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OBJECTIVE: to investigate the association between central line-associated bloodstream infections and clinical and care variables of intensive care unit patients with COVID-19 hospitalized at a reference public health institution. METHOD: a case-control study. RESULTS: the study sample consisted of 70 patients diagnosed with central line-associated bloodstream infections (case group) and 70 non-infected patients (control group). Most patients were male, with mean age of 57.93±13.93 years old and provided with a double lumen catheter. Median time of central line-associated bloodstream infections onset was 11 (8-18) days. Longer time on mechanical ventilation ( P =0.014; OR: 1.79; 95% CI: 0.91-3.51) and prone position ( P =0.017; OR: 2.41; 95% CI: 1.22-4.81) were associated with central line-associated bloodstream infections onset. CONCLUSION: longer time on invasive mechanical ventilation and prone position contributed to central line-associated bloodstream infections onset in COVID-19 patients.

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OBJECTIVES: To evaluate the comparative effectiveness and cost-effectiveness of peripherally inserted central catheters (PICCs) compared with centrally inserted central catheters (CICCs). METHODS: Prospective cohort study was followed by an economic analysis over a 30-day time horizon. Propensity score matching was used to select hospitalized adults with similar indications for PICC or CICC. The composite outcome was device removal or replacement because of complications before the end of treatment. The economic evaluation was based on a decision tree model for cost-effectiveness analysis, with calculation of the incremental cost-effectiveness ratio (ICER) per catheter removal avoided. All costs are presented in Brazilian reais (BRL) (1 BRL = 0.1870 US dollar). RESULTS: A total of 217 patients were followed in each group; 172 (79.3%) of those receiving a PICC and 135 (62.2%) of those receiving a CICC had no device-related complication, respectively. When comparing the events leading to device removal, the risk of composite endpoint was significantly higher in the CICC group (hazard ratio 0.20; 95% CI 0.11-0.35). The cost of PICC placement was BRL 1290.98 versus BRL 467.16 for a CICC. In the base case, the ICER for placing a PICC instead of a CICC was BRL 3349.91 per removal or replacement avoided. On univariate sensitivity analyses, the model proved to be robust within an ICER range of 2500.00 to 4800.00 BRL. CONCLUSIONS: PICC placement was associated with a lower risk of complications than CICC placement. Although the cost of a PICC is higher, its use avoided complications and need for catheter replacement before the end of treatment.

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Importance: Readmissions after an index heart failure (HF) hospitalization are a major contemporary health care problem. Objective: To evaluate the feasibility and efficacy of an intensive telemonitoring strategy in the vulnerable period after an HF hospitalization. Design, Setting, and Participants: This randomized clinical trial was conducted in 30 HF clinics in Brazil. Patients with left ventricular ejection fraction less than 40% and access to mobile phones were enrolled up to 30 days after an HF admission. Data were collected from July 2019 to July 2022. Intervention: Participants were randomly assigned to a telemonitoring strategy or standard care. The telemonitoring group received 4 daily short message service text messages to optimize self-care, active engagement, and early intervention. Red flags based on feedback messages triggered automatic diuretic adjustment and/or a telephone call from the health care team. Main Outcomes and Measures: The primary end point was change in N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline to 180 days. A hierarchical win-ratio analysis incorporating blindly adjudicated clinical events (cardiovascular deaths and HF hospitalization) and variation in NT-proBNP was also performed. Results: Of 699 included patients, 460 (65.8%) were male, and the mean (SD) age was 61.2 (14.5) years. A total of 352 patients were randomly assigned to the telemonitoring strategy and 347 to standard care. Satisfaction with the telemonitoring strategy was excellent (net promoting score at 180 days, 78.5). HF self-care increased significantly in the telemonitoring group compared with the standard care group (score difference at 30 days, -2.21; 95% CI, -3.67 to -0.74; P = .001; score difference at 180 days, -2.08; 95% CI, -3.59 to -0.57; P = .004). Variation of NT-proBNP was similar in the telemonitoring group compared with the standard care group (telemonitoring: baseline, 2593 pg/mL; 95% CI, 2314-2923; 180 days, 1313 pg/mL; 95% CI, 1117-1543; standard care: baseline, 2396 pg/mL; 95% CI, 2122-2721; 180 days, 1319 pg/mL; 95% CI, 1114-1564; ratio of change, 0.92; 95% CI, 0.77-1.11; P = .39). Hierarchical analysis of the composite outcome demonstrated a similar number of wins in both groups (telemonitoring, 49 883 of 122 144 comparisons [40.8%]; standard care, 48 034 of 122 144 comparisons [39.3%]; win ratio, 1.04; 95% CI, 0.86-1.26). Conclusions and Relevance: An intensive telemonitoring strategy applied in the vulnerable period after an HF admission was feasible, well-accepted, and increased scores of HF self-care but did not translate to reductions in NT-proBNP levels nor improvement in a composite hierarchical clinical outcome. Trial Registration: ClinicalTrials.gov Identifier: NCT04062461.

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Objective: to investigate the association between central line-associated bloodstream infections and clinical and care variables of intensive care unit patients with COVID-19 hospitalized at a reference public health institution. Method: a case-control study. Results: the study sample consisted of 70 patients diagnosed with central line-associated bloodstream infections (case group) and 70 non-infected patients (control group). Most patients were male, with mean age of 57.93±13.93 years old and provided with a double lumen catheter. Median time of central line-associated bloodstream infections onset was 11 (8-18) days. Longer time on mechanical ventilation ( P =0.014; OR: 1.79; 95% CI: 0.91-3.51) and prone position ( P =0.017; OR: 2.41; 95% CI: 1.22-4.81) were associated with central line-associated bloodstream infections onset. Conclusion: longer time on invasive mechanical ventilation and prone position contributed to central line-associated bloodstream infections onset in COVID-19 patients.

Objetivo: investigar la asociación entre infecciones de la circulación sanguínea relacionadas con catéter venoso central y variables clínicas y asistenciales de pacientes con COVID-19 ingresados en la unidad de cuidados intensivos de una institución pública de salud de referencia. Método: un estudio caso-control. Resultados: la muestra del estudio estuvo compuesta por 70 pacientes con diagnóstico de infección de la circulación sanguínea relacionada con catéter venoso central (grupo caso) y 70 pacientes no infectados (grupo control). La mayoría de los pacientes eran del sexo masculino, con edad media de 57,93±13,93 años y provistos de catéter de doble luz. El tiempo medio de aparición de las infecciones del torrente sanguíneo asociadas a catéter venoso central fue de 11 (8-18) días. Un mayor tiempo en ventilación mecánica ( P =0,014; RP: 1,79; IC 95%: 0,91-3,51) y en posición de decúbito prono ( P =0,017; RP: 2,41; IC del 95 %: 1,22-4,81) se asociaron con la aparición de infecciones de la circulación sanguínea relacionadas con catéter venoso central. Conclusión: un tiempo más prolongado con ventilación mecánica invasiva y posición de decúbito prono contribuyeron a la aparición de infecciones de la circulación sanguínea relacionadas con catéter venoso central en pacientes con COVID-19.

Objetivo: investigar a associação entre infecção primária de corrente sanguínea relacionada a cateter venoso central e variáveis clínicas e assistenciais de pacientes com COVID-19 internados na unidade de terapia intensiva de uma instituição pública de saúde de referência. Método: estudo caso-controle. Resultados: o estudo foi composto por 70 pacientes com diagnóstico de infecção primária de corrente sanguínea relacionada a cateter venoso central (grupo caso) e 70 pacientes sem infecção (grupo controle). Pacientes predominantemente do sexo masculino, média de idade de 57,93±13,93 anos e portadores de cateter de duplo lúmen. A mediana de tempo de ocorrência das infecções primárias de corrente sanguínea relacionadas a cateter venoso central foi de 11 (8-18) dias. Maior tempo em ventilação mecânica ( P =0,014; RP: 1,79; IC 95%: 0,91-3,51) e posição prona ( P =0,017; RP: 2,41; IC 95%: 1,22-4,81) foram associados à ocorrência de infecções primárias de corrente sanguínea relacionadas a cateter venoso central. Conclusão: maior tempo em ventilação mecânica invasiva e posição prona contribuíram para a ocorrência de infecções primárias de corrente sanguínea relacionadas a cateter venoso central em pacientes com COVID-19.

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IMPORTANCE: Readmissions after an index heart failure (HF) hospitalization are a major contemporary health care problem. OBJECTIVE: To evaluate the feasibility and efficacy of an intensive telemonitoring strategy in the vulnerable period after an HF hospitalization. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted in 30 HF clinics in Brazil. Patients with left ventricular ejection fraction less than 40% and access to mobile phones were enrolled up to 30 days after an HF admission. Data were collected from July 2019 to July 2022. INTERVENTION: Participants were randomly assigned to a telemonitoring strategy or standard care. The telemonitoring group received 4 daily short message service text messages to optimize self-care, active engagement, and early intervention. Red flags based on feedback messages triggered automatic diuretic adjustment and/or a telephone call from the health care team. MAIN OUTCOMES AND MEASURES: The primary end point was change in N-terminal pro-brain natriuretic peptide (NT-proBNP) from baseline to 180 days. A hierarchical win-ratio analysis incorporating blindly adjudicated clinical events (cardiovascular deaths and HF hospitalization) and variation in NT-proBNP was also performed. RESULTS: Of 699 included patients, 460 (65.8%) were male, and the mean (SD) age was 61.2 (14.5) years. A total of 352 patients were randomly assigned to the telemonitoring strategy and 347 to standard care. Satisfaction with the telemonitoring strategy was excellent (net promoting score at 180 days, 78.5). HF self-care increased significantly in the telemonitoring group compared with the standard care group (score difference at 30 days, -2.21; 95% CI, -3.67 to -0.74; P = .001; score difference at 180 days, -2.08; 95% CI, -3.59 to -0.57; P = .004). Variation of NT-proBNP was similar in the telemonitoring group compared with the standard care group (telemonitoring: baseline, 2593 pg/mL; 95% CI, 2314-2923; 180 days, 1313 pg/mL; 95% CI, 1117-1543; standard care: baseline, 2396 pg/mL; 95% CI, 2122-2721; 180 days, 1319 pg/mL; 95% CI, 1114-1564; ratio of change, 0.92; 95% CI, 0.77-1.11; P = .39). Hierarchical analysis of the composite outcome demonstrated a similar number of wins in both groups (telemonitoring, 49 883 of 122 144 comparisons [40.8%]; standard care, 48 034 of 122 144 comparisons [39.3%]; win ratio, 1.04; 95% CI, 0.86-1.26). CONCLUSIONS and relevance: An intensive telemonitoring strategy applied in the vulnerable period after an HF admission was feasible, well-accepted, and increased scores of HF self-care but did not translate to reductions in NT-proBNP levels nor improvement in a composite hierarchical clinical outcome.

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BACKGROUND: Immersive virtual reality (VR) is an innovative strategy for inpatient rehabilitation programs. Using immersive VR in early mobilization protocols has not yet been investigated in the setting of hospitalized patients with acute decompensated heart failure (ADHF), especially to improve perceived dyspnea, a common symptom of heart failure (HF). METHODS: This is a single-center parallel superiority randomized clinical trial. The study will be conducted at a public teaching hospital in Brazil from January 2023 to January 2024. The sample will include adult patients with ADHF hospitalized for at least 24 h, randomly assigned in a 1:1 ratio to the control (standard early mobilization protocol conducted in the intensive care unit (ICU)) or intervention group (the same standard early mobilization protocol but associated with immersive VR). The primary outcome will be assessing perceived dyspnea, and the secondary outcome will be assessing patient experience. DISCUSSION: Using immersive VR in early mobilization protocols in the ICU is expected to improve perceived dyspnea in patients with ADHF as well as patient experience regarding care. This study has the potential to increase patient adherence to early mobilization protocols in the setting of ADHF as well as to promote a positive patient experience. Filling this gap could promote the rational incorporation of technologies in health care. TRIAL REGISTRATION: This study protocol is in its first version. CLINICALTRIALS: gov NCT05596292. Registered on 1 December 2022.

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PURPOSE: This study aims to perform specific causal validation of nursing diagnosis Risk for thrombosis (00291) of the NANDA International (NANDA-I) classification. METHODS: This is a case-control study conducted in a university hospital from January to October 2020. A total of 516 adult patients were included-344 in the Case Group (with venous or arterial thrombosis evidenced by imaging) and 172 in the Control Group (without thrombosis). Statistical analysis was performed by univariate and multivariate logistic regression test, and odds ratios were calculated to measure the effect of exposure between groups. The study was approved by the Research Ethics Committee. FINDINGS: The patients were predominantly female and aged 59 ± 16 years. In the univariate logistic analysis, five risk factors were significantly associated with thrombosis, two at-risk populations and 12 associated conditions. In the multivariate regression model, the following risk factors remained independently associated (p < 0.05): inadequate knowledge of modifiable factors (OR: 3.03; 95% CI: 1.25-8.56) and ineffective medication self-management (OR: 3.2; 95% CI:1.77-6.26); at-risk populations with history (OR: 2.16; 95% CI: 1.29-3.66) and family history of thrombosis (OR:2.60; 95% CI: 1.03-7.49); and the conditions associated with vascular diseases (OR:6.12; 95% CI:1.69-39.42), blood coagulation disorders (OR: 5.14; 95% CI:1.85-18.37), atherosclerosis (OR:2.07; 95% CI: 1.32-3.27), critical illness (OR: 2.28; 95% CI: 1.42-3.70), and immobility (OR: 2.09; 95% CI: 1.10-4.12). CONCLUSIONS: The clinical validation allowed to establish strong evidence for the refinement of the diagnosis Risk for thrombosis and, consequently, to raise its level of evidence in the classification of NANDA-I. IMPLICATIONS FOR NURSING PRACTICE: The evidence pointed out by this study favors the establishment of thrombosis diagnosis in an accurate way by nurses in clinical practice, directing preventive interventions to patients in this risk condition.

OBJETIVO: Realizar a validação causal específica do diagnóstico de enfermagem Risco de trombose (00291) da classificação diagnóstica da NANDA International, Inc. MÉTODOS: Estudo de caso-controle, realizado em hospital universitário entre janeiro e outubro de 2020. Foram incluídos 516 pacientes adultos - 344 no Grupo Caso (com trombose venosa ou arterial evidenciada em exame de imagem) e 172 no Grupo Controle (sem trombose). A análise estatística ocorreu por teste de regressão logística univariada e multivariada, e Odds ratios calculados para medir o efeito da exposição entre os grupos. O estudo foi aprovado em Comitê de Ética. RESULTADOS: Os pacientes foram predominantemente do sexo feminino e idade de 59±16 anos. Na análise logística univariada foi associado significativamente á trombose: cinco fatores de risco, duas populações em risco e 12 condições associadas. No modelo de regressão multivariada permaneceram independentemente associados (P<0,05) os fatores de risco conhecimento inadequado sobre os fatores modificáveis (OR:3,03; IC95%:1,25-8,56) e autogestão ineficaz de medicamentos (OR:3,24; IC95%:1,77-6,26); as populações em risco com história prévia (OR:2,16; IC95%:1,29-3,66) e história familiar de trombose (OR:2,60; IC95%:1,03-7,49); e as condições associadas a doenças vasculares (OR:6,12; IC95%:1,69-39,42), distúrbios de coagulaçõo (OR:5,14; IC95%:1,85-18,37),aterosclerose (OR:2,07; IC95%:1,32-3,27), doença crítica (OR:2,28; IC95%:1,42-3,70) e imobilidade (OR:2,09; IC95%:1,10-4,12). CONCLUSÕES: A validação clínica permitiu estabelecer fortes evidências para o refinamento do diagnóstico Risco de trombose e, consequentemente, elevar seu nível de evidência na classificação da NANDA-I. IMPLICAÇÕES PARA A PRÁTICA: As evidências apontadas pelo estudo favorecem o estabelecimento deste diagnóstico de forma acurada pelos enfermeiros na prática clínica, direcionando intervenções preventivas aos pacientes nesta condiçõo de risco.

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BACKGROUND: Patients admitted with acute decompensated heart failure (HF) are subject to developing worsening episodes that require more complex interventions. The Acute Decompensated Heart Failure National Registry (ADHERE) risk model was developed in the United States to predict the risk of in-hospital worsening HF. OBJECTIVE: To use the ADHERE risk model in the assessment of risk of in-hospital worsening HF and to determine its sensitivity and specificity in hospitalized patients. METHODS: This cohort study was conducted at a Brazilian public university hospital, and data from 2013 to 2020 were retrospectively collected. P values < 0.05 were considered statistically significant. RESULTS: A total of 890 patients with a mean age of 74 ± 8 years were included. The model showed that, in the group of 490 patients at risk, 254 (51.8%) developed in-hospital worsening HF. In the group of 400 patients not at risk, only 109 (27.2%) experienced worsening HF. The results demonstrated a statistically significant curve (area under the curve = 0.665; standard error = 0.018; P < 0.01; confidence interval = 0.609 to 0.701), indicating good accuracy. The model had a sensitivity of 69.9% and a specificity of 55.2%, with a positive predictive value of 52% and a negative predictive value of 72.7%. CONCLUSIONS: In this cohort, we showed that the ADHERE risk model was able to discriminate patients who in fact developed worsening HF during the admission period, from those who did not.

FUNDAMENTO: Pacientes hospitalizados com insuficiência cardíaca (IC) aguda descompensada estão sujeitos a desenvolver episódios de piora que requerem intervenções mais complexas. O modelo de predição de risco "Acute Decompensated Heart Failure National Registry" (ADHERE) foi desenvolvido nos Estados Unidos para prever o risco de piora intra-hospitalar da IC. OBJETIVO: Utilizar o modelo de predição de risco ADHERE para avaliar o risco de piora intra-hospitalar da IC e determinar a sua sensibilidade e especificidade em pacientes hospitalizados. MÉTODOS: O presente estudo de coorte foi realizado em um hospital universitário público brasileiro e os dados de 2013 a 2020 foram coletados retrospectivamente. Foram considerados estatisticamente significativos valores de p < 0,05. RESULTADOS: Foram incluídos 890 pacientes com idade média de 74 ± 8 anos. O modelo mostrou que no grupo de 490 pacientes de risco, 254 (51,8%) desenvolveram piora intra-hospitalar da IC. No grupo de 400 pacientes sem risco, apenas 109 (27,2%) apresentaram piora da IC. Os resultados demonstraram uma curva estatisticamente significativa (área sob a curva = 0,665; erro padrão = 0,018; p < 0,01; intervalo de confiança = 0,609 a 0,701), indicando boa precisão. O modelo apresentou sensibilidade de 69,9% e especificidade de 55,2%, com valor preditivo positivo de 52% e valor preditivo negativo de 72,7%. CONCLUSÕES: Na presente coorte, demonstramos que o modelo de predição de risco ADHERE foi capaz de discriminar pacientes que, de fato, desenvolveram piora da IC durante o período de internação daqueles que não desenvolveram.

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BACKGROUND: The measurement and identification of plasma biomarkers can support the estimation of risk and diagnosis of deep vein thrombosis (DVT) associated with the use of a peripherally inserted central catheter (PICC). OBJECTIVES: This systematic review and meta-analysis aimed to identify the association between the levels of potential biomarkers that reflect the activation of the blood system, long-term vascular complications, inflammatory system, and the occurrence of PICC-related DVT. METHODS: Seven electronic databases (Embase, Web of Science, Medline, Scopus, Cinahl, Cochrane Central Register of Controlled Trials, and ERIC) were searched to identify literature published until December 2022. Studies were required to report: (I) adult and pediatric patients, outpatient or admitted to clinical, surgical, or ICU with PICC; (II) patients with PICC-related DVT and patients without PICC-related DVT as a comparator; and (III) at least one biomarker available. The Newcastle-Ottawa Scale was used to evaluate the quality of the studies. Study precision was evaluated by using a funnel plot for platelets level. We provided a narrative synthesis and meta-analysis of the findings on the biomarkers' outcomes of the studies. We pooled the results using random effects meta-analysis. The meta-analysis was conducted using Review Manager software v5.4. This systematic review is registered in PROSPERO (CRD42018108871). RESULTS: Of the 3564 studies identified (after duplication removal), 28 were included. PICC-related DVT was associated with higher D-dimers (0.37 µg/mL, 95% CI 0.02, 0.72; p = 0.04, I2 = 92%; p for heterogeneity < 0.00001) and with higher platelets (8.76 × 109/L, 95% CI 1.62, 15.91; p = 0.02, I2 = 41%; p for heterogeneity = 0.06). CONCLUSIONS: High levels of D-dimer and platelet were associated with DVT in patients with PICC. However, biomarkers such as APTT, fibrinogen, FDP, glucose, hemoglobin, glycated hemoglobin, INR, prothrombin time, prothrombin fragment 1.2, the thrombin-antithrombin complex, and WBC were not related to the development of DVT associated with PICC.

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BACKGROUND: Peripheral intravenous catheter (PIVC) insertion is the most common invasive procedure in the hospital setting. Ultrasound guided PIVC insertion in specific populations and settings has shown patient care benefits. OBJECTIVE: To compare the success rate of first attempts of ultrasound guided PIVC insertion performed by nurse specialists with conventional PIVC insertion performed by nurse assistants. METHOD: Randomized, controlled, single-center clinical trial registered on the ClinicalTrials.gov platform under registration NTC04853264, conducted at a public university hospital from June to September 2021. Adult patients hospitalized in clinical inpatient units with an indication for intravenous therapy compatible with a peripheral venous network were included. Participants in the intervention group (IG) received ultrasound guided PIVC performed by nurse specialists from the vascular access team, while those in the control group (CG) received conventional PIVC by nurse assistants. RESULTS: The study included a total of 166 patients: IG (n = 82) and CG (n = 84), mean age 59.5 ± 16.5 years, mostly women (n = 104, 62.7%) and white (n = 136, 81.9%). Success rate on the first attempt of PIVC insertion in IG was 90.2% and in CG was 35.7% (p < 0.001), with a relative risk of 2.5 (95% CI 1.88-3.40) for success in IG versus CG. Overall assertiveness rate was 100% in IG and 71.4% in CG. Regarding procedure performance time, the medians in IG and CG were 5 (4-7) and 10 (6-27.5) min respectively (p < 0.001). As for the incidence of negative composite outcomes, IG had lower rates compared to CG, 39% versus 66.7% (p < 0.001), generating a 42% lower probability of negative outcomes in IG, 0.58 (95% CI: 0.43-0.80). CONCLUSION(S): Successful first-try insertion was higher in the group receiving ultrasound-guided PIVC. Moreover, there were no insertion failures and IG presented lower insertion time rates and incidence of unfavorable outcomes.