RESUMO
Historically, the wards of hospitals were divided by services such as medicine, surgery and traumatology, among others. To optimize the use of beds, undifferentiated medical surgical services were implemented in different hospitals in the country. This work organization had consequences in several areas, such as teamwork, the sense of belonging, the quality of teaching and travel times, among other factors. In 2018, at a Clinical hospital, we started a quality improvement project that consisted of assigning low complexity internal medicine teams to limited geographic areas, aiming to have sectorized teams. Through some PlanStudy-Do-Act (PDSA) cycles of continuous improvement, more than 80% of the patients were quickly sectorized, however there were multiple threats during the project. Pre- and post-implementation surveys were conducted with nurses, internal medicine residents, and medical Staff, highlighting an improvement in multiple aspects concerning the quality of communication, interdisciplinary work, the time of visits, and satisfaction, among others.
Assuntos
Humanos , Satisfação do Paciente , Hospitais , Equipe de Assistência ao Paciente , Pacientes , Melhoria de QualidadeRESUMO
Historically, the wards of hospitals were divided by services such as medicine, surgery and traumatology, among others. To optimize the use of beds, undifferentiated medical surgical services were implemented in different hospitals in the country. This work organization had consequences in several areas, such as teamwork, the sense of belonging, the quality of teaching and travel times, among other factors. In 2018, at a Clinical hospital, we started a quality improvement project that consisted of assigning low complexity internal medicine teams to limited geographic areas, aiming to have sectorized teams. Through some PlanStudy-Do-Act (PDSA) cycles of continuous improvement, more than 80% of the patients were quickly sectorized, however there were multiple threats during the project. Pre- and post-implementation surveys were conducted with nurses, internal medicine residents, and medical Staff, highlighting an improvement in multiple aspects concerning the quality of communication, interdisciplinary work, the time of visits, and satisfaction, among others.
Assuntos
Hospitais , Satisfação do Paciente , Humanos , Melhoria de Qualidade , Pacientes , Equipe de Assistência ao PacienteRESUMO
We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.
Assuntos
Humanos , Feminino , Adulto , Pielonefrite Xantogranulomatosa/cirurgia , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapia , Diálise Renal , NefrectomiaRESUMO
Low molecular weight heparin-induced hyperkalemia is not an uncommon side effect. The development of hyponatremia is well described although it is less common. We report a 72-year-old woman with lumbar metastases who developed hyponatremia and hyperkalemia on the tenth day of hospitalization. Hyponatremia, with limited criteria for syndrome of inappropriate secretion of antidiuretic hormone, did not resolve with vigorous volume restriction. Hyperkalemia without an acid-base disorder or baseline renal failure, did not resolve after losartan was stopped. Enoxaparin-induced hypoaldosteronism was proposed and the drug was discontinued. After four days' persistence of the electrolyte disturbance, dexamethasone was changed to Hydrocortisone, and parameters normalized in 24 hours. The patient remained well until discharge and during outpatient control.
Assuntos
Hiperpotassemia , Hiponatremia , Síndrome de Secreção Inadequada de HAD , Idoso , Feminino , Heparina de Baixo Peso Molecular , Hospitalização , Humanos , Hiperpotassemia/induzido quimicamente , Hiponatremia/induzido quimicamenteRESUMO
Low molecular weight heparin-induced hyperkalemia is not an uncommon side effect. The development of hyponatremia is well described although it is less common. We report a 72-year-old woman with lumbar metastases who developed hyponatremia and hyperkalemia on the tenth day of hospitalization. Hyponatremia, with limited criteria for syndrome of inappropriate secretion of antidiuretic hormone, did not resolve with vigorous volume restriction. Hyperkalemia without an acid-base disorder or baseline renal failure, did not resolve after losartan was stopped. Enoxaparin-induced hypoaldosteronism was proposed and the drug was discontinued. After four days' persistence of the electrolyte disturbance, dexamethasone was changed to Hydrocortisone, and parameters normalized in 24 hours. The patient remained well until discharge and during outpatient control.
Assuntos
Humanos , Feminino , Idoso , Hiperpotassemia/induzido quimicamente , Hiponatremia/induzido quimicamente , Síndrome de Secreção Inadequada de HAD , Heparina de Baixo Peso Molecular , HospitalizaçãoRESUMO
We report a 32-year-old woman with chronic kidney disease on hemodialysis undergoing a nephrectomy for left xanthogranulomatous pyelonephritis with a coralliform calculus and septic shock. Her clinical evolution was torpid, subfebrile, with persistent elevation of inflammatory parameters and with the finding of intra-abdominal collections interpreted as post-surgical. Finally faced with microbiological evidence of infection of the collections, the patient was operated and tended to improve. Subsequently, she underwent a difficult mechanical ventilation weaning, identifying the abrupt discontinuation of benzodiazepines as a contributing factor to agitation. We report this patient for educational purposes and to reinforce some quality-of-care concepts such as safety and opportunity of healthcare.
Assuntos
Pielonefrite Xantogranulomatosa , Insuficiência Renal Crônica , Adulto , Feminino , Humanos , Nefrectomia , Pielonefrite Xantogranulomatosa/cirurgia , Diálise Renal , Insuficiência Renal Crônica/complicações , Insuficiência Renal Crônica/terapiaRESUMO
In patients with actively bleeding gastric varices, the treatment of choice is the endoscopic use of sclerosing agents such as cyanoacrylate. We report a 69-year-old man who, after being treated with cyanoacrylate, suffered from recurrent febrile episodes. After an extensive study and broad-spectrum antibiotic treatment, discarding other presumably infectious focus, the superinfection of the cyanoacrylate plug was suspected, and its surgical removal was decided. A partial gastrectomy of the gastric fundus, a splenectomy, and a distal pancreatectomy were performed. The patient evolved without fever and without new episodes of bacteremia, but with decompensation of his cirrhosis manifested by ascites, spontaneous bacterial peritonitis, pneumonia, and collections in the pancreatic bed. These complications were managed with medical treatment consisting in a long course of broad-spectrum antibiotics. Thereafter, the patient evolved satisfactorily.
Assuntos
Idoso , Humanos , Masculino , Varizes Esofágicas e Gástricas , Cianoacrilatos , Soluções Esclerosantes/uso terapêutico , Hemorragia Gastrointestinal/tratamento farmacológico , Cirrose HepáticaRESUMO
In patients with actively bleeding gastric varices, the treatment of choice is the endoscopic use of sclerosing agents such as cyanoacrylate. We report a 69-year-old man who, after being treated with cyanoacrylate, suffered from recurrent febrile episodes. After an extensive study and broad-spectrum antibiotic treatment, discarding other presumably infectious focus, the superinfection of the cyanoacrylate plug was suspected, and its surgical removal was decided. A partial gastrectomy of the gastric fundus, a splenectomy, and a distal pancreatectomy were performed. The patient evolved without fever and without new episodes of bacteremia, but with decompensation of his cirrhosis manifested by ascites, spontaneous bacterial peritonitis, pneumonia, and collections in the pancreatic bed. These complications were managed with medical treatment consisting in a long course of broad-spectrum antibiotics. Thereafter, the patient evolved satisfactorily.
Assuntos
Cianoacrilatos , Varizes Esofágicas e Gástricas , Idoso , Hemorragia Gastrointestinal/tratamento farmacológico , Humanos , Cirrose Hepática , Masculino , Soluções Esclerosantes/uso terapêuticoRESUMO
BACKGROUND: Detecting patients at risk of falls during hospital stay is of utmost importance to implement preventive measures. AIM: To determine the frequency of patients with a high risk of falls admitted to a medical-surgical ward. To assess the preventive measures implemented. MATERIALS AND METHODS: Review of medical records of 376 patients aged 20 to 97 years (28% older than 70 years) admitted to a clinical hospital in a period of four months. RESULTS: Eleven percent of patients had a history of falls, 50% had a sensory deficit, 68% had unstable gait, 8% had a neurological risk condition, 8% had drowsiness or disorientation, 4% had psychomotor agitation or delirium, 86 % used high risk medications, 73% used 2 or more high risk drugs and 72% were using devices that decrease mobility. One hundred forty-one patients (38%) had a high risk of falling. The mean age of the latter was 77 years, 89% had a sensory deficit, 96% had unstable gait, 4% had psychomotor agitation or delirium and 98% used high risk drugs. Less than 1% had a medical prescription of a caregiver, physical restraints or antipsychotics, however, 21% of patients had a caregiver. CONCLUSIONS: The percentage of patients with a high risk of falling is important. The main risk factors were sensory deficit, unstable gait and the use of high risk medications. The low frequency of preventive measures prescriptions is striking.
Assuntos
Acidentes por Quedas/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Pacientes Internados/estatística & dados numéricos , Acidentes por Quedas/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Chile , Humanos , Incidência , Tempo de Internação , Pessoa de Meia-Idade , Fatores de Risco , Adulto JovemRESUMO
Background: Medical emergencies (ME) in hospitalized patients (cardiac and respiratory arrest, suffocation, asphyxia, seizures, unconsciousness) are associated with high morbidity and mortality. Most of these patients have signs of physiological deterioration prior to the appearance of the emergency. Early detection of warning signs by rapid response teams (RRT) may provide an opportunity for the prevention of major adverse events. Aim: To identify clinical signs predicting death, need for mechanical ventilation, or transfer to a more complex unit during the 72 hours prior to the activation of the ME code. To evaluate the association of each trigger with specific major adverse events. Patients and Methods: Medical records of 184 hospitalized adult patients in whom the ME code was activated between 2009 and 2014 were reviewed. Results: Seventy five percent patients who experienced a ME had predictive signs of poor clinical outcome. Polypnea and airway involvement were associated to mechanical ventilation. Hypotension and hypoxemia were associated with mortality. Conclusions: In the absence of RRT, special attention should be given to patients with polypnea, airway involvement, hypotension and desaturation, since these are associated with poor clinical outcomes.