Palliative Experiential Community: Care on Transitions to End of Life (CARONTE)

El concepto de Community of Practice (CoP) se define como un grupo de personas, con un interés, problema, o pasión en común, que comparten conocimientos y experiencias mediante la interacción recíproca entre ellos para generar conocimiento y aprendizaje colectivo. Los elementos esenciales de una CoP son: la comunidad, el dominio, y la práctica. Cuando estos tres aspectos funcionan bien juntos, existe un entorno que facilita el aprendizaje y el desarrollo del conocimiento. En el ámbito sanitario, el fomento de las CoP se dirige principalmente al logro de competencias y habilidades clínicas de los estudiantes. La creación de un entorno de colaboración y apoyo basado en una CoP tiene el potencial de producir resultados positivos en el aprendizaje del estudiante y su desarrollo personal y profesional. El objetivo de esta red es el diseño e implementación de una CoP aplicada a la formación en cuidados paliativos de los estudiantes de enfermería. Para ello, se ha realizado un análisis de los recursos virtuales en salud disponibles y se ha analizado la estructura de los mismos para el diseño inicial de la CoP. Una vez construida la versión 1.0, se evaluará cualitativamente a través de grupos de discusión con profesionales, alumnos y profesores

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Effects of intubation timing in patients with COVID-19 throughout the four waves of the pandemic : a matched analysis

The primary aim of our study was to investigate the association between intubation timing and hospital mortality in critically ill patients with COVID-19-associated respiratory failure. We also analysed both the impact of such timing throughout the first four pandemic waves and the influence of prior non-invasive respiratory support on outcomes. This is a secondary analysis of a multicentre, observational and prospective cohort study that included all consecutive patients undergoing invasive mechanical ventilation due to COVID-19 from across 58 Spanish intensive care units (ICU) participating in the CIBERESUCICOVID project. The study period was between 29 February 2020 and 31 August 2021. Early intubation was defined as that occurring within the first 24 h of intensive care unit (ICU) admission. Propensity score (PS) matching was used to achieve balance across baseline variables between the early intubation cohort and those patients who were intubated after the first 24 h of ICU admission. Differences in outcomes between early and delayed intubation were also assessed. We performed sensitivity analyses to consider a different timepoint (48 h from ICU admission) for early and delayed intubation. Of the 2725 patients who received invasive mechanical ventilation, a total of 614 matched patients were included in the analysis (307 for each group). In the unmatched population, there were no differences in mortality between the early and delayed groups. After PS matching, patients with delayed intubation presented higher hospital mortality (27.3% versus 37.1%, p =0.01), ICU mortality (25.7% versus 36.1%, p=0.007) and 90-day mortality (30.9% versus 40.2%, p=0.02) when compared to the early intubation group. Very similar findings were observed when we used a 48-hour timepoint for early or delayed intubation. The use of early intubation decreased after the first wave of the pandemic (72%, 49%, 46% and 45% in the first, second, third and fourth wave, respectively; first versus second, third and fourth waves p<0.001). In both the main and sensitivity analyses, hospital mortality was lower in patients receiving high-flow nasal cannula (n=294) who were intubated earlier. The subgroup of patients undergoing NIV (n=214) before intubation showed higher mortality when delayed intubation was set as that occurring after 48 h from ICU admission, but not when after 24 h. In patients with COVID-19 requiring invasive mechanical ventilation, delayed intubation was associated with a higher risk of hospital mortality. The use of early intubation significantly decreased throughout the course of the pandemic. Benefits of such an approach occurred more notably in patients who had received high-flow nasal cannul

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study

Background: Evidence indicates that hypodermoclysis is as safe and effective as intravenous rehydration in the treatment of the symptomatology produced by mild to moderate dehydration in patients for whom oral route administration is not possible. However, the knowledge about the use of the subcutaneous hydration and its correlates is still limited. Aim: To explore the perceptions, attitudes and opinions of health professionals in palliative care on the administration of subcutaneous hydration. Design: This is a qualitative focus group study with health professionals of palliative care. Four focus groups were carried out until data saturation. A qualitative content analysis was performed. Setting/participants: A total of 37 participants, physicians and nurses, were recruited from different services of palliative care in Spain. Results: In all, 856 meaning units were identified, from which 56 categories were extracted and grouped into 22 sub-themes, which were distributed among four themes: ‘factors which influence the hydration decision’, ‘factors related to the choice of the subcutaneous route for hydration’, ‘the subcutaneous hydration procedure’ and ‘performance guidelines and/or protocols’. Conclusions: Variables which most often influence the use of subcutaneous route to hydration are those that are linked to the characteristics of the patient, the team and the family, and other like the context and professionals’ subjective perceptions about this medical practice.This project was funded by a grant from the Instituto de Salud Carlos III (Institute of Health Carlos III) (PI10/00847) of the Ministry of Economy and Competitiveness (Spain)

Design and validation of the Complex Case Evaluation Index, an instrument to identify complex patients

Fundamento. Desarrollar y validar un instrumento específico de identificación de pacientes complejos, el Índice de Evaluación de Casos Complejos (IECC). Métodos. Estudio instrumental con dos fases: 1) Elaboración del instrumento: se definieron y operacionalizaron las variables extraídas de la literatura que, posteriormente, fueron sometidas al juicio de expertos. El IECC incluyó catorce variables divididas en dos dimensiones: complejidad del manejo clínico y complejidad del manejo comunitario. 2) Estudio psicométrico: evaluación de la fiabilidad por equivalencia entre observadores (r Pearson), de la validez de criterio respecto al sistema de clasificación Clinical Risk Groups (CRG) y de la validez de constructo a través de grupos conocidos y a través del estudio de conglomerados jerárquicos. Los análisis se realizaron con el paquete estadístico SPSS.v.17. Resultados. La fiabilidad entre observadores para la subescala clínica fue r = 0,97, para la subescala comunitaria r = 0,74 y para la puntuación total r = 0,89. El 88,4% (n = 458) de los 518 casos identificados como complejos por el IECC fueron categorizados por el sistema CRG en las categorías de más complejidad clínica (niveles 6 a 9). Los resultados sustentan la validez de constructo de la escala. El análisis de conglomerados mostró dos clusters diferentes, aunque relacionados. Conclusión. El IECC es un índice breve y de fácil aplicación, con una buena adecuación conceptual y evidencias de su fiabilidad y validez dirigido a la detección de pacientes con necesidades complejas.Background. The aim was to develop and validate the Complex Case Assessment Index (CCAI), a specific instrument to identify complex patients. Methods. Instrumental study in two phases: 1) Development of the scale: the variables extracted from the literature were firstly defined and operationalized, and then submitted for expert judgment. The CCAI included 14 variables divided into two dimensions: complexity of clinical management and complexity of community management. 2) Psychometric study: evaluation of the reliability and validity of the scale by equivalence between observers (Pearson’s r), criterion validity with respect to the Clinical Risk Groups (CRG) classification system, and construct validity through known groups and study of hierarchical clusters were examined. The analyses were carried out with the SPSS version 17 statistical package. Results. Reliability by equivalence between observers was r = 0.97 for the clinical subscale, r = 0.74 for the community subscale, and r = 0.89 for the total score. The CCAI identified 518 cases as complex; 458 of them (88.4%) were categorized by the CRG system in the categories of greatest clinical complexity (levels 6 to 9). The results support the construct validity of the scale. The cluster analysis showed two different, although related, clusters. Conclusion. The CCAI is a fast and easy-to-use index, with good conceptual adequacy and evidence of reliability and validity for screening patients with complex needs

Elaboración de trabajos de intervención dirigidos a la dependencia y fragilidad en geriatría, como método de evaluación de competencias de grado y postgrado. Percepción del alumnado

Conocer la opinión del alumnado sobre los métodos de evaluación continua resulta una herramienta de trabajo para superar barreras, incluir mejoras y adaptar el aprendizaje por competencias a las necesidades del alumnado. El objetivo de este estudio ha sido conocer la opinión de los alumnos que han cursado asignaturas relacionadas con el envejecimiento en las titulaciones de Grado y Postgrado de la Facultad de Ciencias de la Salud de la Universidad de Alicante. Este estudio tiene un diseño cualitativo y la muestra estuvo constituida por alumnos de segundo y cuarto de grado de enfermería y alumnos del máster universitario envejecimiento activo y salud, se plantearon diferentes grupos focales. La recogida de datos se realizó a través grupos focales, que fueron transcritos y sobre los que se llevó a cabo un análisis temático del contenido. Los resultados y conclusiones obtenidos ponen de manifiesto la importancia de conocer la percepción del alumnado sobre su evaluación para mejorar el proceso de evaluación en competencias por parte del equipo docente. Además nuestras conclusiones muestran cómo el alumnado valora positivamente los diferentes trabajos propuestos para su evaluación continua, pero en los tres casos reclaman poder realizar más trabajos que les permitan un acercamiento a la realidad

Opinión de los tutores de prácticas clínicas de enfermería sobre las competencias adquiridas por el alumnado

El docente de enfermería en su desarrollo del papel de tutor clínico en los centros asistenciales, es conocedor privilegiado de las competencias adquiridas por el alumnado durante sus clases teóricas universitarias y si éstas resultan óptimas para poder desarrollar unas prácticas clínicas satisfactorias. Actualmente existen multitud de estudios acerca de la percepción de los alumnos durante sus prácticas clínicas, sin embargo, hasta la fecha se conoce poco a cerca de la opinión de los tutores con respecto a la preparación del alumno desde la academia. Nuestro objetivo fue explorar la percepción de los profesionales de enfermería acerca de la preparación previa que se realiza del alumno desde las diferentes asignaturas impartidas en el grado, para la realización de prácticas clínicas en los centros asistenciales geriátricos, además de evaluar e incorporar las sugerencias de los profesionales con el fin de mejorar y amentar el rendimiento de las prácticas clínicas. Los alumnos muestran una buena preparación para la realización de prácticas, aunque se podría profundizar en aspectos específicos relacionados con la geriatría y la gerontología, además de realizar un esfuerzo por parte de la universidad para reforzar la adquisición de competencias transversales como el trabajo en equipo o desarrollar habilidades de comunicación

Aprendizaje experiencial de competencias trasversales a través de la reflexión y la simulación de baja fidelidad en el envejecimiento activo y saludable

En las últimas décadas se ha producido un envejecimiento de la población a nivel mundial, por lo que la sociedad tiene que estar preparada para hacer frente a una sociedad envejecida que requiere un capital humano preparado para cubrir las necesidades de este colectivo. Los alumnos de enfermería por su perfil profesional serán uno de los colectivos encargados de realizar esta función y por tanto tendrán que estar formados específicamente en geriatría y gerontología. Para ello desde la universidad donde el aprendizaje está dominado fundamentalmente por el aprendizaje en el aula, nuestro objetivo principal es implementar nuevas metodologías que guíen al alumnado al desarrollo de competencias transversales que puedan acercar a la realidad a nuestros estudiantes. Para ello se plantean dos tipos de metodologías basadas en la simulación de baja fidelidad y la reflexión personal. Nuestros resultados muestran que la adquisición de competencias transversales es posible a través de diferentes metodologías en las que el alumno se convierte en protagonista de su propio aprendizaje y donde se pone e manifiesto que la formación específica en gerontología y cuidados al a vejez es una herramienta eficaz para educar en conocimientos, habilidades y actitudes positivas hacia la vejez en los futuros profesionales de enfermería