28 de junho de 2011

Artigo recomendado: Setting standards for simulation in anesthesia: the role of safety criteria in accreditation standards

Nicole Riem, MD; Sylvain Boet, MD; Deven Chandra, MD

Can J Anaesth. 2011 Jun 22, 2011; 58(9)

PURPOSE: In this article, we describe a critical event which occurred in a simulation centre, and we also review possible safety issues for participants and staff involved in medical simulation training.

PRINCIPAL FINDINGS: The authors report an incident with the potential of harming trainees and staff which occurred during a full-scale simulation. The episode raised the question of training safety in simulation centres. In this instance, the computer program controlling the mannequin enabled a continuous and non-regulated outflow of carbon dioxide which led to an intense reaction in the soda lime canister. The absorbent canister became too hot to be touched (a temperature probe, later placed in the centre of the front canister, measured 53°C). All activities involving the mannequin and anesthesia machine were stopped immediately.

CONCLUSIONS: Simulation in healthcare is a valuable educational tool to train for a variety of clinical encounters in a safe environment without harming a patient. Due to technological progress and the use of authentic equipment recreating near real environments, simulation training has become exceedingly realistic. The Society for Simulation in Healthcare (SSH) has published revised accreditation standards for simulation centres which incorporate training safety sub-criteria to address and manage. By highlighting recommendations of other high-risk industries on this issue, SSH proposes a possible approach to enhance safety in medical simulation.

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22 de junho de 2011

Intrahospital transport of patients on invasive ventilation: cardiorespiratory repercussions and adverse events

Transporte intra-hospitalar de pacientes sob ventilação invasiva: repercussões cardiorrespiratórias e eventos adversos

Lea Tami Suzuki Zuchelo, Paulo Antônio Chiavone
J Bras Pneumol. 2009;35(4):367-374

Abstract / Resumo
Objective: To determine the occurrence of cardiorespiratory alterations and to identify 
adverse events during the intrahospital transport of patients on invasive ventilation.
Objetivo: Verificar a ocorrência de alterações cardiorrespiratórias e identificar eventos adversos durante o transporte intra-hospitalar de pacientes sob ventilação invasiva.

Methods: A prospective observational non-randomized study was conducted at two tertiary hospitals between April of 2005 and December of 2006. We included patients on invasive ventilation who required intrahospital transport during the study period. Exclusion criteria were as follows: being under suspicion of brain death; being submitted to alternate periods of mechanical ventilation/nebulization via a T-piece; and being transported to the operating room. Prior to and after transport, we evaluated blood gas analysis results, vital signs, use of medications by means of a continuous infusion pump, parameters regarding the mechanical ventilator, duration of transport, transport distance and number of professionals involved.
Métodos: Estudo observacional prospectivo não-randomizado, conduzido em dois hospitais terciários, entre abril de 2005 e dezembro de 2006. Foram incluídos pacientes sob ventilação invasiva que necessitaram de transporte intra-hospitalar durante o período do estudo. Os critérios de exclusão foram: estar sob suspeita de morte encefálica; ter sido submetido a períodos de ventilação mecânica e de nebulização em tubo T; e ter sido transportado para o centro cirúrgico. Antes e após o transporte, os seguintes parâmetros foram avaliados: gasometria arterial, sinais vitais, uso de medicamentos através de uma bomba de infusão contínua, parâmetros do ventilador mecânico, duração do transporte, distância percorrida e número de profissionais envolvidos.

Results: We included 48 patients in a total of 58 intrahospital transports. Relevant cardiorespiratory alterations were identified in 39 transports, totaling 86 episodes, as well as 16 adverse events related to equipment or personnel failure, such as problems related to batteries and to miscommunication.
Resultados: Foram incluídos 48 pacientes, num total de 58 transportes. Observou-se alteração cardiorrespiratória importante em 39 transportes, totalizando 86 episódios, assim como 16 eventos adversos relacionados à falha de equipamento e falha da equipe, dentre eles problemas com baterias e falhas de comunicação.

Conclusions: During the intrahospital transport of patients on invasive ventilation, cardiorespiratory alterations were common (67.2%), and adverse events occurred in 75.7% of the transports.
Conclusões: Durante o transporte intra-hospitalar de pacientes submetidos à ventilação invasiva, alterações cardiorrespiratórias foram frequentes (67,2%), e eventos adversos ocorreram em 75,7% dos transportes realizados.

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16 de junho de 2011

Artigo recomendado: Outcomes of interfacility critical care adult patient transport: a systematic review

Eddy Fan, Russell D MacDonald, Neill KJ Adhikari, Damon C Scales, Randy S Wax, Thomas E Stewart and Niall D Ferguson
Critical Care 2006, 10:R6 (doi:10.1186/cc3924)

Introduction: We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients.

Methods: We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined.

Results Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams

included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies.

Conclusion: Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.

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13 de junho de 2011

Artigo: Balancing “No Blame” with Accountability in Patient Safety

The New England Journal of Medicine
Robert M. Wachter, M.D., and Peter J. Pronovost, M.D., Ph.D.

This year marks the 10th anniversary of the Institute of Medicine’s report To Err Is Human,1 the document that launched the modern patient-safety movement. Although the movement has spawned myriad initiatives, its main theme, drawn from studies of other high-risk industries that have impressive safety records, boils down to this: Most errors are committed by good, hardworking people trying to do the right thing. Therefore, the traditional focus on identifying who is at fault is a distraction. It is far more productive to identify error-prone situations and settings and to implement systems that prevent caregivers from committing errors, catch errors before they cause harm, or mitigate harm from errors that do reach patients.2,3

Most health care providers embraced the “no blame” model as a refreshing change from an errors landscape previously dominated by a malpractice system that was generally judged as punitive and arbitrary. And this shift has unquestionably borne fruit. For example, rather than trying to perfect doctors’ handwriting and memories, computerized systems catch medication errors before they reach patients.4 Implementing simple checklists markedly increases the use of evidencebased prevention strategies, leading to fewer surgical complications and bloodstream infections associated with central venous catheters.5,6 But beginning a few years ago, some prominent health care leaders began to question the singular embrace of the “no blame” paradigm.

Leape, a patient-safety pioneer and early proponent of systems thinking,2 described the need for a more aggressive approach to poorly performing physicians,7 and the Joint Commission has made addressing the problem of disruptive caregivers a priority.8 Goldmann identified the need to create accountability for failure to perform hand hygiene.9 Rather than a “no blame” culture, Marx promoted a “just culture,” which differentiates blameworthy from blameless acts.10,11 Many health care organizations (including our own) have recognized that a unidimensional focus on creating a blame-free culture carries its own safety risks. But despite this recognition, finding the appropriate balance has been elusive, and few organizations have implemented meaningful systems of accountability, particularly for physicians.

In this article, we describe some of the barriers to physician accountability, enumerate patient-safety practices that are ready for an accountability approach, and suggest penalties for the failure to adhere to such practices. We focus on situations in which the action (or inaction) of individual physicians poses a clear risk to patients, rather than on the broader issues of clinical competence or disruptive behavior; readers who are interested in the latter issues are referred to other sources.7,12,13

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9 de junho de 2011

Artigo recomendado: Unanticipated Difficult Airway in Anesthetized Patients

Prospective Validation of a Management Algorithm
Xavier Combes, M.D.,* Bertrand Le Roux, M.D.,* Powen Suen, M.D.,* Marc Dumerat, M.D.,* Cyrus Motamed, M.D.,‡ Stéphane Sauvat, M.D.,* Philippe Duvaldestin, M.D.,† Gilles Dhonneur, M.D.§

Background: Management strategies conceived to improve patient safety in anesthesia have rarely been assessed prospectively. The authors undertook a prospective evaluation of a predefined algorithm for unanticipated difficult airway management.

Methods: After a 2-month period of training in airway management, 41 anesthesiologists were asked to follow a predefined algorithm for management in the case of an unanticipated difficult airway. Two different scenarios were distinguished: “cannot intubate” and “cannot ventilate.” The gum elastic bougie and the Intubating Laryngeal Mask Airway™ (ILMA™) were proposed as the first and second steps in the case of impossible laryngoscope-assisted tracheal intubation, respectively. In the case of impossible ventilation or difficult ventilation, the IMLA was recommended, followed by percutaneous transtracheal jet ventilation. The patient’s details, adherence rate to the algorithm, efficacy, and complications of airway management processes were recorded.

Results: Impossible ventilation never occurred during the 18-month study. One hundred cases of unexpected difficult airway were recorded (0.9%) among 11,257 intubations. Deviation from the algorithm was recorded in three cases, and two patients were wakened before any alternative intubation technique attempt. All remaining patients were successfully ventilated with either the facemask (89 of 95) or the ILMA™ (6 of 95). Six difficult-ventilation patients required the ILMA™ before completion of the first intubation step. Eighty patients were intubated with the gum elastic bougie, and 13 required a blind intubation through the ILMA™. Two patients ventilated with the ILMA™ were never intubated.

Conclusion: When applied in accordance with a predefined algorithm, the gum elastic bougie and the ILMA™ are effective to solve most problems occurring during unexpected difficult airway management.

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6 de junho de 2011

Artigo: Decision making in interhospital transport of critically ill patients: national questionnaire survey among critical care physicians

Erik Jan van Lieshout, Rien de Vos, JanM. Binnekade, Rob de Haan, Marcus J. Schultz, MargreethB. Vroom
Intensive Care Med (2008) 34:1269–1273


This study assessed the relative importance of clinical and transport-related factors in physicians’ decision-making regarding the interhospital transport of critically ill patients.

The medical heads of all 95 ICUs in The Netherlands were surveyed with a questionnaire using 16 case vignettes to evaluate preferences for transportability; 78 physicians (82%) participated. The vignettes varied in eight factors with regard to severity of illness and transport conditions.
Their relative weights were calculated for each level of the factors by conjoint analysis and expressed in β. The reference value (β = 0) was defined as the optimal conditions for critical care transport; a negative β indicated preference against transportability.

The type of escorting personnel (paramedic only: β = –3.1) and transport facilities (standard ambulance β = –1.21) had the greatest negative effect on preference for transportability. Determinants reflecting severity of illness were of relative minor importance (dose of noradrenaline β = –0.6, arterial 
oxygenation β = –0.8, level of peep β = –0.6). Age, cardiac arrhythmia, and the indication for transport had no significant effect.

Escorting personnel and transport facilities in interhospital transport were considered as most important by intensive care physicians in determining transportability. When these factors are optimal, even severely critically ill patients are considered able to undergo transport. Further clinical research should tailor transport conditions to optimize the use of expensive resources in those inevitable road trips.

Transportation of patients · Patient transfer · Interhospital transfer · Critical care · 
Questionnaire · Conjoint analysis

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1 de junho de 2011

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