Emergency medicine´s scope of action carries an inherent risk of inadequate care for patients in need for palliative care. The relevance of this theme requires a deep reflection as well as its mandatory inclusion in the agenda of the different medical training societies.

Introduction: Early readmission rate (≤ 2 after discharge) tothe Intensive Care Units (ICU) is used as a quality measure.Since readmitted patients have poor outcomes, tools toidentify them before readmission happens are needed. TheModified Early Warning Score (MEWS) identifies patientsat high risk of clinical deterioration, admission to ICU andintra-hospital mortality when done at the Emergency Roomor at the ward. We tested MEWS as a predictor of early readmissions to the ICU when done at the moment of dischargefrom these Units.Material and Methods: We conducted a case-control study(1:1) comparing patients with early readmissions with controls without readmissions to a polyvalent ICU, during a period of 9 years. Logistic regression was used to determine thediscriminative power of MEWS to predict early readmissionsto the ICU. The predictive precision of the score was calculated by the area under the receiver operating characteristiccurve.Results: We paired 114 patients with early readmission (rateof 1.5%) with 114 controls. Any value of MEWS > 0 was associated with a significant increase in the risk of early readmission. A value of MEWS = 0 showed a negative predictivevalue of 99.7%. The area under the receiver operating characteristic curve of the MEWS to the prediction of early readmissions was 0.69 (IC95%: 0.62-0.76; p < 0.001).Discussion: The predictive precision of MEWS to this purpose was higher than other scores reported in the literature.Conclusion: MEWS is an easy clinical score with the potentialto increase patient safety at the moment of discharge fromthe ICU.

Introduction: The Acute Differentiated Care Unit of Hospital Center of Cova da Beira was created in August 2013 with the aim of functioning as an internment unit with capacity to provide medical care corresponding to level II of critical care. Methods: A retrospective, observational study of descriptive character that focused on patients treated in the UCAD during its first year of operation (from September 2013 to September 2014). On each inpatient episode was collected information about demography; diagnosis and comorbidities of the trea-ted patients; intra-hospital transfers; reasons for internment; rates of utilization of advanced hemodynamic and ventilatory supports and mortality results, average time of internment and outpatients’ destination of the patients admitted in the Diffe-rentiated Acute Care Unit of Hospital Center of Cova da Beira during the period in study. Results: The patients treated in the Acute Differentiated Care Unit of Hospital Center of Cova da Beira belong to higher age groups with the average age being 73 years. The inpatient average time was only 2 days and the unit´s occupancy rate was around 88%. The main reasons for hospitalization were diseases of the respiratory tract, followed by cardiovascular disease. A substantial number of patients had, as secondary diagnoses, cardiovascular diseases, diseases of the endocri-ne glands, nutrition, metabolism and immune disorders and diseases of the respiratory system. Of the various performed procedures, stands out the use of intravenous antibiotics and oxygen therapy. Conclusions: The creation of this unit has reinforced the growing need to integrate the different levels of care within the hospital structure, allowing to fill some gaps of Hospital Center of Cova da Beira.

The ”programmed death” is a reality in intensive care units. Belgium, in 2002, was the first European country and the second on the World to accept the euthanasia.The families, even suffering, quickly decide about questions of treatment/therapeutic suspension. Thus, the Belgian population seems to be more aware of this problematic and decisions confrontation.According to this, nurses play an important role on the evaluation of the patient health state evolution, in the communication between the other team members and in the support of the patient family.There always will be difficult decisions to be made, for the health care teams and for the patient family, requiring a constant ethical/moral reflection, having always in sight the respect and the dignity of the human being.

Introduction: The Confusion Assessment Method for Intensive Care Unit (CAM-ICU) is of great potential value in the emergency department (ED). However, there is still uncertainty about its diagnostic accuracy and reliability, with studies warranting larger cohorts. In one of the largest and most heterogeneous cohorts considered to date, the aim was to vali[1]date and explore the applicability of the CAM-ICU (European Portuguese) as a delirium screening and diagnostic tool in the ED setting of a main hospital referral centre. Methods: Data were randomly and prospectively recorded in a convenience sample of patients with 18 years or older admitted to the ED of Hospital de Braga (Braga, Portugal). Delirium status was primarily assessed using the CAM- -ICU. For the validation aspect, the reference standard was a psychiatric evaluation, conducted within 3 hours of the CAM- -ICU by a psychiatrist blind to the finding, using the DSM-5 diagnostic criteria, without external interference on the regular proceedings in the ED on the timing, number and operationalization of psychiatric evaluations in the setting. Results: After exclusion/inclusion criteria, of the 592 patients evaluated, 19.8% were diagnosed with delirium using the CAM-ICU. The reference standard was applied to 81 patients. The CAM-ICU presented a sensitivity of 95.2% (95% CI= 74.1 to 99.8) and specificity of 88.3% (95% CI= 76.8 to 94.8). CAM-ICU showed an accuracy of 90.1% with the reference standard. Conclusion: The CAM-ICU (Portuguese version) is practical, valid and reliable instrument for the assessment of delirium in the real setting of an ED showing sensibility, specificity and accuracy for delirium diagnosis.

Introduction: Intermediate Medical Care Units (IMCU) are real needs of modern hospitals. They improve quality of care and reduce costs and, at the same time, make way for coordination between all hospital departments. We present a study of an IMCU, since its opening in 2005 until 2014, in order to ascertain what’s the reality when in charge of Internal Medicine.Material and Methods: The authors performed a retrospective and descriptive analysis of the patients admitted in the above IMCU between October the 29th 2005 and December the 31st 2014. Results: In the IMCU 1641 patients were admitted, 46% female and 54% male, with an average age of 61 years. The average hospital stay was about 4 days. Most of the patients came from the emergency department (45.3%), followed by the ward of Internal Medicine (27.1%) and the Intensive Care Unit (20.9%). The main reasons for admission were pneumonia (33.5%), which came up with great expression, intoxication (8.7%), pulmonary embolism (8.3%) and global respiratory failure (7.1%). The mortality rate was 5.7%. Step-up occurred in 7.9% of patients and step-down in 92.1%, with the vast majority of patients being transferred to the ward of Internal Medicine. In the 2 years since its institution in the IMCU, non-invasive ventilation was performed in 23.0% of patients enrolled and mainly used in the context of exacerbation of chronic obstructive pulmonary disease (39.9% of cases), pneumonia (30.3%) and acute pulmonary edema (20.8%). Conclusion: This unit reinforces the importance of IMCUs as a bridge between the different departments and as form of intervention in a plurality of ways, resulting in a high degree of effectiveness and efficiency in improving care and maximizing resources, with a low mortality rate.

Dentre as várias espécies fúngicas descritas na literatura, as leveduras do gênero Candida são os agentes de infecção hospitalar de maior importância em Unidade de Terapia Intensiva (UTI), representando um desafio à sobrevida dos pacientes com graves doenças de base, devido à suscetibilidade destes pacientes à invasão fúngica. A identificação fenotípica das leveduras assim como levantamentos periódicos podem revelar tendências importantes ou mesmo o surgimento de novas espécies, auxiliando o desenvolvimento de medidas preventivas direcionadas. Os objetivos deste trabalho foram realizar um levantamento epidemiológico das leveduras encontradas em ponta de cateter e hemoculturas de pacientes de uma UTI oncológica e comparar espécies isoladas, verificando diferenças de frequência em relação ao local isolado. Trata-se de um estudo observacional retrospectivo analítico-descritivo realizado na UTI de um instituto oncológico, no período de janeiro de 2010 a dezembro de 2013, a partir do banco de dados do Laboratório de Microbiologia e da Comissão de Controle de Infecção Hospitalar (CCIH), coletados em formato eletrônico e processados para análise estatística para avaliar correlação de espécies pelo programa SPSS 20.0 e medida de tendências. Os resultados foram, para ponta de cateter, 40 foram positivas, sendo 15 para C. albicans (37,5%), 13 para C. parapsilosis (32,5%), 05 para C. tropicalis (12,5%) e 07 para outras leveduras (17,5%). Quanto às hemoculturas 58 foram positivas, sendo 18 para C. albicans (31,0%), 17 para C. tropicalis (29,3%), 10 para C. parapsilosis (17,2%), 05 para C. krusei (8,6%) e 08 para outras leveduras (13,9%). Foram encontradas diferenças quanto à frequência das espécies em relação a topografia estudada.