Impact of long-stay beds on the performance of a tertiary hospital in emergencies

ABSTRACT OBJECTIVE To assess the impact of implementing long-stay beds for patients of low complexity and high dependency in small hospitals on the performance of an emergency referral tertiary hospital. METHODS For this longitudinal study, we identified hospitals in three municipalities of a regional department of health covered by tertiary care that supplied 10 long-stay beds each. Patients were transferred to hospitals in those municipalities based on a specific protocol. The outcome of transferred patients was obtained by daily monitoring. Confounding factors were adjusted by Cox logistic and semiparametric regression. RESULTS Between September 1, 2013 and September 30, 2014, 97 patients were transferred, 72.1% male, with a mean age of 60.5 years (SD = 1.9), for which 108 transfers were performed. Of these patients, 41.7% died, 33.3% were discharged, 15.7% returned to tertiary care, and only 9.3% tertiary remained hospitalized until the end of the analysis period. We estimated the Charlson comorbidity index – 0 (n = 28 [25.9%]), 1 (n = 31 [56.5%]) and ≥ 2 (n = 19 [17.5%]) – the only variable that increased the chance of death or return to the tertiary hospital (Odds Ratio = 2.4; 95%CI 1.3;4.4). The length of stay in long-stay beds was 4,253 patient days, which would represent 607 patients at the tertiary hospital, considering the average hospital stay of seven days. The tertiary hospital increased the number of patients treated in 50.0% for Intensive Care, 66.0% for Neurology and 9.3% in total. Patients stayed in long-stay beds mainly in the first 30 (50.0%) and 60 (75.0%) days. CONCLUSIONS Implementing long-stay beds increased the number of patients treated in tertiary care, both in general and in system bottleneck areas such as Neurology and Intensive Care. The Charlson index of comorbidity is associated with the chance of patient death or return to tertiary care, even when adjusted for possible confounding factors.

Performance evaluation of hospitals that provide care in the public health system, Brazil

OBJECTIVE To analyze if size, administrative level, legal status, type of unit and educational activity influence the hospital network performance in providing services to the Brazilian Unified Health System.METHODS This cross-sectional study evaluated data from the Hospital Information System and the Cadastro Nacional de Estabelecimentos de Saúde (National Registry of Health Facilities), 2012, in Sao Paulo, Southeastern Brazil. We calculated performance indicators, such as: the ratio of hospital employees per bed; mean amount paid for admission; bed occupancy rate; average length of stay; bed turnover index and hospital mortality rate. Data were expressed as mean and standard deviation. The groups were compared using analysis of variance (ANOVA) and Bonferroni correction.RESULTS The hospital occupancy rate in small hospitals was lower than in medium, big and special-sized hospitals. Higher hospital occupancy rate and bed turnover index were observed in hospitals that include education in their activities. The hospital mortality rate was lower in specialized hospitals compared to general ones, despite their higher proportion of highly complex admissions. We found no differences between hospitals in the direct and indirect administration for most of the indicators analyzed.CONCLUSIONS The study indicated the importance of the scale effect on efficiency, and larger hospitals had a higher performance. Hospitals that include education in their activities had a higher operating performance, albeit with associated importance of using human resources and highly complex structures. Specialized hospitals had a significantly lower rate of mortality than general hospitals, indicating the positive effect of the volume of procedures and technology used on clinical outcomes. The analysis related to the administrative level and legal status did not show any significant performance differences between the categories of public hospitals.

Aeromonas spp. isolated from oysters (Crassostrea rhizophorea) from a natural oyster bed, Ceará, Brazil

Between April and October 2002, thirty fortnightly collections of oysters (Crassostrea rhizophorea) from a natural oyster bed at the Cocó River estuary in the Sabiaguaba region (Fortaleza, Ceará, Brazil) were carried out, aiming to isolate Aeromonas spp. strains. Oyster samples were submitted to the direct plating (DP) and the presence/absence (P/A) methods. Aeromonas were identified in 15 (50%) samples analyzed by the DP method and in 13 (43%) analyzed by the P/A method. A. caviae, A. eucrenophila, A. media, A. sobria, A. trota, A. veronii bv. sobria, A. veronii bv. veronii and Aeromonas sp. were isolated. The predominant species was A. veronii (both biovars), which was identified in 13 (43%) samples, followed by A. media in 11 (37%) and A. caviae in seven (23%). From the 59 strains identified, 28 (48%) presented resistance to at least one of the eight antibiotics tested.

INSECTICIDE-TREATED BED NETS IN RONDÔNIA, BRAZIL: EVALUATION OF THEIR IMPACT ON MALARIA CONTROL

Mosquito nets treated with long-lasting insecticide (LLINs), when used in compliance with guidelines of the World Health Organization, may be effective for malaria vector control. In 2012, approximately 150,000 LLINs were installed in nine municipalities in the state of Rondônia. However, no studies have assessed their impact on the reduction of malaria incidence. This study analyzed secondary data of malaria incidence, in order to assess the impact of LLINs on the annual parasite incidence (API). The results showed no statistically significant differences in API one year after LLIN installation when compared to municipalities without LLINs. The adoption of measures for malaria vector control should be associated with epidemiological studies and evaluations of their use and efficiency, with the aim of offering convincing advantages that justify their implementation and limit malaria infection in the Amazon Region.

Efficacy of insecticide impregnated bed-nets to control malaria in a rural forested area in Southern Cameron

Due to current spreading of chemoresistant strains of Plasmodium falciparum malaria control must incorporate vector control programmes. Due to well known constraints house sprayings cannot be performed as before. Personal protection can be developed and a large scale use of insecticide treated bed-nets appeared to be very useful to reduce man-vector contact in Asia, South America and West and East Africa. No trial has done is forest Central Africa where transmission is permanent. We performed such a trial in the southern part of Cameroon (using deltamethrin, at 25mg/m*) and obtained similar data to those observed in the Gambia Burkina Faso and Tanzania with a noteworthy reduction of both transmission and high parasitaemia of P. falciparum (respectively 78% and 75%) meaning a drop of malaria morbidity.

Effect of untreated bed nets on blood-fed Phlebotomus argentipes in kala-azar endemic foci in Nepal and India

Observational studies in the Indian subcontinent have shown that untreated nets may be protective against visceral leishmaniasis (VL). In this study, we evaluated the effect of untreated nets on the blood feeding rates of Phlebotomus argentipes as well as the human blood index (HBI) in VL endemic villages in India and Nepal. The study had a "before and after intervention" design in 58 households in six clusters. The use of untreated nets reduced the blood feeding rate by 85% (95% CI 76.5-91.1%) and the HBI by 42.2% (95% CI 11.1-62.5%). These results provide circumstantial evidence that untreated nets may provide some degree of personal protection against sand fly bites.

Small-scale area effect on species richness and nesting occupancy of cavity-nesting bees and wasps

Small-scale area effect on species richness and nesting occupancy of cavity-nesting bees and wasps. The research was conducted in an urban forest remnant in southeast Brazil. We tested the predictions of the following hypotheses: (1) larger areas present higher species richness of bees and wasps, (2) solitary bees and wasps occupy more nests in larger areas, (3) rare species occupy more nests in smaller areas. We sampled Aculeate bees and wasps using trap nests from February to November 2004. We placed trap nests in sampling units (SU) with different size (25, 100 and 400 m²) located in 6 ha of secondary mesophytic forest. One hundred and thirty-seven trap nests were occupied by seven species of bees and four species of wasps. We found an increase in wasp, but not bee species richness following increase in SU size. Hymenoptera richness (i.e. bees plus wasps) was also greater in larger SU. Both the number and density of occupied nests increased with SU size. The wasp Trypoxylon lactitarse responded significantly to area size, larger SU having more occupied nests. The same pattern was exhibited by the wasp Auplopus militaris, the Megachile bee species, and the bee Anthodioctes megachiloides. Only Trypoxylon sp. was not affected by SU size. Our results show that cavity-nesting bee and wasps respond differently to the area effects. Such findings must be complemented by information on the frequency and dynamics of area colonization and nest occupancy by species of solitary Hymenoptera.

Nutritional potential of green banana flour obtained by drying in spouted bed

This study evaluated the chemical composition of peeled and unpeeled green banana Cavendish (AAA) flour obtained by drying in spouted bed, aiming at adding nutritional value to food products. The bananas were sliced and crushed to obtain a paste and fed to the spouted bed dryer (12 cm height and T = 80 ºC) in order to obtain flour. The flours obtained were subjected to analysis of moisture, protein, ash, carbohydrates, total starch, resistant starch, fiber. The green banana flours, mainly unpeeled, are good sources of fiber and resistant starch with an average of 21.91g/100g and 68.02g/100g respectively. The protein content was found in an average of 4.76g/100g, being classified as a low biological value protein with lysine as the first limiting amino acid. The results showed that unpeeled green banana flour obtained by spouted bed drying can be a valuable tool to add nutritional value to products in order to increase their non-digestible fraction.

Analysis of land use and occupancy in permanent preservation areas according to the hydrography of Ribeirão Água Fria - Bofete, SP - Brazil

The use conflicts are determined by the inadequate occupations of the soil, as it is the case of soil occupation inside of permanent preservation areas. This study aimed to determine the classes of the soil use and if there are conflicts inside of permanent preservation areas along the drainage network of the Água Fria Stream watershed, located in Bofete city - São Paulo, Brazil. It locates geographically between the coordinates: 48°09'30" to 48°18'30" longitude WGr., 22°58'30" to 23°04'30" latitude S, with an area of 15242.84 ha. The map of soil use was elaborated through the interpretation directly in the computer screen of satellite digital image. In the orbital data, the study area is inserted in the quadrant A, of image TM/Landsat - 5, orbit 220, point 76, passage 9/8th/2007. The Geographical Information System used was CartaLinx. The conflict areas of the watershed were obtained from the crossing between the maps of soil use and of PPAs. The results allowed the conclusion that more than half of the area (51.09%) is occupied by pastures, reflex of sandy soils and low fertility. It was also verified that although almost half of the watershed is covered with some type of vegetation (48.78% of natural forest /reforestation), it has approximately a third of permanent preservation areas used inappropriately by pastures (88.15%), reforestation (10.42%) and exposed soil (1.43%), totaling 343.07ha of conflicting areas, in a total of 993.26 ha of PPAs.

Energetic efficiency of a deep bed swine production system

The aim of this work was to evaluate the energy flows of a commercial production system of swine deep bed in its finishing phase, located in Juiz de Fora, in the State of Minas Gerais, Brazil. Thus, an energy efficiency study was carried out by monitoring a lot of animals, during a 94-day period. The energy rate of each compound involved in the production process was quantified and the matrixes of energy consumption were determined in the form of animal feeding, electrical energy, piglets, material used as deep bed, human labor, equipment, swine buildings, production of alive swine for slaughter, organic fertilizer production (swine deep bed or swine deep litter). From the direct input energy, 80.57% correspond to animal feeding, 11.90% to pigs for slaughter and 6.76% to piglets, while from the energy output 53.45% correspond to the terminating swine and 46.55% to organic fertilizer (swine deep bed). By the results obtained, we can conclude that such production system has corresponded to an industrial and highly specialized agro ecosystem, importing a great part of the energy consumed in the production process, with 41% of energy efficiency.

Start-up of horizontal anaerobic reactors with sludge blanket and fixed bed for wastewater treatment from coffee processing by wet method

In this study it was evaluated the start-up procedures of anaerobic treatment system with three horizontal anaerobic reactors (R1, R2 and R3), installed in series, with volume of 1.2 L each. R1 had sludge blanket, and R2 and R3 had half supporter of bamboo and coconut fiber, respectively. As an affluent, it was synthesized wastewater from mechanical pulping of the coffee fruit by wet method, with a mean value of total chemical oxygen demand (CODtotal) of 16,003 mg L-1. The hydraulic retention time (HRT) in each reactor was 30 h. The volumetric organic loading (VOL) applied in R1 varied from 8.9 to 25.0 g of CODtotal (L d)-1. The mean removal efficiencies of CODtotal varied from 43 to 97% in the treatment system (R1+R2+R3), stabilizing above 80% after 30 days of operation. The mean content of methane in the biogas were of 70 to 76%, the mean volumetric production was 1.7 L CH4 (L reactor d)-1 in the system, and the higher conversions were around at 0.20 L CH4 (g CODremoved)-1 in R1 and R2. The mean values of pH in the effluents ranged from 6.8 to 8.3 and the mean values of total volatile acids remained below 200 mg L-1 in the effluent of R3. The concentrations of total phenols of the affluent ranged from 45 to 278 mg L-1, and the mean removal efficiency was of 52%. The start-up of the anaerobic treatment system occurred after 30 days of operation as a result of inoculation with anaerobic sludge with active microbiota.

Prediction of free-stall occupancy rate in dairycattle barns through fuzzy sets

The goal of this study was to develop a fuzzy model to predict the occupancy rate of free-stalls facilities of dairy cattle, aiding to optimize the design of projects. The following input variables were defined for the development of the fuzzy system: dry bulb temperature (Tdb, °C), wet bulb temperature (Twb, °C) and black globe temperature (Tbg, °C). Based on the input variables, the fuzzy system predicts the occupancy rate (OR, %) of dairy cattle in free-stall barns. For the model validation, data collecting were conducted on the facilities of the Intensive System of Milk Production (SIPL), in the Dairy Cattle National Research Center (CNPGL) of Embrapa. The OR values, estimated by the fuzzy system, presented values of average standard deviation of 3.93%, indicating low rate of errors in the simulation. Simulated and measured results were statistically equal (P>0.05, t Test). After validating the proposed model, the average percentage of correct answers for the simulated data was 89.7%. Therefore, the fuzzy system developed for the occupancy rate prediction of free-stalls facilities for dairy cattle allowed a realistic prediction of stalls occupancy rate, allowing the planning and design of free-stall barns.

Hydrogen production from cassava processing wastewater in an anaerobic fixed bed reactor with bamboo as a support material

Attempting to associate waste treatment to the production of clean and renewable energy, this research sought to evaluate the biological production of hydrogen using wastewater from the cassava starch treatment industry, generated during the processes of extraction and purification of starch. This experiment was carried out in a continuous anaerobic reactor with a working volume of 3L, with bamboo stems as the support medium. The system was operated at a temperature of 36°C, an initial pH of 6.0 and under variations of organic load. The highest rate of hydrogen production, of 1.1 L.d-1.L-1, was obtained with application of an organic loading rate of 35 g.L-1.d-1, in terms of total sugar content and hydraulic retention time of 3h, with a prevalence of butyric and acetic acids as final products of the fermentation process. Low C/N ratios contributed to the excessive growth of the biomass, causing a reduction of up to 35% in hydrogen production, low percentages of H2 and high concentrations of CO2in the biogas.

Fluid dynamic modelling and simulation of circulating fluidized bed reactors: importance of the interface turbulence transfer

The main objective of this work is to analyze the importance of the gas-solid interface transfer of the kinetic energy of the turbulent motion on the accuracy of prediction of the fluid dynamic of Circulating Fluidized Bed (CFB) reactors. CFB reactors are used in a variety of industrial applications related to combustion, incineration and catalytic cracking. In this work a two-dimensional fluid dynamic model for gas-particle flow has been used to compute the porosity, the pressure, and the velocity fields of both phases in 2-D axisymmetrical cylindrical co-ordinates. The fluid dynamic model is based on the two fluid model approach in which both phases are considered to be continuous and fully interpenetrating. CFB processes are essentially turbulent. The model of effective stress on each phase is that of a Newtonian fluid, where the effective gas viscosity was calculated from the standard k-epsilon turbulence model and the transport coefficients of the particulate phase were calculated from the kinetic theory of granular flow (KTGF). This work shows that the turbulence transfer between the phases is very important for a better representation of the fluid dynamics of CFB reactors, especially for systems with internal recirculation and high gradients of particle concentration. Two systems with different characteristics were analyzed. The results were compared with experimental data available in the literature. The results were obtained by using a computer code developed by the authors. The finite volume method with collocated grid, the hybrid interpolation scheme, the false time step strategy and SIMPLEC (Semi-Implicit Method for Pressure Linked Equations - Consistent) algorithm were used to obtain the numerical solution.