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Introduction and objectives Heart failure management programs reduce hospitalizations. Some studies also show reduced mortality. The determinants of program success are unknown. The aim of the present study was to update our understanding of the reductions in mortality and readmissions produced by these programs, elucidate their components, and identify the factors determining program success. Methods Systematic literature review (1990-2014; PubMed, EMBASE, CINAHL, Cochrane Library) and manual search of relevant journals. The studies were selected by 3 independent reviewers. Methodological quality was evaluated in a blinded manner by an external researcher (Jadad scale). These results were pooled using random effects models. Heterogeneity was evaluated with the I 2 statistic, and its explanatory factors were determined using metaregression analysis. Results Of the 3914 studies identified, 66 randomized controlled clinical trials were selected (18 countries, 13 535 patients). We determined the relative risks to be 0.88 for death (95% confidence interval [95%CI], 0.81-0.96; P 2 , 6.1%), 0.92 for all-cause readmissions (95%CI, 0.86-0.98; P 2 , 58.7%), and 0.80 for heart failure readmissions (95%CI, 0.71-0.90; P 2 , 52.7%). Factors associated with program success were implementation after 2001, program location outside the United States, greater baseline use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, a higher number of intervention team members and components, specialized heart failure cardiologists and nurses, protocol-driven education and its assessment, self-monitoring of signs and symptoms, detection of deterioration, flexible diuretic regimen, early care-seeking among patients and prompt health care response, psychosocial intervention, professional coordination, and program duration. Conclusions We confirm the reductions in mortality and readmissions with heart failure management programs. Their success is associated with various structural and intervention variables.

Resumen Introduccion y objetivos Los programas de atencion a pacientes de insuficiencia cardiaca reducen ingresos hospitalarios. Algunos estudios reducen mortalidad. Se desconocen los determinantes del exito. El objetivo es actualizar el conocimiento sobre la reduccion de mortalidad y reingresos de estos programas, describir sus componentes e identificar factores condicionantes de resultados. Metodos Revision sistematica de la bibliografia (1990-2014) (PubMed, EMBASE, CINAHL, Cochrane Library) y busqueda manual en revistas relevantes. Tres revisores independientes seleccionaron los estudios. La calidad metodologica fue evaluada a ciegas por una investigadora externa (escala Jadad). Los resultados se combinaron mediante modelos de efectos aleatorios. La heterogeneidad se evaluo con el estadistico I2, y se determinaron sus factores explicativos mediante analisis de metarregresion. Resultados Se identificaron 3.914 estudios. Se seleccionaron 66 ensayos clinicos controlados y aleatorizados (18 paises, 13.535 pacientes), y se observaron riesgos relativos de muerte de 0,88 (intervalo de confianza del 95% [IC95%], 0,81-0,96; p II , mayor numero de profesionales y componentes de la intervencion, especializacion del cardiologo y la enfermera, educacion protocolizada y evaluada, automonitorizacion de signos y sintomas, reconocimiento de descompensacion, pauta flexible de diureticos, aviso y atencion precoz, intervencion psicosocial, coordinacion de profesionales y duracion del programa. Conclusiones Se confirma la reduccion de mortalidad y reingresos con los programas de insuficiencia cardiaca, cuyo exito se asocio con diferentes variables de estructura e intervencion.

Resumen Objetivos Cuantificar la incidencia de extubaciones no programadas (ENP) en una unidad de cuidados intensivos (UCI) polivalente y determinar los factores de riesgo. Metodo Estudio observacional, prospectivo y analitico realizado en una UCI polivalente de 8 camas durante un periodo de 6 meses. Los 79 participantes se eligieron por orden consecutivo de ingreso. Los criterios de inclusion fueron que estuviesen sometidos a ventilacion mecanica (VM) durante al menos durante 12 h y que pasaran por la fase de destete de VM. Se valoro edad, dias con tubo endotraqueal (TET), dias de estancia en la UCI, fase de destete de VM y nivel de sedacion y/o agitacion mediante la escala sedacion agitacion de Riker y el indice pronostico APACHE II. Se calculo la densidad de incidencia para ENP y se compararon las variables medidas en el grupo de pacientes extubados y no extubados mediante el test de comparacion de la U de Mann-Whitney. Resultados De los 79 casos que constituyeron la muestra, se constataron 15 casos (18,9%) de ENP, de los que el 76,9% ocurrio durante la fase de destete. Un 73,3% (11 casos) se debio a autoextubacion, un 20% (3 casos) por causa accidental y un 6,6% (un caso) por obstruccion del TET. La edad menor o igual a 60 anos fue un factor de riesgo, no objetivandose relacion con otros factores a estudio: dias de estancia, dias con TET y APACHE. Conclusiones Los pacientes en riesgo de ENP se caracterizan por una edad mas joven y un estado de agitacion segun la escala Riker. Las ENP ocurren, generalmente, cuando el paciente se encuentra durante la fase de destete del ventilador.

To identify the incidence of unplanned extubations (UE) in a general intensive care unit (ICU) and associated risk factors.An analytical, observational and prospective study was performed in an eight-bed general ICU over a 6-month period. The participants consisted of 79 consecutive patients who underwent mechanical ventilation for 12 h or more and who were under the ventilator weaning phase. The variables studied were age, days of endotracheal intubation, length of stay in the ICU, weaning phase and the APACHE II prognostic score; the degree of sedation and/or agitation was evaluated using Riker's Sedation-Agitation Scale. The incidence density of UEs was calculated and the variables measured in the extubated and non-extubated groups were compared using the Mann Whitney U-test.Among the 79 patients studied, UE occurred in 15 (18.9%). Of these events, 76.9% occurred during the ventilator weaning phase. There were 11 cases (73.3%) of self-extubations, three cases (20%) of accidental removal and one case (6.6%) of endotracheal tube obstruction. Age equal to or less than 60 years was a risk factor. No relationship was found with the remaining factors studied: days of hospital stay, days of endotracheal intubation or APACHE score.Patients at risk for UE were younger and showed agitation on the Riker scale. UEs usually occurred during the ventilator weaning phase.