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.

Microbiological and physicochemical evaluations of juice extracted from different parts of sugar cane stalks from three varieties cultivated under organic management

The artisanal production of cachaça, a beverage obtained by the fermentation of sugar cane juice after distillation, especially by small-sized producers, has traditionally used natural ferment ("fermento caipira") which consists of sugar cane juice with crushed corn, powdered rice, or citrus fruits. In despite of the difficulties in quality control due to the high level of contaminants and longer periods of preparation, the sensorial quality of the beverage may be attributed to the physiological activities of wild yeasts and even bacteria present during fermentation when this ferment is used. In this context, the aim here was to evaluate the microbiological (yeasts) and physicochemical characteristics of sugar cane juice extracted from different parts of three different varieties (RB72454, RB835486, and RB867515) of the cane stalk (lower, medium, and upper sections) in three harvesting periods (from May to December 2007) in an area under organic management. The juice from the upper section (from the eleventh internode to the top) of the sugar cane stalk could be indicated for the preparation of the natural ferment since it is as a source of yeasts and reducing sugars, especially the variety RB867515. Due to the seasonality, the best period for using this part of the sugar cane stalk is at the beginning of harvesting when the phenolic compounds are at low concentration, but there are higher number of Saccharomyces population and other yeast species. The high acidity in this section of the plant could result in a better control of bacterial contamination. These findings explain the traditional instructions of adding the upper sections for the preparation of natural ferment and can help its management in order to get a better performance with respect to organic cachaça production.

Evaluation and additional recommendations for preparing a whole blood control material

OBJECTIVE: The assessment of an easy to prepare and low cost control material for Hematology, available for manual and automated methods. MATERIAL AND METHOD: Aliquots of stabilized whole blood were prepared by partial fixation with aldehydes; the stability at different temperatures (4. 20 and 37 °C) during periods of up to 8-9 weeks and aliquot variability with both methods were controlled. RESULTS: Aliquot variability with automated methods at day 1, expressed as CV% (coefficient of variation) was: white blood cells (WBC) 2.7, red blood cells (RBC) 0.7, hemoglobin (Hb) 0.6, hematocrit (Hct) 0.7, mean cell volume (MCV) 0.3, mean cell hemoglobin (MCH) 0.6, mean cell hemoglobin concentration (MCHC) 0.7, and platelets (PLT) 4.6. The CV (coefficient of variation) percentages obtained with manual methods in one of the batches were: WBC 23, Hct 2.8, Hb 4.5, MCHC 5.9, PLT 41. Samples stored at 4ºC and 20ºC showed good stability, only a very low initial hemolysis being observed, whereas those stored at 37ºC deteriobed a rapidly (metahemoglobin formation, aggregation of WBC and platelets, as well as alteration of erythrocyte indexes). CONCLUSIONS: It was confirmed that, as long as there is no exposure to high temperatures during distribution, this material is stable, allowing assessment, both esternal and internal, for control purposes, with acceptable reproductivity, both for manual and auttomatic methods.

The role of discriminant analysis in the refinement of customer satisfaction assessment

OBJECTIVE: To test discriminant analysis as a method of turning the information of a routine customer satisfaction survey (CSS) into a more accurate decision-making tool. METHODS: A 7-question, 10-multiple choice, self-applied questionnaire was used to study a sample of patients seen in two outpatient care units in Valparaíso, Chile, one of primary care (n=100) and the other of secondary care (n=249). Two cutting points were considered in the dependent variable (final satisfaction score): satisfied versus unsatisfied, and very satisfied versus all others. Results were compared with empirical measures (proportion of satisfied individuals, proportion of unsatisfied individuals and size of the median). RESULTS: The response rate was very high, over 97.0% in both units. A new variable, medical attention, was revealed, as explaining satisfaction at the primary care unit. The proportion of the total variability explained by the model was very high (over 99.4%) in both units, when comparing satisfied with unsatisfied customers. In the analysis of very satisfied versus all other customers, significant relationship was identified only in the case of the primary care unit, which explained a small proportion of the variability (41.9%). CONCLUSIONS: Discriminant analysis identified relationships not revealed by the previous analysis. It provided information about the proportion of the variability explained by the model. It identified non-significant relationships suggested by empirical analysis (e.g. the case of the relation very satisfied versus others in the secondary care unit). It measured the contribution of each independent variable to the explanation of the variation of the dependent one.

Microbiological quality of drinking water of urban and rural communities, Brazil

OBJECTIVE: To evaluate the microbiological quality of treated and untreated water samples came from urban and rural communities and to examine the relationship between coliforms occurrence and average water temperature, and a comparison of the rainfall levels. METHODS: A sample of 3,073 untreated and treated (chlorinated) water from taps (1,594), reservoir used to store treated water (1,033), spring water (96) and private well (350) collected for routine testing between 1996 and 1999 was analyzed by the multiple dilution tube methods used to detect the most probable number of total and fecal coliforms. These samples were obtained in the region of Maringá, state of Paraná, Brazil. RESULTS: The highest numbers water samples contaminated by TC (83%) and FC (48%) were found in the untreated water. TC and FC in samples taken from reservoirs used to store treated water was higher than that from taps midway along distribution lines. Among the treated water samples examined, coliform bacteria were found in 171 of the 1,033 sampling reservoirs. CONCLUSIONS: Insufficient treatment or regrowth is suggested by the observation that more than 17% of these treated potable water contained coliform. TC and FC positive samples appear to be similar and seasonally influenced in treated water. Two different periods must be considered for the occurrence of both TC and FC positive samples: (i) a warm-weather period (September-March) with high percentage of contaminated samples; and (ii) cold-weather period (April-August) were they are lower. Both TC and TF positive samples declined with the decreased of water temperature.

Evaluation of standard reagents for radial-immunodiffusion assays. In vitro control of rabies vaccines

The RID assay is one of the in vitro methods used for in-process control in the production of rabies vaccines for veterinary use. It has been shown to be very useful for determining antigen concentration in the final bulk product. The work presented in this paper, including the production and standardization of candidate standard reagents for use in the Radial Immunodiffusion Assay (RID) was carried out at the Pan American Institute for Food Protection and Zoonoses (INPPAZ/PAHO/WHO). The study was completed with the cooperation of the Faculty of Veterinary Sciences, National University of La Plata (NULP), Argentina, where the validation of the proposed standards and the quality control of samples from 28 different batches of rabies vaccines produced with Pasteur strain rabies virus (PV) in BHK cells were performed. The activity of the vaccines was determined by in vivo (NIH) and in vitro (RID)assays. The results of the candidate reagents for the reagent standardization tests showed stability, sensitivity and reproducibility. The Relative Potency the 1.2 between the problem vaccines and the reference vaccine was estimated by variance and regression analysis. The results of our validation study show that the INPPAZ (PAHO/WHO) is capable of producing and distributing the above-mentioned standard reagents, as well as of providing support for the incorporation of the RID technique (sensitive, rapid and inexpensive) to the laboratories that manufacture rabies vaccines in Latin America and the Caribbean.

Case-control study of an outbreak of acute toxoplasmosis in an industrial plant in the state of São Paulo, Brazil

Foodborne diseases represent operational risks in industrial restaurants. We described an outbreak of nine clustered cases of acute illness resembling acute toxoplasmosis in an industrial plant with 2300 employees. These patients and another 36 similar asymptomatic employees were diagnosed with anti-T. gondii IgG titer and avidity by ELISA. We excluded 14 patients based on high IgG avidity and chronic toxoplasmosis: 13 from controls and one from acute disease other than T. gondii infection. We also identified another three asymptomatic employees with T.gondii acute infection and also anti-T. gondii IgM positive as remaining acute cases. Case control study was conducted by interview in 11 acute infections and 20 negative controls. The ingestion of green vegetables, but not meat or water, was observed to be associated with the incidence of acute disease. These data reinforce the importance of sanitation control in industrial restaurants and also demonstrate the need for improvement in quality control regarding vegetables at risk for T. gondii oocyst contamination. We emphasized the accurate diagnosis of indexed cases and the detection of asymptomatic infections to determine the extent of the toxoplasmosis outbreak.

Quality of essential drugs in tropical countries: evaluation of antimalarial drugs in the Brazilian Health System

INTRODUCTION: The emergence of drug resistance is one of the main problems concerning malaria treatment. The use of counterfeit and/or substandard antimalarial drugs can contribute to the development of parasite resistance. Thus, the aim of this study was to evaluate the quality of antimalarial drugs distributed in Brazil. METHODS: Samples containing chloroquine phosphate, mefloquine hydrochloride, primaquine phosphate, and quinine sulfate tablets were delivered to the Rio de Janeiro central storeroom (CENADI), state storerooms (SS), and Basic Health Units (BHUs) in the north region of Brazil - a total of 10 sample sets. After 5 months of storage, the samples were collected, and in vitro quality control analyses according to official and published methods were performed. RESULTS: Inadequate drug storage conditions were found in two SS and in all BHUs evaluated. There were no quality deviations found in the chloroquine samples. The quinine samples exhibited weight variation above the allowed limits. The primaquine samples were found to have packaging deficiency. The release of mefloquine in samples from some regions showed a statistically significant difference when compared with the CENADI samples. CONCLUSIONS: It is important to periodically evaluate the quality and storage conditions of essential drugs. The quality deviations found with the primaquine and quinine samples are not related to storage conditions and must be addressed urgently. The decreased mefloquine release from tablets is related to formulation problems or influenced by inadequate storage conditions, prompting further investigation. Even with the mentioned problems, the samples would probably not contribute to resistant parasite selection.

Effect of management systems and cover crops on organic matter dynamics of soil under vegetables

Vegetable production in conservation tillage has increased in Brazil, with positive effects on the soil quality. Since management systems alter the quantity and quality of organic matter, this study evaluated the influence of different management systems and cover crops on the organic matter dynamics of a dystrophic Red Latosol under vegetables. The treatments consisted of the combination of three soil tillage systems: no-tillage (NT), reduced tillage (RT) and conventional tillage (CT) and of two cover crops: maize monoculture and maize-mucuna intercrop. Vegetables were grown in the winter and the cover crops in the summer for straw production. The experiment was arranged in a randomized block design with four replications. Soil samples were collected between the crop rows in three layers (0.0-0.05, 0.05-0.10, and 0.10-0.30 m) twice: in October, before planting cover crops for straw, and in July, during vegetable cultivation. The total organic carbon (TOC), microbial biomass carbon (MBC), oxidizable fractions, and the carbon fractions fulvic acid (C FA), humic acid (C HA) and humin (C HUM) were determined. The main changes in these properties occurred in the upper layers (0.0-0.05 and 0.05-0.10 m) where, in general, TOC levels were highest in NT with maize straw. The MBC levels were lowest in CT systems, indicating sensitivity to soil disturbance. Under mucuna, the levels of C HA were lower in RT than NT systems, while the C FA levels were lower in RT than CT. For vegetable production, the C HUM values were lowest in the 0.05-0.10 m layer under CT. With regard to the oxidizable fractions, the tillage systems differed only in the most labile C fractions, with higher levels in NT than CT in the 0.0-0.05 m layer in both summer and winter, with no differences between these systems in the other layers. The cabbage yield was not influenced by the soil management system, but benefited from the mulch production of the preceding maize-mucuna intercrop as cover plant.

Hardcopy quality parameters to ensure structures detection at digital mammography

Objective To develop procedures to ensure consistency of printing quality of digital images, by means of hardcopy quantitative analysis based on a standard image. Materials and Methods Characteristics of mammography DI-ML and general purpose DI-HL films were studied through the QC-Test utilizing different processing techniques in a FujiFilm®-DryPix4000 printer. A software was developed for sensitometric evaluation, generating a digital image including a gray scale and a bar pattern to evaluate contrast and spatial resolution. Results Mammography films showed maximum optical density of 4.11 and general purpose films, 3.22. The digital image was developed with a 33-step wedge scale and a high-contrast bar pattern (1 to 30 lp/cm) for spatial resolution evaluation. Conclusion Mammographic films presented higher values for maximum optical density and contrast resolution as compared with general purpose films. The utilized digital processing technique could only change the image pixels matrix values and did not affect the printing standard. The proposed digital image standard allows greater control of the relationship between pixels values and optical density obtained in the analysis of films quality and printing systems.

Evolution of mammographic image quality in the state of Rio de Janeiro

Objective:To evaluate the evolution of mammographic image quality in the state of Rio de Janeiro on the basis of parameters measured and analyzed during health surveillance inspections in the period from 2006 to 2011.Materials and Methods:Descriptive study analyzing parameters connected with imaging quality of 52 mammography apparatuses inspected at least twice with a one-year interval.Results:Amongst the 16 analyzed parameters, 7 presented more than 70% of conformity, namely: compression paddle pressure intensity (85.1%), films development (72.7%), film response (72.7%), low contrast fine detail (92.2%), tumor mass visualization (76.5%), absence of image artifacts (94.1%), mammography-specific developers availability (88.2%). On the other hand, relevant parameters were below 50% conformity, namely: monthly image quality control testing (28.8%) and high contrast details with respect to microcalcifications visualization (47.1%).Conclusion:The analysis revealed critical situations in terms of compliance with the health surveillance standards. Priority should be given to those mammography apparatuses that remained non-compliant at the second inspection performed within the one-year interval.

Shewhart's control charts and process capability ratio applied to a sewage treatment station

The current study used statistical methods of quality control to evaluate the performance of a sewage treatment station. The concerned station is located in Cascavel city, Paraná State. The evaluated parameters were hydrogenionic potential, settleable solids, total suspended solids, chemical oxygen demand and biochemical oxygen demand in five days. Statistical analysis was performed through Shewhart control charts and process capability ratio. According to Shewhart charts, only the BOD(5.20) variable was under statistical control. Through capability ratios, we observed that except for pH the sewage treatment station is not capable to produce effluents under characteristics that fulfill specifications or standard launching required by environmental legislation.

Quality Indicators of Cervical Cytopathology Tests in the Public Service in Minas Gerais, Brazil

Objective The objective of this study is to assess the performance of cytopathology laboratories providing services to the Brazilian Unified Health System (Sistema Único de Saúde - SUS) in the State of Minas Gerais, Brazil. Methods This descriptive study uses data obtained from the Cervical Cancer Information System from January to December 2012. Three quality indicators were analyzed to assess the quality of cervical cytopathology tests: positivity index, percentage of atypical squamous cells (ASCs) in abnormal tests, and percentage of tests compatiblewith high-grade squamous intraepithelial lesions (HSILs). Laboratories were classified according to their production scale in tests per year≤5,000; from 5,001 to 10,000; from 10,001 to 15,000; and 15,001. Based on the collection of variables and the classification of laboratories according to production scale, we created and analyzed a database using Microsoft Office Excel 97-2003. Results In the Brazilian state of Minas Gerais, 146 laboratories provided services to the SUS in 2012 by performing a total of 1,277,018 cervical cytopathology tests. Half of these laboratories had production scales≤5,000 tests/year and accounted for 13.1% of all tests performed in the entire state; in turn, 13.7% of these laboratories presented production scales of > 15,001 tests/year and accounted for 49.2% of the total of tests performed in the entire state. The positivity indexes of most laboratories providing services to the SUS in 2012, regardless of production scale, were below or well below recommended limits. Of the 20 laboratories that performed more than 15,001 tests per year, only three presented percentages of tests compatible with HSILs above the lower limit recommended by the Brazilian Ministry of Health. Conclusion The majority of laboratories providing services to the SUS in Minas Gerais presented quality indicators outside the range recommended by the Brazilian Ministry of Health.

Avaliação da qualidade dos dados populacionais e cobertura dos registros de óbitos para as regiões brasileiras

OBJETIVO: Avaliar a qualidade dos dados populacionais e a cobertura dos registros de óbitos para as Unidades da Federação Brasileira (UF), por sexo, no ano de 1990. MÉTODOS: Os dados populacionais extraídos dos Censos Demográficos foram avaliados através de métodos demográficos clássicos. Os registros de óbitos, extraídos da Fundação Instituto Brasileiro de Geografia e Estatística e do Ministério da Saúde, foram avaliados através de três técnicas de mensuração do sub-registro de óbitos. RESULTADOS: A precisão das declarações das idades das UF, em sua maioria, passou do status de "pouco preciso" ou "moderado" para "preciso" na década de 80. A cobertura dos óbitos, em 1990, foi classificada como "boa" ou "satisfatória" para todos os Estados do Sul, Sudeste, Centro-Oeste e para os do Nordeste, abaixo do Rio Grande do Norte. O restante dos estados foram classificados como "regular" ou "insatisfatório". CONCLUSÕES: Houve uma melhora importante na qualidade das declarações da população recenseada e aumento da cobertura de óbitos e que, para muitas UF, é possível gerar confiáveis indicadores de mortalidade.

Chagas disease in an area of recent occupation in Cochabamba, Bolivia

INTRODUCTION: A descriptive, entomological and seroepidemiological study on Chagas disease was conducted in a place of recent occupation on the outskirts of Cochabamba, Bolivia: Avaroa/Primer de Mayo (population:3,000), where the socio-economic level is low and no control measures have been made available. METHODS: The immunofluorescent antibody test (IFAT) was used for IgG and IgM anti-Trypanosoma cruzi antibodies in filter paper bloodspot eluates from 128 subjects (73 females, 55 males) selected by systematic sampling. Concerning each subject age, gender, birthplace, occupation, duration of residence and building materials used in their houses were recorded. Vectors were captured both in domestic and peridomestic environments. RESULTS: Seropositive, 12.5% (16/128): females, 15.1% (11/73); males, 9.1% (5/55). Average time of residence: 6.1 years for the whole population sample and 7.4 years for the seropositive subjects. Most houses had adobe walls (76.7% , n= 30), galvanized iron rooves (86.7%) and earthen floors (53.4%) 80% of the walls had crevices. One hundred forty seven specimens of Triatoma infestans were captured, of which 104 (70.7%) were domestic, and 1 peridomestic Triatoma sordida. Precipitin host identification: birds, 67.5%; humans, 27.8%; rodents, 11.9%; dogs, 8.7%; cats, 1.6%. House infestation and density indices were 53.3 and 493.0 respectively. We found 21 (14.3%) specimens of T. infestans infected with trypanosomes, 18 (85.7%) of which in domestic environments. DISCUSSION: The elements for the vector transmission of Chagas disease are present in Avaroa/Primer de Mayo and the ancient custom of keeping guinea pigs indoors adds to the risk of human infection. In neighboring Cochabamba, due to substandard quality control, contaminated blood transfusions are not infrequent, which further aggravates the spread of Chagas disease. Prompt action to check the transmission of this infection, involving additionally the congenital and transfusional modes of acquisition, is required.