Implementation of the trauma registry as a tool for quality improvement in trauma care in a brazilian hospital: the first 12 months

ABSTRACTObjective:to analyze the implementation of a trauma registry in a university teaching hospital delivering care under the unified health system (SUS), and its ability to identify points for improvement in the quality of care provided.Methods:the data collection group comprised students from medicine and nursing courses who were holders of FAPESP scholarships (technical training 1) or otherwise, overseen by the coordinators of the project. The itreg (ECO Sistemas-RJ/SBAIT) software was used as the database tool. Several quality "filters" were proposed to select those cases for review in the quality control process.Results:data for 1344 trauma patients were input to the itreg database between March and November 2014. Around 87.0% of cases were blunt trauma patients, 59.6% had RTS>7.0 and 67% ISS<9. Full records were available for 292 cases, which were selected for review in the quality program. The auditing filters most frequently registered were laparotomy four hours after admission and drainage of acute subdural hematomas four hours after admission. Several points for improvement were flagged, such as control of overtriage of patients, the need to reduce the number of negative imaging exams, the development of protocols for achieving central venous access, and management of major TBI.Conclusion: the trauma registry provides a clear picture of the points to be improved in trauma patient care, however, there are specific peculiarities for implementing this tool in the Brazilian milieu.

Vancomycin-resistant enterococcus outbreak in a pediatric intensive care unit: report of successful interventions for control and prevention

The objective of this study is to retrospectively report the results of interventions for controlling a vancomycin-resistant enterococcus (VRE) outbreak in a tertiary-care pediatric intensive care unit (PICU) of a University Hospital. After identification of the outbreak, interventions were made at the following levels: patient care, microbiological surveillance, and medical and nursing staff training. Data were collected from computer-based databases and from the electronic prescription system. Vancomycin use progressively increased after March 2008, peaking in August 2009. Five cases of VRE infection were identified, with 3 deaths. After the interventions, we noted a significant reduction in vancomycin prescription and use (75% reduction), and the last case of VRE infection was identified 4 months later. The survivors remained colonized until hospital discharge. After interventions there was a transient increase in PICU length-of-stay and mortality. Since then, the use of vancomycin has remained relatively constant and strict, no other cases of VRE infection or colonization have been identified and length-of-stay and mortality returned to baseline. In conclusion, we showed that a bundle intervention aiming at a strict control of vancomycin use and full compliance with the Hospital Infection Control Practices Advisory Committee guidelines, along with contact precautions and hand-hygiene promotion, can be effective in reducing vancomycin use and the emergence and spread of vancomycin-resistant bacteria in a tertiary-care PICU.

Characteristics of HIV patients who missed their scheduled appointments

ABSTRACT OBJECTIVE: To analyze whether sociodemographic characteristics, consultations and care in special services are associated with scheduled infectious diseases appointments missed by people living with HIV. METHODS: This cross-sectional and analytical study included 3,075 people living with HIV who had at least one scheduled appointment with an infectologist at a specialized health unit in 2007. A secondary data base from the Hospital Management & Information System was used. The outcome variable was missing a scheduled medical appointment. The independent variables were sex, age, appointments in specialized and available disciplines, hospitalizations at the Central Institute of the Clinical Hospital at the Faculdade de Medicina of the Universidade de São Paulo, antiretroviral treatment and change of infectologist. Crude and multiple association analysis were performed among the variables, with a statistical significance of p ≤ 0.05. RESULTS: More than a third (38.9%) of the patients missed at least one of their scheduled infectious diseases appointments; 70.0% of the patients were male. The rate of missed appointments was 13.9%, albeit with no observed association between sex and absences. Age was inversely associated to missed appointment. Not undertaking anti-retroviral treatment, having unscheduled infectious diseases consultations or social services care and being hospitalized at the Central Institute were directly associated to missed appointments. CONCLUSIONS: The Hospital Management & Information System proved to be a useful tool for developing indicators related to the quality of health care of people living with HIV. Other informational systems, which are often developed for administrative purposes, can also be useful for local and regional management and for evaluating the quality of care provided for patients living with HIV.

Malaria and Vascular Endothelium

Involvement of the cardiovascular system in patients with infectious and parasitic diseases can result from both intrinsic mechanisms of the disease and drug intervention. Malaria is an example, considering that the endothelial injury by Plasmodium-infected erythrocytes can cause circulatory disorders. This is a literature review aimed at discussing the relationship between malaria and endothelial impairment, especially its effects on the cardiovascular system. We discuss the implications of endothelial aggression and the interdisciplinarity that should guide the malaria patient care, whose acute infection can contribute to precipitate or aggravate a preexisting heart disease.

The Bernhard Nocht Institute: 100 years of tropical medicine in Hamburg

The Bernhard Nocht Institute (BNI) is a four months younger and much smaller sibling of the Instituto Oswaldo Cruz. It was founded on 1 October 1900 as an Institut für Schiffs- und Tropenkrankheiten (Institute for Maritime and Tropical Diseases) and was later named after its founder and first director Bernhard Nocht. Today it is the Germany's largest institution for research in tropical medicine. It is a government institution affiliated to the Federal Ministry of Health of Germany and the Department of Health of the State of Hamburg. As the center for research in tropical medicine in Germany the BNI is dedicated to research, training and patient care in the area of human infectious diseases, which are of particular relevance in the tropics. It is the primary mission of the BNI to develop means to the control of these diseases. Secondary missions are to provide expertise for regional and national authorities and to directly and indirectly improve the health care for national and regional citizens in regard to diseases of the tropics.

Leprosy, a neglected disease that causes a wide variety of clinical conditions in tropical countries

Leprosy is an ancient disease that remains endemic and continues to be a major public health problem in some tropical countries, where it has been internationally recognized as being linked to the underdevelopment conditions. The natural course of the disease covers a wide variety of clinical conditions with systemic involvement. In this paper, we review the findings obtained in studies of the pathological mechanisms of leprosy, including a survey of the literature and of our own work. The understanding and control of the wide variety of clinical conditions should help improve patient care and thus prevent the onset of physical impairment and the stigma of the disease.

Certifying the interruption of Chagas disease transmission by native vectors: cui bono?

Certifying the absence of Chagas disease transmission by native vectors lacks scientific grounds and weakens long-term control-surveillance systems to the detriment of people living under risk conditions. Instead, a regular "certification of good practice" (including vector control-surveillance, case detection/patient care and blood safety) could help achieve sustained disease control.

Process and results of the development of an ICNP® Catalogue for Cancer Pain

This was a methodological study conducted to describe the process and results of the development of an International Classification for Nursing Practice (ICNP®) Catalogue for Cancer Pain. According to the International Council of Nurses (ICN), this catalogue contains a subset of nursing diagnoses, outcomes, and interventions to document the implementation of the nursing process in cancer patients. This catalogue was developed in several steps according to the guidelines recommended by the ICN. As a result, 68 statements on nursing diagnoses/outcomes were obtained, which were classified according to the theoretical model for nursing care related to cancer pain into physical (28), psychological (29), and sociocultural and spiritual (11) aspects. A total of 116 corresponding nursing interventions were obtained. The proposed ICNP® Catalogue for Cancer Pain aims to provide safe and systematic orientation to nurses who work in this field, thus improving the quality of patient care and facilitating the performance of the nursing process.

Measurement of nurses' workload in an oncology outpatient clinic

The growing demand and the degree of patient care in oncological outpatient services, as well as the complexity of treatment have had an impact on the workload of nurses. This study aimed at measuring the workload and productivity of nurses in an oncological outpatient service. An observational study using a work sampling technique was conducted and included seven nurses working in an oncological outpatient service in the south-eastern region of Brazil. A total of 1,487 intervention or activity samples were obtained. Nurses used 43.2% of their time on indirect care, 33.2% on direct care, 11.6% on associated activities, and 12% on personal activities. Their mean productivity was 88.0%. The findings showed that nurses in this service spend most of their time in indirect care activities. Moreover, the productivity index in this study was above that recommended in the literature.

Therapeutic Listening as a health intervention strategy: an integrative review

Objective To investigate and evaluate the available evidence in the literature regarding the use of Therapeutic Listening as a health intervention strategy. Method Integrative review conducted on the following databases PubMed, CINAHL, The Cochrane Library, EMBASE, LILACS and APA PsycNET without restrictions of year or type of study. The keywords were combined in different ways to ensure extensive search of primary studies. Results Among the 15 studies on Therapeutic Listening, 33% addressed the effect of training on listening skills, 27% focused on the efficacy of listening as an intervention, 20% explored the experiences lived by the subjects regarding listening and 20% discussed various aspects of listening. Conclusion Most studies have strong to moderate level of evidence, although addressing different aspects related to Therapeutic Listening, they have in common the need for recognition of skills on the part of health professionals, to develop an effective process of listening.


Dialysis, time and death: comparisons of two consecutive decades among patients treated at the same Brazilian dialysis center

The survival of hemodialysis patients is likely to be influenced not only by well-known risk factors like age and comorbidity, but also by changes in dialysis technology and practices accumulated along time. We compared the survival curves, dialysis routines and some risk factors of two groups of patients admitted to a Brazilian maintenance hemodialysis program during two consecutive decades: March 1977 to December 1986 (group 1, N = 162) and January 1987 to June 1997 (group 2, N = 237). The median treatment time was 22 months (range 1-198). Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank method. The Cox proportional hazard regression model was used to investigate the more important variables associated with outcome. The most important changes in dialysis routine and in patient care during the total period of observation were the progressive increase in the dose of dialysis delivered, the prohibition of potassium-free dialysate, the use of bicarbonate as a buffer and the upgrading of the dialysis equipment. There were no significant differences between the survival curves of the two groups. Survival rates at 1, 5 and 10 years were 84, 53 and 29%, respectively, for group 1 and 77, 42 and 21% for group 2. Patients in group 1 were younger (45.5 ± 15.2 vs 55.2 ± 15.9 years, P<0.001) and had a lower prevalence of diabetes (11.1 vs 27.4%, P<0.001) and of cardiovascular disease (9.3 vs 20.7%, P<0.001). According to the Cox multivariate model, only age (hazard ratio (HR) 1.04, confidence interval (CI) 1.03-1.05, P<0.001) and diabetes (HR 2.55, CI 1.82-3.58, P<0.001) were independent predictors of mortality for the whole group. Patients of group 2 had a lower prevalence of sudden death (19.1 vs 9.7%, P<0.001). After adjusting for age, diabetes and other mortality risk factors, the risk of death was 17% lower in group 2, although this difference was not statistically significant. We conclude that the negative effects of advanced age and of higher frequency of comorbidity on the survival of group 2 patients were probably offset by improvements in patient care and in the quality and dose of dialysis delivered, so that the survival curves did not undergo significant changes along time.

Noninvasive classification of liver disease in asymptomatic and oligosymptomatic male alcoholics

The predominant type of liver alteration in asymptomatic or oligosymptomatic chronic male alcoholics (N = 169) admitted to a psychiatric hospital for detoxification was classified by two independent methods: liver palpation and multiple quadratic discriminant analysis (QDA), the latter applied to two parameters reported by the patient (duration of alcoholism and daily amount ingested) and to the data obtained from eight biochemical blood determinations (total bilirubin, alkaline phosphatase, glycemia, potassium, aspartate aminotransferase, albumin, globulin, and sodium). All 11 soft and sensitive, and 13 firm and sensitive livers formed fully concordant groups as determined by QDA. Among the 22 soft and not sensitive livers, 95% were concordant by QDA grouping. Concordance rates were low (55%) in the 73 firm and not sensitive livers, and intermediate (76%) in the 50 not palpable livers. Prediction of the liver palpation characteristics by QDA was 95% correct for the firm and not sensitive livers and moderate for the other groups. On a preliminary basis, the variables considered to be most informative by QDA were the two anamnestic data and bilirubin levels, followed by alkaline phosphatase, glycemia and potassium, and then by aspartate aminotransferase and albumin. We conclude that, when biopsies would be too costly or potentially injurious to the patients to varying extents, clinical data could be considered valid to guide patient care, at least in the three groups (soft, not sensitive; soft, sensitive; firm, sensitive livers) in which the two noninvasive procedures were highly concordant in the present study.

Exercise may cause myocardial ischemia at the anaerobic threshold in cardiac rehabilitation programs

Myocardial ischemia may occur during an exercise session in cardiac rehabilitation programs. However, it has not been established whether it is elicited when exercise prescription is based on heart rate corresponding to the anaerobic threshold as measured by cardiopulmonary exercise testing. Our objective was to determine the incidence of myocardial ischemia in cardiac rehabilitation programs according to myocardial perfusion SPECT in exercise programs based on the anaerobic threshold. Thirty-nine patients (35 men and 4 women) diagnosed with coronary artery disease by coronary angiography and stress technetium-99m-sestamibi gated SPECT associated with a baseline cardiopulmonary exercise test were assessed. Ages ranged from 45 to 75 years. A second cardiopulmonary exercise test determined training intensity at the anaerobic threshold. Repeat gated-SPECT was obtained after a third cardiopulmonary exercise test at the prescribed workload and heart rate. Myocardial perfusion images were analyzed using a score system of 6.4 at rest, 13.9 at peak stress, and 10.7 during the prescribed exercise (P < 0.05). The presence of myocardial ischemia during exercise was defined as a difference ≥2 between the summed stress score and summed rest score. Accordingly, 25 (64%) patients were classified as ischemic and 14 (36%) as nonischemic. MIBI-SPECT showed myocardial ischemia during exercise within the anaerobic threshold. The 64% prevalence of ischemia observed in the study should not be looked on as representative of the whole population of patients undergoing exercise programs. Changes in patient care and exercise programs were implemented as a result of our finding of ischemia during the prescribed exercise.

Epidermal growth factor receptor (EGFR) mutations in lung cancer: preclinical and clinical data

Lung cancer leads cancer-related mortality worldwide. Non-small-cell lung cancer (NSCLC), the most prevalent subtype of this recalcitrant cancer, is usually diagnosed at advanced stages, and available systemic therapies are mostly palliative. The probing of the NSCLC kinome has identified numerous nonoverlapping driver genomic events, including epidermal growth factor receptor (EGFR) gene mutations. This review provides a synopsis of preclinical and clinical data on EGFR mutated NSCLC and EGFR tyrosine kinase inhibitors (TKIs). Classic somatic EGFR kinase domain mutations (such as L858R and exon 19 deletions) make tumors addicted to their signaling cascades and generate a therapeutic window for the use of ATP-mimetic EGFR TKIs. The latter inhibit these kinases and their downstream effectors, and induce apoptosis in preclinical models. The aforementioned EGFR mutations are stout predictors of response and augmentation of progression-free survival when gefitinib, erlotinib, and afatinib are used for patients with advanced NSCLC. The benefits associated with these EGFR TKIs are limited by the mechanisms of tumor resistance, such as the gatekeeper EGFR-T790M mutation, and bypass activation of signaling cascades. Ongoing preclinical efforts for treating resistance have started to translate into patient care (including clinical trials of the covalent EGFR-T790M TKIs AZD9291 and CO-1686) and hold promise to further boost the median survival of patients with EGFR mutated NSCLC.