Sumamos Excelencia Project: Implementation of Best Practices in Clinical Practice (Thrid Edition)

Availability of the alcohol-based preparations in the Intensive Care Units (Hospital care) as close as possible to the place where an activity that requires contact with the patient and/or their immediate environment is going to be carried out and without having to leave the patient's area. Point of care is the place where the patient, the health professional and the care or treatment that involves contact with the patient coincide. (Number of ICU beds in the unit, with base alcoholic preparations at the point of care / Number of ICU beds in the unit) x100

Availability of the alcohol-based preparations in the hospital units (excluding ICU beds) as close as possible to the place where an activity that requires contact with the patient and/or their immediate environment is going to be carried out and without having to leave the patient's area. Point of care is the place where the patient, the health professional and the care or treatment that involves contact with the patient coincide. (Number of hospitalization beds in the unit, with alcohol-based preparations at the point of care)/(Number of beds in the unit) x100

Litres of alcohol-based preparations consumed in primary care centres. (Number of liters of alcohol-based preparations delivered in primary care / Total number of consultations in the evaluated period) x10000

Litres of alcohol-based preparations consumed in hospital units without admission (outpatient consultations, day hospital, etc.). (Number of liters of alcohol-based preparations@delivered in a hospital unit without admission / Total number of consultations in the evaluated period) x1000

Litres of alcohol-based preparations consumed in Nursing Homes (Number of liters of alcohol-based preparations delivered in Nursing Homes / Total number of residents in the evaluated period) x100

Detection of pain at admission. (Total number of patients in whom pain detection was performed upon admission or at the start of care, and it is registered / Total number of patients discharged or attended in the collection period data) x100

Detection of pain related to a procedure likely to cause pain. This indicator evaluates whether the assessment of pain linked to the painful procedure is carried out before and after the procedure, it is also recommended to assess pain during the procedure in cases where it is possible. (Total number of patients in whom pain has been detected after a procedure likely to cause pain, and is registered / Total number of patients in whom a procedure likely to cause pain has been performed in the data collection period data) x100

Detection of pain after a change in the patient's clinical situation (clinical situation: significant clinical change, in the general condition of the patient or in their pain, which requires the referral of the patient to a professional with the skills to resolve it). (Total number of patients in whom pain has been detected after a change in their clinical situation, and it is registered / Total number of patients with a change in their clinical situation in the data collection period) x100

Pain assessment measured with a pain intensity assessment tool. (Total number of patients who have an assessment of pain intensity, and it is recorded / Total number of patients with positive detection of pain in the data collection period) x100

Comprehensive pain assessment takes into account various factors related to pain, including: location of pain, circumstances related to the onset of pain, type of pain, pain intensity, associated symptoms, effect of pain on activities, effect of pain on patient rest and sleep, treatment, relevant medical history, factors that influence pain management. To be considered a comprehensive assessment, at least 60% of the 10 criteria must be performed and recorded. (Total number of patients who have done a comprehensive pain assessment, and it is registered / Total number of patients with positive pain detection in the data collection period) x100

Establishing and implementing a pain management care plan for the patient based on the results of the person's assessment, which would include: pharmacological and non-pharmacological measures, the person's goals and appropriate and effective pain management strategies. (Total number of patients with a care plan for acute or chronic pain, and it is registered / Total number of patients with positive detection of pain or susceptible to have pain in the data collection period) x100

Patient or/and caregiver education on the importance of communicating pain, pharmacological, physical and psychological pain management options, how to take the analgesic medication, manage the possible side effects and how the follow-up will be done and who can be consulted with possible doubts. (Total number of patients, family members or caregivers who have received education on pain management, at least once during the care process, and it is registered / Total number of patients with positive detection of pain or likely to have pain in the data collection period) x100

Intensity of pain on admission or in the first 24 hours after surgery or at the start of care measured in numerical format, with the value that corresponds to the scale used in the unit for the assessment of pain, units must indicate on the form the scale they have used. (Sum of pain intensity of patients with positive pain detection or likely to have pain / Total number of patients with assessed pain intensity in the data collection period)

Maximum scored reported by patients and registered by nurses after pain intensity assessment using an assessment tool. Units must indicate on the form the assessment tool they have used. (Sum of the maximum intensity of pain during the stay or care of patients with positive detection of pain or likely to have pain / Total number of patients with pain intensity assessed in the data collection period)

Quantitative assessment of the intensity of tobacco or tobacco products use measured with a validated tool (Total number of patients who have undergone a quantification assessment and it is recorded )/(Total number of patients with positive detection of active smoking @ in the period of data collection ) x100 Active smoker: person who is currently smoking or has smoked in the last 30 days.

Non-active smoker: smoked the last cigarette or similar product more than 30 days but less than 183 days (6 months) ago.

Assessment carried out with a comprehensive and systematic approach, taking into account various factors related to smoking, such as: Motivation to quit smoking (measured with the Richmond test); Degree of nicotine dependence (measured with the full Fagerström test); Current nicotine withdrawal symptoms; Previous quit attempts; Current need for smoking cessation treatments; Factors influencing patient behaviour change. The criterion is met when at least 50% of the 6 criteria (at least 3) are fulfilled and recorded (Total number of patients who have had a comprehensive smoking assessment performed and recorded)/(Total number of patients with positive screening for active smoking in the data collection period )/(Total number of patients with a positive screening for active smoking in the data collection period ) x100

Active smoker: person who is currently smoking or has smoked in the last 30 days.

Assessment carried out with a comprehensive and systematic approach, taking into account various factors related to smoking, such as: Existence or not of current nicotine withdrawal symptoms; Relapses; Current stage of change; Other symptoms. The criterion is fulfilled when at least 3 of the 5 criteria are fulfilled and recorded (Total number of patients who have undergone a 'comprehensive non-active smoking assessment' and are recorded) / (Total number of non-active smoking patients in the data collection period) x100

Active smoker: person who is currently smoking or has smoked in the last 30 days.

Non-active smoker: smoked the last cigarette or similar product more than 30 days but less than 183 days (6 months) ago.

Number of brief interventions (BI) based on the 5 As and 5 Rs carried out in smoking patients. For a BI to be considered as having been carried out, the nurse must at least: convey the advice to 'stop smoking', advise the patient on smoking cessation, offer support and accompaniment and specific comments on the health risks related to smoking and the benefits related to smoking cessation. (Number of smoking patients who have undergone Brief Intervention)/(Total number of smoking patients seen in the data collection period) x100 Brief intervention (BI): Intervention in which there is a brief (less than five minutes) contact between the health care provider and the patient.

Active smoker: person who is currently smoking or has smoked in the last 30 days.

Non-active smoker: smoked the last cigarette or similar product more than 30 days but less than 183 days (6 months) ago.

Referral to smoking cessation follow-up consultations is considered to be referral to primary care consultations and/or specific monographic smoking cessation consultations. If the unit is capable of carrying out the follow-up, the recommendation will be considered to have been made when the follow-up is planned in the same unit (Number of smoking patients referred for smoking follow-up after being seen/(Total number of smoking patients seen in the period of data collection) x100

Active smoker: person who is currently smoking or has smoked in the last 30 days.

Non-active smoker: smoked the last cigarette or similar product more than 30 days but less than 183 days (6 months) ago.

Documented evidence of the patient's expressed desire to quit smoking after the brief intervention (Total number of patients who have expressed an expressed desire to quit smoking after the brief intervention)/(Total number of patients with positive smoking screening who have undergone a BI in the data collection period)/(Total number of patients with positive smoking screening who have undergone a BI in the data collection period)x100

Active smoker: person who is currently smoking or has smoked in the last 30 days.

Non-active smoker: smoked the last cigarette or similar product more than 30 days but less than 183 days (6 months) ago.

Brief intervention: Intervention in which there is a brief (less than five minutes) contact between the health care provider and the patient.

Documented evidence of the non-active smoker patient's expressed desire to maintain their willingness to remain smoke-free after the comprehensive assessment. (Total number of patients who maintain their willingness to quit smoking after comprehensive assessment of active smoking)/(Total number of non-active smoking patients who have undergone a comprehensive assessment in the data collection period)x100

Active smoker: person who is currently smoking or has smoked in the last 30 days.

Non-active smoker: smoked the last cigarette or similar product more than 30 days but less than 183 days (6 months) ago.

Assessment of the risk of pressure injuries in the first 24 hours of admission, after the initiation of care or the first visit in primary care with a structured, validated and reliable tool, together with clinical judgement (Total number of people with complete assessment of pressure injuries at admission or initiation of care)/(Total number of people with health care provision) x100.

Reassessment of the risk of PBI: reassessment of the risk of developing pressure sores upon a significant clinical change in the person's general condition, change of caregiver, change of setting or care unit and at discharge; with a structured, validated and reliable tool, together with clinical judgement. (Total number of people with reassessment of pressure sores)/(Total number of people with health care provision) x100.

Nutritional screening of the person at risk of developing pressure injuries with a structured, validated and reliable tool. (Total number of persons at risk of pressure injuries who have been nutritionally screened)/(Total number of persons at risk of pressure injuries) x100.

Recording whether a support surface that meets the person's needs has been used to prevent the occurrence of pressure injuries (Total number of persons at risk of pressure injuries who have a support surface applied)/(Total number of persons at risk of pressure injuries) x100

Establishing and implementing a pressure injury prevention care plan for the patient based on the results of the person's assessment, which would include: comprehensive skin and tissue assessment; preventive skin and tissue care; early mobilisation; use of pressure relief devices/support surfaces; health education. (Total number of people with a pressure injury prevention care plan)/(Total number of people at risk of pressure injuries) x100

Number of patients presenting with a pressure injury at the start of care (Total number of people with one or more pressure injuries)/(Total number of people with health care provision) x100

Total number of people who develop one or more pressure injuries during care (Total number of people who develop one or more pressure injuries since admission or start of care)/(Total number of people with health care provision ) x 100

Total number of persons who develop one or more pressure injuries during care and who had been assessed as being at risk of developing pressure injuries (Total number of persons developing one or more pressure injuries since admission or start of care)/(Total number of persons at risk of PBI with healthcare provision) x 100

Stage of the most severe pressure injury developed by patients classified as at risk or not at risk of developing pressure injuries.

Falls risk screening carried out on all patients aged 65 years and over to determine their risk of falling. (Total number of people with falls risk screening recorded)/(Total number of people) x100.

Multifactorial falls risk assessment carried out on patients at high risk of falls. This should include at least: mobility, activities of daily living and cognitive function (Total number of people with recorded falls risk assessment)/(Total number of people at risk of falls) x100.

Individualised falls and injury prevention plan for people at risk of falling, taking into account the scope of care and its possibilities, patient preferences and multifactorial assessment by professionals (Total number of people at high risk of falls with a recorded falls prevention care plan)/(Total number of people at high risk of falls) x100

Risk reassessments made after any significant change in health following a fall, at 30-90 days for people at high risk of falls or one year since the last reassessment for people at low risk. (Total number of people with falls risk reassessment recorded)/(Total number of people eligible for risk reassessment) x100

Considers whether people at risk of falls have been referred to a specialist for exercise or whether exercise interventions have been implemented. (Number of people at high risk of falls who have participated in @exercise and physical training interventions)/(Total number of people at high risk of falls where the indicator applies) x100

Number of falls that have occurred during the hospital stay or duration of care.(Total number of people who have fallen)/(Total number of people) x100

Injuries resulting from the fall, according to the following scale: None, slight injury, moderate injury, severe injury, fear of falling, death. (Total number of persons with fall/s that have had consequences)/(Total number of persons who have fallen) x100

Initial assessment of presence of urinary incontinence. Total number of patients in whom the presence of urinary incontinence has been initially assessed, and who are registered / Total number of patients with positive detection of urinary incontinence during the data collection period) * 100

Record of all urination and leakage for 3 consecutive days before and after the intervention. (Total number of patients with a voiding diary of 3 days recorded / Total number of patients with urinary incontinence discharged or attended during the data collection period) * 100

Using verbal and physical prompts or signals to make people pay attention to their dry/wet situation and the need to go to the bathroom. (Total number of patients with a scheduled urination care plan, and it is registered / Total number of patients with urinary incontinence and a 3-day voiding diary discharged or attended in the data collection period) * 100

Program of education and programmed evacuation in which the intervals of micturition are gradually adjusted. (Total number of patients with a bladder training care plan, and it is registered / Total number of patients with urinary incontinence and a 3-day voiding diary discharged or attended in the data collection period) * 100

The individualized education and training of pelvic floor exercises. (Total number of patients with a pelvic floor exercise care plan, and it is registered / Total number of patients with urinary incontinence and a 3-day voiding diary discharged or attended in the data collection period) * 100

Severity of urinary incontinence. Total number of patients with different levels of urinary incontinence 24 hours prior to assessment / Total number of patients with urinary incontinence during the data collection period) x 100

Impact of urinary incontinence. (Total number of patients whose urinary incontinence has an impact on their quality of life, in the 24 hours prior to the assessment / Total number of patients with urinary incontinence during the data collection period) x 100

Perception of improvement in urinary incontinence. (Total number of patients who perceive an improvement 6 weeks after the intervention / Total number of patients with urinary incontinence before the start of the intervention) x100

Requires realization and documentation of a comprehensive assessment of children from birth to 12 years has been carried out considering all of the following elements: Growth; Feeding / breastfeeding (as appropriate); Physical activity; Sedentary behaviour / screen time; Family environment. (Number of children from birth to 12 years (and parents or carers) who have had a full assessment)/(Number of children from birth to 12 years ) x100.

Delivery and documentation of age-appropriate healthy behaviour promotion recommendations (e.g.: Support for breastfeeding, exclusive or complementary feeding (if appropriate); Healthy behaviour promotion on feeding; Healthy behaviour promotion on physical activity; Healthy behaviour promotion on sedentary/ screen time. (Number of children from birth to 12 years (and parents/caregivers) who have received healthy behaviour promotion interventions)/(Number of children from birth to 12 years) x100

Requires documented evidence that parents/primary caregivers have received age-appropriate education on any of the following topics: breastfeeding, role modelling, child feeding practices, family physical activity; screen time, physical activity, healthy eating. (Number of parents or caregivers of children from birth to 12 years who have been provided with education and support to maintain healthy habits)/(Number of children from birth to 12 years ) x100

Children from 0 to 183 days inclusive who have received exclusive breastfeeding, directly from the breast or stored. (Number of children 0-6 months (or-183 days) who received EXCLUSIVE breastfeeding in the previous 24 hours, and is registered / Total number of children 0-6 months with one or more visits well-infant-child follow-up in the previous year) x100

Children with more than 183 days of life who received breastfeeding directly from the breast or stored. (Number of children >6 months and up to 2 years (more than 183 days-2 years) who received breastfeeding in the previous 24 hours, and is registered / Total number of children >6 months - and up 2 years with one or more well-infant-child follow-up visits in the previous year) x100

Number of children from birth from 0 to 12 years of age who meet the recommendations on amount of daily physical activity. (Number of children from birth to 12 years of age who meet the recommendations on amount of daily exercise, and are registered / Total number of children from birth to 12 years of age with one or more follow-up visits of the healthy infant-child in the previous year, with assessment of physical activity or comprehensive assessment) x100

Number of children from birth to 12 years old who spent the recommended time for their age in front of a screen. (Number of children from birth to 12 years old, whose daily screen time is the recommended for their age, as of parents' declaration, and is registered / Total number of children from births up to 12 years of age with one or more follow-up visits to the well-child infant in the previous year, with assessment of screen time or comprehensive assessment) x100

Number of children aged 2-12 consuming fruit and vegetables daily and up to 5 times a day, and recorded (Number of children aged 2-12 consuming fruit and vegetables daily or up to 5 times a day)/(Number of children aged 2-12 ) x100

Requires that mothers of newborns have been assessed for their intention to breastfeed during hospital admission for delivery (Number of mothers assessed for their intention to breastfeed)/(Total number of mothers) x100

Assessment of breastfeeding completed within the first 24 hours of the newborn life. It should include all of the following components: knowledge and attitudes; level of self-efficacy or self-confidence regarding breastfeeding; concerns; support network; breastfeeding technique in relation to positioning, latch-on, effective milk transfer; assessment of the newborn/infant (regarding breastfeeding). To carry out the assessment, a breastfeeding assessment tool may be used. (Number of dyads assessed on the breastfeeding process in the first 24 hours/Total number of dyads) x100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

Skin-to-skin contact is the placement of a newborn, naked or with a diaper and cap, in a prone position on the bare chest of a person, covered with a previously heated blanket to prevent heat loss. It should be facilitated immediately (up to 1 hour) after birth or once the child and the nursing person are clinically stable. (Number of infants performing skin-to-skin immediately after birth or with clinically stable dyad /Total number of infants) x100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

In Hospital Care, it is considered completed if postpartum training and resources have been provided to the mother by the interprofessional team on breastfeeding before hospital discharge. The specific components are: Latching/postpartum and latch-on; Milk transfer; Breastfeeding based on infant cues; Other. ((Number of mothers receiving information and education on breastfeeding and support for the breastfeeding process)/ Total number of dyads) x100 Dyad: Pair consisting of mother and breastfeeding infant who form a bond with each other.

In hospital care, it is considered completed if education and support in breastfeeding has been carried out for family members before hospital discharge. (Number of dyads whose family has received education and support in breastfeeding / Total number of dyads) x100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

Requires the infant to have been breastfed for the first feeding after birth (Number of infants who were breastfed for the first feeding)/(Total number of infants discharged) x100

Type of breastfeeding of the newborn during the hospital stay. (Number of infants exclusively breastfed, receiving mixed breastfeeding or not breastfed during hospital stay / Total number of infants discharged) x100 Exclusive breastfeeding: The infant receives directly or indirectly breast milk. He does not receive any other type of solid or liquid food.

Mixed breastfeeding: The infant receives breast milk as well as other solid and liquid foods (including water), including non-human milk or formula.

Non-breastfeeding: The infant receives artificial milk and/or animal milk. The infant does not receive breast milk.

In Primary Care, early assessment is considered completed between hospital discharge and day 8 of the neonate's life (included). To carry out the assessment, a breastfeeding assessment tool may be used. (Number of dyads assessed early on the process of breastfeeding (between hospital discharge and 8 days of life / Total number of dyads between hospital discharge and 8 days of life of the newborn) x 100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

In Primary Care, the follow-up evaluation is carried out between 9 days of life and 6 months/183 days of life of the neonate (included). To carry out the assessment, a breastfeeding assessment tool may be used. (Number of dyads assessed on the breastfeeding process from 9 days of life to 6 months / Total number of dyads from 9 days of life to 6 months of the newborn) x100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

In Primary Care, it is considered completed if training has been carried out and resources have been provided to the mother after hospital discharge by the interprofessional team in breastfeeding, at least once in the period after discharge to 8 days or in the period from 9 days to 6 months, in the same visit or in successive visits. (Number of lactating persons receiving education in breastfeeding / Total number of dyads) x100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

In Primary Care, it is considered accomplished if breastfeeding education and support has been provided to family members, at least once in the period after discharge to 8 days or in the period from 9 days to 6 months, in the same visit or on successive visits. (Number of dyads whose family has received education and support in breastfeeding / Total number of dyads) x100 Dyad: A couple formed by the mother and the nursing baby who form a bond with each other.

Type of breastfeeding of the newborn from birth to 8 days of life assessed in Primary care. (Number of newborns who were exclusively breastfed, received mixed breastfeeding or were not breastfed from birth to 8 days of life / Total number of newborns between 0 and 8 days of life) x100 Exclusive breastfeeding: The infant receives directly or indirectly breast milk. He does not receive any other type of solid or liquid food.

Mixed breastfeeding: The infant receives breast milk as well as other solid and liquid foods (including water), including non-human milk or formula.

Non-breastfeeding: The infant receives artificial milk and/or animal milk. The infant does not receive breast milk.

Type of breastfeeding of the newborn from 9 to 90 days of life, assessed in Primary Care. (Number of infants exclusively breastfed, receiving mixed breastfeeding or not breastfed from 9 days to 90 days of life / Total number of infants from 9 to 90 days of life) x100 Exclusive breastfeeding: The infant receives directly or indirectly breast milk. He does not receive any other type of solid or liquid food.

Mixed breastfeeding: The infant receives breast milk as well as other solid and liquid foods (including water), including non-human milk or formula.

Non-breastfeeding: The infant receives artificial milk and/or animal milk. The infant does not receive breast milk.

Type of breastfeeding of the newborn from 91 to 182 days of life assessed in Primary care (Number of newborns who received exclusive breastfeeding, receiving mixed breastfeeding or not breastfed from 91 days to 182 days of life / Total number of newborns from 91 to 182 days of life) x100 Exclusive breastfeeding: The infant receives directly or indirectly breast milk. He does not receive any other type of solid or liquid food.

Mixed breastfeeding: The infant receives breast milk as well as other solid and liquid foods (including water), including non-human milk or formula.

Non-breastfeeding: The infant receives artificial milk and/or animal milk. The infant does not receive breast milk.

Number of newborns who received exclusive breastfeeding on day 183 of life (Number of newborns who received exclusive breastfeeding on day 183 of life / Total number of newborns with 183 days completed) x100

Hospital unit, primary care unit or nursing home unit.

Age, health problems and care required by the patients attended by the unit on a regular basis.

Supervisor, mid-level leader, high-level leader, clinical nurse, other rol in the institution

Supervisor, mid-level leader, high-level leader, clinical nurse, other rol in the institution

Patients discharge date in case of hospital admissions.

Date when patients were attended in case of primary care.

Date when patients were a resident in case of socio-healthcare centres.

Age of patients.

Sex of patients.

Type of incontinence presented by the patient who has been assessed as an incontinent patient. It may be stress, urge or mixed incontinence.

Factors that cause the patient to experience episodes of incontinence. They may be: Multifactorial causes (cognitive, previous urinary problems, neurological causes, malignancy, surgery); Medication; Overweight/Obesity; Tobacco use; Lifestyle and fluid intake.

Age of the mother.

First time the mother is facing breastfeeding or not.

Way in which the newborn was born: vaginal delivery, instrumental birth, caesarean section.

Number of weeks of pregnancy.

Weight of the newborn at birth, measured in grams.

Child's weight measured in kilograms.

Child's height measured in centimetres.

Reason for admission/consultation of patients. Reason for the patient to be admitted to the Hospital or to attend the consultation.

History of previous painful experiences of the patient.

Currently smoking or have quit less than 1 month ago or non-active if quit more than 1 month ago but less than 6 months ago.

Number of relapses since patient stopped smoking

Numbers of pressure injuries that the patient had at the start of care

Patient's stage of change according to Prochaska y Diclemente

Number of cigarettes or derivatives consumed by the patient per day and year

Barriers for the implementation of evidence-based recommendations in the units assessed using a questionnaire adapted from the The comprehensive, integrated checklist of determinants of practice (TICD checklist) and the Consolidated Framework for Implementation Research.

Strategies designed for the implementation of evidence-based recommendations in the units assessed using a questionnaire adapted from the Expert Recommendations for Implementing Change (ERIC).

Competencies in evidence-based practice of the healthcare professionals working in the units that are implementing evidence-based recommendations, assessed with the questionnaire EBP-COQ Prof©.

Clinical leadership skills of the healthcare professionals working in the units that are implementing evidence-based recommendations, assessed with the clinical leadership survey©.

Empowerment of the healthcare professionals working in the units that are implementing evidence-based recommendations, assessed with the Conditions for Work Effectiveness Questionnaire - II ©.

EBP climate and leadership in the units participating in the project measured with the evidence-based practice nursing leadership and work environment scales ©.

Sex of the professionals participating in the local implementation team

Age of the professionals participating in the local implementation team

Professional's qualifications of the professionals participating in the local implementation team

Professional's experience of the professionals participating in the local implementation team