Estudio piloto para evaluar un protocolo de cuidado de enfermería en neonatos de un hospital nivel III

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Abstract

Introducción: La instalación de un catéter central de inserción percutánea es una acción del profesional de Enfermería que constituye una estrategia de cuidado. Objetivo: Evaluar el cumplimiento del protocolo de inserción del catéter central de inserción percutánea en una Unidad Neonatal en la ciudad de Medellín-Colombia. Metodología: Estudio descriptivo, efectuado entre marzo-abril de 2012, para el cual se utilizó un muestreo no probabilístico y se implementaron tres listas de chequeo (inserción, curación y seguimiento) para la evaluación del proceso de inserción. Resultados: El cumplimiento del protocolo de inserción fue 92%; se resaltan como aspectos importantes para la inserción los siguientes: el catéter que más se utilizó (83.3%) fue el de una sola pieza, la región ante cubital fue el lugar que con mayor frecuencia se colocó (41.7%), la punta del catéter intracardiaco fue el sitio que con mayor frecuencia se puso (25%) ; el tiempo promedio de permanencia del catéter fue 10 días y la principal causa de retiro del mismo fue la finalización del tratamiento (70%), seguida de la presencia de cordón flebítico (20%). Conclusiones: Existe una alta adherencia al protocolo, posiblemente porque en el servicio se hace con mucha frecuencia revisión de estándares y por otro lado, educación permanente al personal de enfermería. No obstante, la complicación más relevante fue el cordón flebítico probablemente por el desplazamiento de la punta del catéter y la continuidad de infusión de la nutrición parenteral de alta osmolaridad.

Translated abstract

Introduction: The installation of a percutaneously inserted central catheter is an action of the nurse, which is a strategy of care. Objective: To evaluate the compliance of the insertion protocol of the percutaneously inserted central catheter in a Neonatal Intensive Care Unit in the city of Medellin, Colombia. Methodology: Descriptive study conducted between March-April 2012, for which a non-probability sampling was used and three checklists were implemented (insertion, healing and monitoring) to evaluate the insertion process. Results: The insertion protocol compliance was 92%. Some relevant aspects for the insertion are highlighted: the most commonly used catheter was the one made with one piece (83.3%), the antecubital region was the place where the catheter was most frequently used (41.7%), intracardiac catheter tip was the site where the catheter was most frequently placed (25%), The average residence time of the catheter was of 10 days and the main reason for removal was the completion of treatment (70%), followed by the presence of phlebitic cord (20%). Conclusions: There is a high adherence to the protocol, possibly because during the service, standards are frequently revised and on the other hand, the continuing education of nurses. However, the most relevant complication was phlebitic cord, probably because of the displacement of the catheter tip and the continued infusion of parenteral nutrition of high osmolarity.

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Peripherally inserted central venous catheters in the acute care setting: A safe alternative to high-risk short-term central venous catheters.

Basel Al Raiy, Mohamad Fakih, Nicole Bryan-Nomides … (2010)

Peripherally inserted central venous catheters (PICCs) serve as an alternative to short-term central venous catheters (CVCs) for providing intravenous (IV) access in the hospital. It is not clear which device has a lower risk of central line-associated bloodstream infection (CLABSI). We compared CVC- and PICC-related CLABSI rates in the setting of an intervention to remove high-risk CVCs. We prospectively followed patients with CVCs in the non-intensive care units (ICUs) and those with PICCs hospital-wide. A team evaluated the need for the CVC and the risk of infection, recommended the discontinuation of unnecessary or high-risk CVCs, and suggested PICC insertion for patients requiring prolonged access. Data on age, gender, type of catheter, duration of catheter utilization, and the development of CLABSIs were obtained. A total of 638 CVCs were placed for 4917 catheter-days, during which 12 patients had a CLABSI, for a rate of 2.4 per 1000 catheter-days. A total of 622 PICCs were placed for 5703 catheter-days, during which 13 patients had a CLABSI, for a rate of 2.3 per 1000 catheter-days. The median time to development of infection was significantly longer in the patients with a PICC (23 vs 13 days; P=.03). In the presence of active surveillance and intervention to remove unnecessary or high-risk CVCs, CVCs and PICCs had similar rates of CLABSIs. Given their longer time to the development of infection, PICCs may be a safe alternative for prolonged inpatient IV access. 2010 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Mosby, Inc. All rights reserved.

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Making health care safer: a critical analysis of patient safety practices.

W. Colin Duncan, Jennifer Markowitz, K Shojania … (2000)

Patient safety has received increased attention in recent years, but mostly with a focus on the epidemiology of errors and adverse events, rather than on practices that reduce such events. This project aimed to collect and critically review the existing evidence on practices relevant to improving patient safety. Patient safety practices were defined as those that reduce the risk of adverse events related to exposure to medical care across a range of diagnoses or conditions. Potential patient safety practices were identified based on preliminary surveys of the literature and expert consultation. This process resulted in the identification of 79 practices for review. The practices focused primarily on hospitalized patients, but some involved nursing home or ambulatory patients. Protocols specified the inclusion criteria for studies and the structure for evaluation of the evidence regarding each practice. Pertinent studies were identified using various bibliographic databases (e.g., MEDLINE, PsycINFO, ABI/INFORM, INSPEC), targeted searches of the Internet, and communication with relevant experts. Included literature consisted of controlled observational studies, clinical trials and systematic reviews found in the peer-reviewed medical literature, relevant non-health care literature and "gray literature." For most practices, the project team required that the primary outcome consist of a clinical endpoint (i.e., some measure of morbidity or mortality) or a surrogate outcome with a clear connection to patient morbidity or mortality. This criterion was relaxed for some practices drawn from the non-health care literature. The evidence supporting each practice was summarized using a prospectively determined format. The project team then used a predefined consensus technique to rank the practices according to the strength of evidence presented in practice summaries. A separate ranking was developed for research priorities. Practices with the strongest supporting evidence are generally clinical interventions that decrease the risks associated with hospitalization, critical care, or surgery. Many patient safety practices drawn primarily from nonmedical fields (e.g., use of simulators, bar coding, computerized physician order entry, crew resource management) deserve additional research to elucidate their value in the health care environment. The following 11 practices were rated most highly in terms of strength of the evidence supporting more widespread implementation. Appropriate use of prophylaxis to prevent venous thromboembolism in patients at risk; Use of perioperative beta-blockers in appropriate patients to prevent perioperative morbidity and mortality; Use of maximum sterile barriers while placing central intravenous catheters to prevent infections; Appropriate use of antibiotic prophylaxis in surgical patients to prevent postoperative infections; Asking that patients recall and restate what they have been told during the informed consent process; Continuous aspiration of subglottic secretions (CASS) to prevent ventilator-associated pneumonia; Use of pressure relieving bedding materials to prevent pressure ulcers; Use of real-time ultrasound guidance during central line insertion to prevent complications; Patient self-management for warfarin (Coumadin) to achieve appropriate outpatient anticoagulation and prevent complications; Appropriate provision of nutrition, with a particular emphasis on early enteral nutrition in critically ill and surgical patients; and Use of antibiotic-impregnated central venous catheters to prevent catheter-related infections. An evidence-based approach can help identify practices that are likely to improve patient safety. Such practices target a diverse array of safety problems. Further research is needed to fill the substantial gaps in the evidentiary base, particularly with regard to the generalizability of patient safety practices heretofore tested only in limited settings and to promising practices drawn from industries outside of health care.