Incidents related to patient safety are a problem of great impact in Intensive Care Medicine (ICM). Multiple strategies have been developed to identify them, analyze, and develop policies aim at reducing their incidence and minimizing their effects and consequences. The development of a safety culture, an adequate organizational and structural design of the ICM, which contemplates the implementation of effective safe practices, with a provision of human resources adjusted to the care activity carried out and the periodic analysis of the different events and their factors, will allow us to bring the risk of critical patient care closer to zero, as would be desirable.

The severity of the critically ill patient, the practice of diagnostic procedures and invasive treatments, the high number of drugs administered, a high volume of data generated during the care of the critically ill patient along with a technical work environment, the stress and workload of work of professionals, are circumstances that favor the appearance of errors, turning Intensive Medicine Services into risk areas for adverse events to occur. Knowing their epidemiology is the first step to improve the safety of the care we provide to our patients, because it allows us to identify risk areas, analyze them and develop strategies to prevent the adverse events, or if this is not possible, be able to manage them. This article analyzes the main studies published to date on incidents related to safety in the field of critically ill patients.

Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients.

The usefulness of ultrasound for chest exploration was described in 1968. It was not until the 1990s, when its use became widespread in Intensive Care Units as a diagnostic, monitoring and procedural guide tool. The fact that it is a non-invasive tool, accessible at the bedside, with a sensitivity and specificity close to computerized tomography (CT) and with a short learning curve, have made it a mandatory technique in the management of critically ill patients. It is essential to know that there are different air/fluid ratio generated by different pathologies that gives rise to one echographic pattern or another. The identification of these patterns together with the clinical information will allow to make an accurate diagnosis in most settings of respiratory failure. Likewise, we must not forget the importance of evaluating diaphragmatic function by ultrasound during weaning from mechanical ventilation.

Gender is a social determinant that impacts health and generates inequalities at all levels. It has impacts patients and critical conditions, health professionals and professional career development, and scientific societies from a perspective of social justice. All the International scientific societies of Intensive Care Medicine committed to contributing a gender perspective agree on the institutional need for achieving a formal positioning standpoint. The Spanish Society of Intensive and Critical Medicine and Coronary Units (SEMICYUC) is committed to ensuring the equality, inclusion and representativeness of its health professionals to fight the existing gender gap in the field of Intensive Medicine.

OBJECTIVE: To establish a cross-cultural adaptation of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey and to use this instrument to evaluate the impact of a safety intervention.
METHODS: Cross-cultural adaptation and before-and-after evaluation study.
METHODS: 5 ICU.
METHODS: Medical residents, attending physicians, and nurses at those ICU.
METHODS: Adaptation of the SCORE survey to Spanish culture. The adapted survey was used to assess all safety-culture-related domains before and one-year after implementing the use of a safety tool, Real-Time Random Safety Audits (in Spanish: Análisis Aleatorios de Seguridad en Tiempo Real, AASTRE).
METHODS: Adaptabiliy of the Spanish version of SCORE survey in the ICU setting and evaluation of the effect of AASTRE on their domains.
RESULTS: The cross-cultural adaptation was adequate. Post-AASTRE survey scores [mean (standard deviation, SD)] were significantly better in the domains learning environment [50.55 (SD 20.62) vs 60.76 (SD 23.66), p<.0001], perception of local leadership [47.98 (SD 23.57) vs 62.82 (SD 27.46), p<.0001], teamwork climate [51.19 (SD 18.55) vs 55.89 (SD 20.25), p=.031], safety climate [45.07 (SD 17.60) vs 50.36 (SD 19.65), p=.01], participation decision making [3 (SD 0.82) vs 3.65 (SD 0.87), p<.0001] and advancement in the organization [3.21 (SD 0.77) vs 4.04 (SD 0.77), p<.0001]. However, post-AASTRE scores were significantly worse in the domains workload and burnout climate.
CONCLUSIONS: The cross-cultural adaptation of the SCORE survey into Spanish is a useful tool for ICUs. The application of the AASTRE is associated with improvements in six SCORE domains, including the safety climate.

The current official model of training in Intensive Care Medicine (ICM) in Spain is based on exposure to experiences through clinical rotations. The main objective was to determine the level of competency (I novice to V independent practitioner) achieved by the residents at the end of the 3rd year of training (R3) in ICM through a simulation-based OSCE. Secondary objectives were: (1) To identify gaps in performance, and (2) To investigate the reliability and feasibility of conducting simulation-based assessment at multiple sites.
Observational multicenter study.
Thirteen Spanish ICU Departments.
Thirty six R3.
The participants performed on five, 15-min, high-fidelity crisis scenarios in four simulation centers. The performances were video recorded for later scoring by trained raters.
Via a Delphi technique, an independent panel of expert intensivists identified critical essential performance elements (CEPE) for each scenario to define the levels of competency.
A total of 176 performances were analyzed. The internal consistency of the check-lists were adequate (KR-20 range 0.64-0.79). Inter-rater reliability was strong [median Intraclass Correlation Coefficient across scenarios: 0.89 (0.65-0.97)]. Competency levels achieved by R3 were: Level I (18.8%), II (35.2%), III (42.6%), IV/V (3.4%). Overall, a great heterogeneity in performance was observed.
The expected level of competency after one year in the ICU was achieved only in half of the performances. A more evidence-based educational approach is needed. Multiple center simulation-based assessment showed feasibility and reliability as an evaluation method of competency.
COBALIDATION. NCT04278976. (https://register.
gov).

To analyze whether frailty can improve the prediction of mortality in patients admitted to the ICU after digestive surgery.
Prospective, observational, 6-month follow-up study of a cohort of patients admitted to the ICU between June 1, 2018, and June 1, 2019.
Surgical ICU of a third level hospital.
Series of successive patients older than 70 years who were admitted to the ICU immediately after a surgical intervention on the digestive system. 92 patients were included and 2 were excluded due to loss of follow-up at 6 months.
Upon admission to the ICU, severity and prognosis were assessed by APACHE II, and fragility by the Clinical Frailty Scale and the modified Frailty Index.
ICU, in-hospital and 6-month mortality.
The model that best predicts mortality in the ICU is the APACHE II, with an area under the ROC curve (AUC) of 0.89 and a good calibration. The model that combines APACHE II and Clinical Frailty Scale is the one that best predicts in-hospital mortality (AUC: 0.82), significantly improving the prediction of isolated APACHE II (AUC: 0.78; Integrated Discrimination Index: 0.04). Frailty is a predictor of mortality at 6 months, being the model that combines Clinical Frailty Scale and Frailty Index the one that has shown the greatest discrimination (AUC: 0.84).
Frailty can complement APACHE II by improving its prediction of hospital mortality. Furthermore, it offers a good prediction of mortality 6 months after surgery. For mortality in ICU, frailty loses its predictive power, whereas isolated APACHE II shows excellent predictive capacity.

OBJECTIVE: 1. To determine the satisfaction of tutors and residents with a specific methodology used to implement CoBaTrICE. 2. To determine the reliability and validity of the global rating scales designed ad hoc to assess the performance of the residents for training purposes.
METHODS: Prospective cohort study.
METHODS: All the residents and tutors of the ICU Department of the Hospital Universitario y Politécnico la Fe de Valencia.
METHODS: CoBaTrICE implementation started in March 2016, it was based on: (1) Training the tutors in feedback techniques; (2) Performing multiple objective and structured work based assessments to achieve the competences of the program; and (3) The use of an electronic portfolio to promote learning reflection and to collect the evidence that learning was taking place.
METHODS: The acceptance of CoBaTrICE was explored through a satisfaction survey conducted after 9 months of implementation of the training program. The 15 residents and 5 tutors of the ICU Department were asked about the methodology of the formative assessments, the quality of the feedback, self-learning regulation and the electronic portfolio usefulness. The validity of the global rating scales was assessed through the tests alfa de Cronbach, reliability and generalizability indexes, and intraclass correlation coefficient.
RESULTS: The implementation of CoBaTrICE was satisfactory in all the dimensions studied. The global rating scales used for formative purposes showed reliability and validity.
CONCLUSIONS: The methodology used to implement CoBaTrICE was highly valued by tutors and residents. The global rating scales used for formative purposes showed reliability and validity.

OBJECTIVE: To compare the quantity and quality of publications during the residency training period in Cardiology, Intensive Care Medicine, Internal Medicine and Medical Oncology in Spain.
METHODS: A retrospective cohort study of residents from 4 specialties lasting 5 years (2014-2019). The number and type of publications indexed in PubMed®, the names of the journals and their bibliometric indexes (impact factor and quartiles), and author\'s positions were evaluated.
RESULTS: The 649 residents included in the study generated 801 publications (publication/resident ratio 1.23). Cardiology residents published significantly more (ratio 2.57) and Intensive Care Medicine residents less (ratio 0.42) than the remaining specialties (Internal Medicine, ratio 1.06; Medical Oncology, ratio 0.76; p < .001). Overall, only 44.5% of residents participated in a publication, with 27.6% participating in an original article; this latter percentage increased significantly among cardiologists (47.7%; p < .001). The predominant types of publications were original articles (47.9%) and clinical reports (36.8%). The proportion of publications in first quartile journals was higher for Cardiology residents (44.6% of total). The resident was the first or last author in only one-third of the publications. Scientific productivity was related to specialty, but not to gender or the size of the hospital in which the residency training occurred.
CONCLUSIONS: Intensive Care Medicine, Internal Medicine and Medical Oncology residents publish insufficiently, while the scientific production from Cardiology residents could be considered acceptable.