo predictivo para analizar los factores asociados a los EA evitables. 2) Estudio observacional de corte transversal realizado sobre el total de pacientes hospitalizados en un hospital de alta complejidad. A partir de la aplicación del AEP, se analizó la prevalencia de la inadecuación de la admisión, sus causas, la asociación de la inadecuación con factores de riesgo intrínsecos (FRI) del paciente en un modelo multivariante y el coste económico asociado a días de hospitalización evitables derivados de la causa de admisión inadecuada. Se desarrolló un modelo multivariante de regresión logística para analizar las variables asociadas a las admisiones hospitalarias inadecuadas. 3) Estudio observacional de diseño transversal realizado sobre pacientes hospitalizados en mayo de 2019. Se estimaron las admisiones hospitalarias inadecuadas con el AEP y se detectaron y caracterizaron los EA mediante la metodología del HMPS. Se analizó la asociación entre admisiones hospitalarias inadecuadas y EA mediante modelos multivariantes explicativos de regresión logística y lineal ajustados por variables confusoras. Se evaluó el comportamiento de la admisión hospitalaria inadecuada como factor contribuyente en modelos predictivos para la detección de EA y la media de EA por paciente. Finalmente, se compararon las características y el impacto económico de los EA acontecidos tras admisiones inadecuadas con las de los EA acontecidos tras admisiones adecuadas. Resultados: Los resultados principales de cada fase fueron: 1) Se estudiaron 636 pacientes. La prevalencia de EA fue del 12,4%. El fallecimiento durante la estancia mostró asociación con la presencia de EA (Odds Ratio (OR) [Intervalo de confianza al 95% (IC95%)]: 2,15 [1,07 a 4,52]), frente a ausencia y con el ingreso urgente (OR [IC95%]: 17,11 [6,63 a 46,26]), frente a programado. La evitabilidad de los EA fue del 70,2%, asociándose con la estancia en Unidad de Cuidados Intensivos (UCI) (OR [IC95%]: 2,75 [1,07 a 7,06], frente a servicio médico, con la presencia de úlceras por presión (OR [IC95%]: 2,77 [1,39 a 5,51]), catéter venoso central (OR [IC95%]: 2,58 [1,33 a 5,00]), y alteraciones de la movilidad (OR [IC95%]: 2,24 [1,35 a 3,71]), frente a ausencias. Los EA conllevaron un aumento del coste económico de 909.716,8€ por días adicionales de estancia hospitalaria y de 12.461,9€ por paciente. 2) Se estudiaron 611 pacientes que cumplieron los criterios de inclusión del AEP. 73 tuvieron una admisión inadecuada, encontrándose una prevalencia de inadecuación en las admisiones del 11,9% (IC95%: 9,5 a 14,8). El incremento del número de FRI se asoció con la inadecuación, siendo mayor en pacientes con 1 FRI (OR [IC95%]: 11,27 [3,4 a 37,1]), frente a ausencia, y en admisiones a cargo de especialidades del ámbito quirúrgico (OR [IC95%]: 1,92 [1,1 a 3,4]), frente a ámbito médico. Presentar un pronóstico de enfermedad terminal redujo el riesgo de admisiones hospitalarias inadecuadas (OR [IC95%]: 0,27 [0,1 a 0,9]), frente a pronóstico de recuperación completa al estado basal. Las admisiones inadecuadas generaron 562 días de estancia evitables, equivalente a 140.463,6€ totales, correspondiendo en su mayoría a admisiones inadecuadas de carácter urgente (97.730,1€). El coste diario de las admisiones hospitalarias inadecuadas por paciente fue de 249,4€/día; esto equivale a 18.265,75€ diarios de pérdida para el centro teniendo en cuenta el total de pacientes con admisiones hospitalarias inadecuadas. 3) Se estudiaron 558 pacientes. Las admisiones hospitalarias inadecuadas aumentaron el riesgo de EA (OR [IC95%]: 3,54 [1,87 a 6,69]), frente a adecuado y duplicó la media de EA por paciente (Coeficiente [IC95%]: 0,19 [0,08 a 0,30]) de incremento frente a adecuado, ajustando por confusores. La admisión inadecuada fue variable predictora de la presencia de EA y del número de EA por paciente. Los EA producidos tras admisiones hospitalarias inadecuadas añadieron 2,4 días adicionales de estancia en UCI respecto a los de admisiones adecuadas y supusieron un sobrecoste de 166.324,9€ para la muestra estudiada. Conclusiones: Las conclusiones principales de cada fase son: 1) La prevalencia de EA es similar a lo hallado en otros estudios. Los EA favorecen una peor evolución de los pacientes. Aunque los EA evitables son menos graves, su mayor frecuencia supone un mayor impacto global para el paciente y el sistema sanitario. 2) La prevalencia de inadecuación en las admisiones es similar a la frecuencia hallada por otros estudios. Los pacientes con un número intermedio de comorbilidades presentaron mayor prevalencia de inadecuación. La inadecuación supuso un importante impacto económico evitable. 3) Los pacientes con admisiones hospitalarias inadecuadas se asociaron con un mayor riesgo de ocurrencia posterior de EA. Debido al carácter multifactorial de los EA, las admisiones inadecuadas se posicionan como uno de sus posibles factores contribuyentes. Los EA acontecidos tras admisiones inadecuadas prolongan más días la estancia en UCI y suponen un mayor sobrecoste económico que los EA producidos tras admisiones adecuadas.

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

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

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

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 impact. 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 preventable. 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

Impact of the COVID-19 Pandemic on Inappropriate Use of the Emergency Department

Background: Inappropriate use of the emergency department (IEDU)—consisting of the unnecessary use of the resource by patients with no clinical need—is one of the leading causes of the loss of efficiency of the health system. Specific contexts modify routine clinical practice and usage patterns. This study aims to analyse the influence of COVID-19 on the IEDU and its causes. Methods: A retrospective, cross-sectional study conducted in the emergency department of a high-complexity hospital. The Hospital Emergency Suitability Protocol (HESP) was used to measure the prevalence of IEDU and its causes, comparing three pairs of periods: (1) March 2019 and 2020; (2) June 2019 and 2020; and (3) September 2019 and 2020. A bivariate analysis and multivariate logistic regression models, adjusted for confounding variables, were utilized. Results: In total, 822 emergency visits were included (137 per period). A total prevalence of IEDU of 14.1% was found. There was a significant decrease in IEDU in March 2020 (OR: 0.03), with a prevalence of 0.8%. No differences were found in the other periods. A mistrust in primary care was the leading cause of IEDU (65.1%). Conclusions: The impact of COVID-19 reduced the frequency of IEDU during the period of more significant population restrictions, with IEDU returning to previous levels in subsequent months. Targeted actions in the field of population education and an improvement in primary care are positioned as strategies that could mitigate its impact

Apropriateness of hospital admissions due to COVID-19 in the 2nd and 5th phase of the pandemic

OBJECTIVE: The increase in the demand for healthcare caused by COVID-19 implies a lower availability of health resources and influences the appropriateness of their use. Due to the variability of demand during the pandemic, the study aimed to compare the appropriateness of hospital admissions between the 2nd and 5th phases of the pandemic according to the criteria of the Hospital Emergency Service (CiHRyC). These results were compared with those obtained according to the Pneumonity Severity Index (FINE) and the Appropriateness Evaluation Protocol (AEP). As a secondary objective, the clinical and sociodemographic characteristics of the patients studied were described. METHODS: 80 patients hospitalized from the Emergency Department were randomly selected in two study periods (2nd and 5th pandemic phase) obtained from the registry of hospitalizations of the Preventive Medicine service of Hospital Ramon y Cajal. Prevalences of inappropriateness were estimated according to the CiHRyC, FINE and AEP and an analysis was performed using univariate logistic regression between epidemiological variables of both periods collected through the electronical medical records. RESULTS: Inappropriateness of admissions were 35% and 45% in the 2nd and 5th phase of the pandemic according with CiHRyC, 25% and 5/% according with FINE and 0% and 5% according with AEP. Median age was 71.4 and 50.0 years in 2nd and 5th phase (p=0.02). 72.5% and 17.5% of the patients in the 2nd and 5th phases had at least one risk factor for COVID-19 severe illness (p<0.01). CONCLUSIONS: The measurement tools used identified more inappropriately cases in the 5th phase of the pandemic than in the 2nd one. CiHRyC coincided with FINE and AEP in the result of their evaluation. OBJETIVO: El aumento de la demanda asistencial hospitalaria producida por la COVID-19 supone una menor disponibilidad de recursos sanitarios e influye en la adecuación de su utilización. Debido a la variabilidad de la demanda durante la pandemia, el objetivo del estudio fue comparar la adecuación de los ingresos hospitalarios entre la 2ª y 5ª fase de la pandemia según los criterios del servicio de Urgencias del Hospital (CiHRyC). Se compararon estos resultados con los obtenidos según el Pneumonity Severity Index (FINE) y el Appropriateness Evaluation Protocol (AEP). Como objetivo secundario se describieron las características clínicas y sociodemográficas de los pacientes estudiados. METODOS: Se seleccionaron aleatoriamente 80 pacientes hospitalizados desde Urgencias en dos periodos de estudio (2ª y 5ª fase pandémica) obtenidos del registro de hospitalizaciones del servicio de Medicina Preventiva del Hospital Ramón y Cajal. Se estimaron las prevalencias de inadecuación según los CiHRyC, el FINE y el AEP para admisiones y se realizó un análisis mediante regresión logística univariante entre las variables epidemiológicas de ambos periodos recogidas mediante la Historia Clínica Electrónica (HCE). RESULTADOS: La inadecuación de la hospitalización fue del 35% y 45% en la 2ª y 5ª fase de la pandemia con los CiHRyC, del 25% y 57% con el FINE y del 0% y 5% con el AEP. La mediana de edad fue de 71,4 y 50 años en la 2ª y 5ª fase (p=0,02). El 72,5% y el 17,5% de los pacientes de la 2ª y 5ª fase tuvieron al menos un factor de riesgo de complicaciones de COVID-19 (p<0,01). CONCLUSIONES: Los instrumentos de medida empleados (CiHRyC, el FINE y el AEP) identificaron más casos inadecuadamente ingresados en la 5ª fase de la pandemia que en la 2ª, coincidiendo el CiHRyC con el FINE y el AEP en el resultado de su evaluación.Fundamentos: El aumento de la demanda asistencial hospitalaria producida por la COVID-19 supone una menor disponibilidad de recursos sanitarios e influye en la adecuación de su utilización. Debido a la variabilidad de la demanda durante la pandemia, el objetivo del estudio fue comparar la adecuación de los ingresos hospitalarios entre la 2ª y 5ª fase de la pandemia según los criterios del servicio de Urgencias del Hospital (CiHRyC). Se compararon estos resultados con los obtenidos según el Pneumonity Severity Index (FINE) y el Appropriateness Evaluation Protocol (AEP). Como objetivo secundario se describieron las características clínicas y sociodemográficas de los pacientes estudiados. Métodos: Se seleccionaron aleatoriamente 80 pacientes hospitalizados desde Urgencias en dos periodos de estudio (2ª y 5ª fase pandémica) obtenidos del registro de hospitalizaciones del servicio de Medicina Preventiva del Hospital Ramón y Cajal. Se estimaron las prevalencias de inadecuación según los CiHRyC, el FINE y el AEP para admisiones y se realizó un análisis mediante regresión logística univariante entre las variables epidemiológicas de ambos periodos recogidas mediante la Historia Clínica Electrónica (HCE). Resultados: La inadecuación de la hospitalización fue del 35% y 45% en la 2ª y 5ª fase de la pandemia con los CiHRyC, del 25% y 57% con el FINE y del 0% y 5% con el AEP. La mediana de edad fue de 71,4 y 50 años en la 2ª y 5ª fase (p=0,02). El 72,5% y el 17,5% de los pacientes de la 2ª y 5ª fase tuvieron al menos un factor de riesgo de complicaciones de COVID-19 (p<0,01). Conclusiones: Los instrumentos de medida empleados (CiHRyC, el FINE y el AEP) identificaron más casos inadecuadamente ingresados en la 5ª fase de la pandemia que en la 2ª, coincidiendo el CiHRyC con el FINE y el AEP en el resultado de su evaluación