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Resumen Introduccion El diagnostico y el tratamiento precoces de la sepsis sigue siendo un reto en los servicios de urgencias hospitalarios. Objetivo El objetivo es evaluar el rendimiento de la escala quick Sequential related Organ Failure Assessment (qSOFA) para la activacion de un Codigo Sepsis en urgencias, respecto la aplicacion de los criterios previos basados en los parametros Systemic Inflammatory Response Syndrome (SIRS). Metodos Se incluyeron los pacientes ≥ 18 anos que consultaron en un servicio de urgencias de un hospital de tercer nivel durante dos periodos de tiempo (mayo-octubre de 2015) mediante criterios SIRS (grupo SIRS), y en los mismos meses de 2017 mediante criterios qSOFA (grupo qSOFA). Resultados Se analizaron 125 episodios: 70 correspondieron al grupo SIRS y 55 al grupo qSOFA. Los grupos fueron comparables respecto a antecedentes, con mayor presencia de enfermedad neoplasica en el grupo qSOFA. No se evidenciaron diferencias en la forma de presentacion, la actuacion realizada en urgencias, los ingresos en unidades de criticos, el uso de vasopresores o la estancia media hospitalaria entre los dos grupos. Si se objetivo una mayor tasa de mortalidad a 30 dias en el grupo qSOFA (21,81% vs 4,3%; p = 0,003). En el estudio multivariado destaca la enfermedad neoplasica como factor independiente de mal pronostico (OR: 5,36; p = 0,01), y la activacion mediante criterios SIRS como factor de buen pronostico (OR: 0,15; p = 0,021). Conclusiones La activacion del Codigo Sepsis mediante criterios qSOFA comporta una disminucion en la deteccion, con mayor mortalidad asociada. Es necesario buscar otras herramientas complementarias para la deteccion precoz de la sepsis en urgencias.

The early diagnosis and treatment of sepsis remains a challenge in hospital emergency departments.The objective was to evaluate the performance of the qSOFA (quick Sequential related Organ Failure Assessment) for activating a Sepsis Code in the emergency department, compared to applying previous criteria based on SIRS (Systemic Inflammatory Response Syndrome).Patients ≥18years were included who consulted an emergency department of a tertiary hospital over two periods of time (May-October 2015), using SIRS criteria (SIRS Group) and over the same months in 2017 using qSOFA criteria (qSOFA Group).One hundred and five episodes were analysed: 70 corresponded to the SIRS Group and 55 to the qSOFA Group. The groups were comparable in terms of history, with a greater presence of neoplastic disease in the qSOFA Group. No differences were observed in the form of presentation, the action taken in the emergency department, admissions to critical care units, use of vasopressors or mean hospital stay between the two groups. A higher 30-day mortality rate was observed in the qSOFA group (21.81% vs. 4.3%; P=.003). In the multivariate study, neoplastic disease was noteworthy as an independent factor of poor prognosis (OR 5.36; P=.01), and activation using the SIRS criteria as a factor of good prognosis (OR .15; P=.021).The activation of the Sepsis Code using qSOFA criteria results in a reduction in detection, with greater associated mortality. Other complementary tools need to be sought for the early detection of sepsis in the emergency department.

Resumen Objetivos Evaluar el impacto de la implantacion de un codigo sepsis (CS) en la evolucion de pacientes con sepsis grave (SG)/shock septico (SS). Determinar los factores independientes asociados a mortalidad. Metodo Estudio de cohortes de pacientes con diagnostico de SG/SS que consultaron en urgencias de un hospital terciario durante 6 meses. Se analiza el cumplimiento de las recomendaciones de la Surviving Sepsis Campaign, la estancia media, el ingreso en criticos y la mortalidad a 30 dias. Se comparan 2 grupos: activacion CS (A) y no activacion (NA). Resultados Se detectaron 114 episodios, 61,4% del grupo A y 38,6% del NA. El grupo A presenta con mayor frecuencia presion arterial sistolica 3 mmol/l (48,3% vs 80%; p = 0,01) y foco abdominal (34,3% vs 13%; p = 0,01). En el grupo A mas frecuentemente se cursaron hemocultivos en la primera hora (95% vs 41,7%; p Una determinacion de proteina C reactiva > 200 mg/l (odds ratio 33,7; p Conclusiones La implantacion de un CS mejora el cumplimiento de las recomendaciones y se asocia a una reduccion de los ingresos en unidades de criticos, estancia media y mortalidad. La elevacion de la proteina C reactiva y la no activacion del codigo son factores independientes asociados a mortalidad. Existe un gran margen de mejora en la deteccion de los pacientes con SG/SS, asi como en la optimizacion del tratamiento inicial en urgencias.

Diagnostic errors have to be recognised as a possible adverse event inherent to clinical activity and incorporate them as another quality indicator. Different sources of information report their frequency, although they may still be underestimated. Contrary to what one could expect, in most cases, it does not occur in infrequent diseases. Causes can be complex and multifactorial, with individual cognitive aspects, as well as the health system. These errors can have an important clinical and socioeconomic impact. It is necessary to learn from diagnostic errors in order to develop an accurate and reliable system with a high standard of quality.

Resumen Debemos reconocer el error diagnostico como un episodio adverso posible e inherente al acto clinico, e incorporarlo con normalidad al resto de los indicadores de calidad asistencial. Por diferentes fuentes de informacion podemos conocer su frecuencia, aunque probablemente todavia esta subestimada. En contra de lo que se podria suponer, en la mayoria de los casos no acontece en enfermedades infrecuentes. Sus causas suelen ser complejas y multifactoriales, con aspectos tanto cognitivos individuales como del sistema. Estos errores pueden tener un gran impacto clinico y socioeconomico. Es necesario aprender de los errores diagnosticos para desarrollar un sistema seguro, propio de una cultura de calidad.

Resumen: Antecedentes: Poder aprender de sus errores supone para los clínicos un elemento de gran interés. Esta función la plantea la retroinformación clínica en sentido formativo (feedback), reconocida como un elemento útil en la mejora de la calidad asistencial y la seguridad clínica. Objetivos: Describir nuestra experiencia en feedback formativo, analizando las características de los casos clínicos incorporados, así como la opinión de los profesionales que recibieron la formación. Material y métodos: Estudio descriptivo, que recoge la experiencia de un año, en la práctica de feedback formativo sobre incidentes clínicos. Se determinó: fuente de notificación, descripción del incidente e impacto clínico, mensajes clave y tipo de feedback (grupal y/o individual). Así mismo, se planteó una encuesta de opinión al grupo de facultativos. Resultados: Se incluyeron 27 casos, que suponen un 0,06% de las asistencias. Las fuentes de notificación fueron: el propio SUH en 19 (70,3%) casos, unidad de atención a la ciudadanía en 3 (11,1%), dirección de calidad en 2 (7,4%), unidad de admisiones en 2 (7,4%) y servicio de microbiología en uno (3,7%). Los casos correspondían en un 7,4% a aspectos de carácter diagnóstico, 40,7% terapéutico, y 55,5% de ambos. La encuesta a los profesionales, aunque con una participación del 36%, mostró unas valoraciones positivas en todos los aspectos planteados. Conclusiones: Incorporar el feedback formativo para los profesionales resulta factible, parece ser bien recibido y podría representar una herramienta útil en la mejora de la seguridad clínica. Abstract: Background: To learn from one's mistakes is an element of great interest for clinicians. This strategy is proposed as clinical feedback in a training sense, recognized as a useful element for the improvement of healthcare quality and clinical safety. Objectives: To describe our experience in training feedback, analysing the characteristics of the clinical cases included, as well as the opinion of the professionals who received the training. Material and methods: A descriptive study, which gathers the experience of one year in the practice of educational feedback on clinical incidents. Source of notification, description of the incident and clinical impact, key messages and type of feedback (individual and / or group level) were determined. In addition, an opinion survey was proposed to all the doctors. Results: 27 cases were included, which represent .06% of the total medical care provided. The sources of notification were the emergency department in 19 (70.3%) cases, citizenship unit 3 (11.1%), quality management 2 (7.4%), admissions unit 2 (7.4%) and microbiology department 1 (3.7%). Of the cases, 7.4% corresponded to aspects related to diagnosis, 40.7% to therapy, and 55.5% to both. The survey for professionals showed a predominance of positive assessments in all aspects raised, although participation was 36%. Conclusions: Incorporating training feedback for professionals is feasible, seems to be well accepted and could prove a useful tool for improving clinical safety. Palabras clave: Feedback formativo, Seguridad clínica, Urgencias, Keywords: Training feedback, Clinical safety, Emergency

To evaluate the impact of a code sepsis (CS) activation, complying with recommendations, the evolution of patients with severe sepsis in the emergency room and determine independent factors associated to mortality.All patients attending the emergency room with severe sepsis during a 6-month period were included. Complying with Surviving Sepsis Campaign recommendations, patients' average stay, intensive care admissions and 30-day mortality were assessed. Two groups were compared: CS activation (A) and no activation (NA).A total of 114 episodes were found, 61.4% belonging to group A and 38.6% to NA. Patients in group A presented hypotension more frequently (61.5% vs 34.4%; P=.005). Patients in group NA more frequently had lactate levels of3mmol/L (48.3% vs 80%; P=.01), and abdominal focus of sepsis (34.3% vs 13%; P=.01). In group A, blood cultures were more frequently drawn in the first hour (95% vs 41.7%; P.001), early antibiotic was administered (76.9% vs 25%; p=.005) and fluid replacement carried out (54.5% vs 18.2%; P=.01). Global achievement of CS objectives was higher in group A (31.4% vs 9.1%; P=.006). In group NA more patients were admitted to the intensive care unit (10% vs 36.4%; P.001), had longer average stays (10.2 days SD 6.9 vs 14.4 days SD 5.8; P.001) and a higher mortality rate (4.3% vs 34.1%; P.001). CRP200mg/l (OR 33.7; P.001) and the no activation of CS (OR 13.3; p=.001) resulted in being independent factors associated with mortality.The implementation of a CS improves compliance with SSC recommendations and decreases intensive care admissions, average stays and mortality.

Legionnaires' disease is a relatively common cause of community-acquired pneumonia and of some outbreaks of hospital-acquired pneumonia. Moreover, Legionella pneumophila is frequently involved in the aetiology of the subset of pneumonias that is characterised by severe clinical course and high mortality. No sure clinical, radiographical or analytical features are useful in differentiating Legionella infection from other aetiologies of pneumonia. On the basis of these data, a rational initial therapeutic approach to community-acquired pneumonia, as well as to nosocomial pneumonia in certain circumstances, has to include an antimicrobial agent that is clinically effective against Legionella spp. Clinical studies have provided evidence that erythromycin is the first-line treatment. An intravenous dosage of 1g every 6 hours as initial therapy will be effective in most cases. Parenteral treatment may be switched to oral administration only after clinical response is observed. In vitro susceptibilities and preliminary experimental and clinical results suggest that clarithromycin will most likely become the preferred treatment once an intravenous preparation is available worldwide. However, orally administered clarithromycin at the dosage of 500 mg every 12 hours may be recommended in those developing countries in which health systems cannot afford the costs of intravenous therapy. In the case of clinically severe illness or in seriously immunosuppressed hosts with confirmed legionellosis, a combined therapeutic approach is warranted. Rifampicin 600 mg every 12 hours intravenously or orally has to be added to the usual dosage of erythromycin. Other alternative therapies, but with less distinct clinical efficacy, that can be combined with erythromycin are doxycycline 100 mg every 12 hours intravenously or orally, and intravenous ciprofloxacin 200 mg every 6 hours.

Bronchial stump aspergillosis (BSA) is an unusual entity. We report a case presenting hemoptysis four years after right upper lobe resection because of lung cancer. Simple removal of the silk suture is most likely the treatment of choice. No additional local or systemic antifungal therapy is needed.

Fundamento Valorar la sospecha diagnosticade tromboembolia pulmonar (TEP) en elarea de urgencias. Pacientes Y Metodos Se analizan los casosde dos anos, y se compara el grupo A (sospechade TEP) con el grupo B (sin sospechade TEP). Resultados De 57 casos, no se sospechoTEP en 14 (25%). Hubo diferencias significativasen los signos de trombosis venosaprofunda (mayor frecuencia en el grupo A),insuficiencia cardiaca y derrame pleural(mayor frecuencia en el grupo B). Los diagnosticosalternativos fueron insuficienciacardiaca y neumonia. Conclusiones Los pacientes con TEP nosospechada no presentan un perfil clinicodiferencial. La TEP se confunde con insuficienciacardiaca y neumonia.