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.

Difficulties in access and estimates of public beds in intensive care units in the state of Rio de Janeiro

ABSTRACT OBJECTIVE To estimate the required number of public beds for adults in intensive care units in the state of Rio de Janeiro to meet the existing demand and compare results with recommendations by the Brazilian Ministry of Health. METHODS The study uses a hybrid model combining time series and queuing theory to predict the demand and estimate the number of required beds. Four patient flow scenarios were considered according to bed requests, percentage of abandonments and average length of stay in intensive care unit beds. The results were plotted against Ministry of Health parameters. Data were obtained from the State Regulation Center from 2010 to 2011. RESULTS There were 33,101 medical requests for 268 regulated intensive care unit beds in Rio de Janeiro. With an average length of stay in regulated ICUs of 11.3 days, there would be a need for 595 active beds to ensure system stability and 628 beds to ensure a maximum waiting time of six hours. Deducting current abandonment rates due to clinical improvement (25.8%), these figures fall to 441 and 417. With an average length of stay of 6.5 days, the number of required beds would be 342 and 366, respectively; deducting abandonment rates, 254 and 275. The Brazilian Ministry of Health establishes a parameter of 118 to 353 beds. Although the number of regulated beds is within the recommended range, an increase in beds of 122.0% is required to guarantee system stability and of 134.0% for a maximum waiting time of six hours. CONCLUSIONS Adequate bed estimation must consider reasons for limited timely access and patient flow management in a scenario that associates prioritization of requests with the lowest average length of stay.

Sewage impact on the composition and distribution of Polychaeta associated to intertidal mussel beds of the Mar del Plata rocky shore, Argentina

The polychaete composition and distribution within mussel beds were studied in order to assess organic pollution due to domestic sewage in a rocky shore of Mar del Plata (Argentina) during 1997. Four stations and a control site were randomly sampled around the local effluent. Quantitative data on polychaetes, as well as sediment accumulated among mussels and its organic carbon content were measured. Polychaete distribution patterns are related to the organic matter gradient, being Capitella cf. capitata, Neanthes succinea (Frey & Leuckart, 1847) and Boccardia polybranchia (Haswell, 1885) the dominant indicator species close to the effluent. At medial distances, the cirratulids Caulleriella alata (Southern, 1914) and Cirratulus cirratus (Müller, 1776) are very important in abundance. The syllids Syllis prolixa Ehlers, 1901 and S. gracilis Grube, 1840 are distributed along the study area, but dominate at the medial stations and at the control site. The orbiniid Protoariciella uncinata Hartmann-Schröder, 1962 is subdominant at the control station.

Diel density variation of amphipods associated with Sargassum beds from two shores of Ubatuba, Southeastern, Brazil

Densities of mobile epifaunal assemblages associated with macrophytes are very variable during the day and the activity of visually-oriented predators is thought to have an important influence on this pattern. Here we compared densities of amphipods associated with a common brown alga, Sargassum stenophyllum (Phaeophyceae), at sites contrasting in water turbidity. We expected that diel variation of amphipods would occur in a shore with clear waters (Perequê), whereas no variation was expected in a shore with turbid waters (Lamberto). Amphipod density varied during the day at both shores, with no indication of a larger variation at Perequê. Most species showed two density peaks, one at night and the other in the afternoon. These peaks occurred close the times of high tide, suggesting that tidal rhythms could influence more amphipod densities than the activity of predators. Thus, more studies are necessary to understand factors that influence short-term variation of epifaunal assemblages.

Gas-solid two-phase flow in the riser of circulating fluidized beds: mathematical modelling and numerical simulation

A mathematical model is developed for gas-solids flows in circulating fluidized beds. An Eulerian formulation is followed based on the two-fluids model approach where both the fluid and the particulate phases are treated as a continuum. The physical modelling is discussed, including the formulation of boundary conditions and the description of the numerical methodology. Results of numerical simulation are presented and discussed. The model is validated through comparison to experiment, and simulation is performed to investigate the effects on the flow hydrodynamics of the solids viscosity.

Acute lead-induced vasoconstriction in the vascular beds of isolated perfused rat tails is endothelium-dependent

Chronic lead exposure induces hypertension in humans and animals, affecting endothelial function. However, studies concerning acute cardiovascular effects are lacking. We investigated the effects of acute administration of a high concentration of lead acetate (100 µΜ) on the pressor response to phenylephrine (PHE) in the tail vascular bed of male Wistar rats. Animals were anesthetized with sodium pentobarbital and heparinized. The tail artery was dissected and cannulated for drug infusion and mean perfusion pressure measurements. Endothelium and vascular smooth muscle relaxation were tested with acetylcholine (5 µg/100 µL) and sodium nitroprusside (0.1 µg/100 µL), respectively, in arteries precontracted with 0.1 µM PHE. Concentration-response curves to PHE (0.001-300 µg/100 µL) were constructed before and after perfusion for 1 h with 100 µΜ lead acetate. In the presence of endothelium (E+), lead acetate increased maximal response (Emax) (control: 364.4 ± 36, Pb2+: 480.0 ± 27 mmHg; P < 0.05) and the sensitivity (pD2; control: 1.98 ± 0.07, 2.38 ± 0.14 log mM) to PHE. In the absence of endothelium (E-) lead had no effect but increased baseline perfusion pressure (E+: 79.5 ± 2.4, E-: 118 ± 2.2 mmHg; P < 0.05). To investigate the underlying mechanisms, this protocol was repeated after treatment with 100 µM L-NAME, 10 µM indomethacin and 1 µM tempol in the presence of lead. Lead actions on Emax and pD2 were abolished in the presence of indomethacin, and partially abolished with L-NAME and tempol. Results suggest that acute lead administration affects the endothelium, releasing cyclooxygenase-derived vasoconstrictors and involving reactive oxygen species.

Influence of the N/K ratio on the production and quality of cucumber in hydroponic system

The objective of this work was to evaluate the quality of fruits and the nutritional status of cucumber CV. Aodai cultivated in nutrient solutions with different N:K ratios. The hydroponic cultivation was initially performed, during the vegetative growth, in nutrient solution with 1:2.0 mmol L-1 N:K, and, later, during fruit setting, in four different nutrient solutions with N:K (w/w) at the ratios 1:1.4, 1:1.7, 1:2.0 and 1:2.5. An additional treatment with a nutrient solution containing the ratio 1:2.2 (w/w) N:K during the vegetative growth and N:K 1:1.4 (w/w) during fruit setting, both with 10% ammonium (NH4+) was included. The treatments were arranged in a randomized design with six replicates. Irrigation was carried out with deionized water until seed germination, and then with nutrient solution until 30 days after germination, when plants were transplanted. Plants in the hydroponic growing beds were irrigated with the solutions for vegetative growth, and, after 21 days, the solutions were replaced by solutions for fruit setting. At 45 and 60 days after transplanting, the fresh weight, length, diameter, volume and firmness of the fruit were evaluated, and, at 45 days after transplanting, the macronutrient concentrations in the leaves were determined. The use of different N:K ratios during fruit setting influenced the cucumber production. The ratio of 1.0:1.7 N: K (w/w), with 10% of N in the form of ammonia, is recommended for the whole cycle.

A blockmodel study of managerial hierarchies, verbal networks, and organizational culture in four hospitals

This study demonstrates and applies a social network methodology for studying the dynamics of hierarchies in organizations. Social network (blockmodel) analysis of verbal networks in four hospitals contrasted hierarchical and structurally equivalent partitions of the sociomatrices of frequent ties and perceptions of organizational culture. It was found that the verbal networks in these organizations follow a center periphery pattern rather than a hierarchical logic and that perceptions of culture vary more by verbal network than by formal hierarchy. The perceptions of culture of central groups in one organization are much like those of peripheral groups in another. In all four hospitals, structurally equivalent social networks are more important in predicting subcultures than are hierarchical groupings and hierarchy has a limited impact on the development of verbal networks. These findings suggest the value of an amoeba rather than a pyramid metaphor in interpreting the cultures and relational structures of organizations.

Tipos de empreendedores em penturbia brasileira

Este artigo visa analisar de que forma diferentes atores sociais, em particular os empreendedores locais, se articulam - ou não - na construção de modelo de desenvolvimento econômico regional baseado na noção de penturbia, conforme proposta por Lessinger (1986). Neste artigo, identificou-se a cidade de Tiradentes (MG) como caso exemplar de penturbia brasileira. Em termos metodológicos, a pesquisa que subsidiou seus resultados é de natureza indutiva, orientada pelos princípios da Grounded Theory. De cunho etnográfico, o estudo envolveu análise documental, observação direta e realização de 39 entrevistas semiestruturadas e em profundidade junto a dirigentes de pousadas, restaurantes e ateliês, representantes de fundações e associações de artesãos, membros da igreja e políticos. Para o tratamento dos dados fez-se uso do software N-vivo 8.0. Como resultado foi possível a identificação de duas grandes categorias de empreendedores, emergentes das antinomias locais. Tais categorias, por sua vez, subdividiram-se em subcategorias, as quais refletem, bem como desafiam, tipologias internacionais de artesão, artista, bricoleur e engenheiro. A frequência e a orientação dessas categorias para com modelos alternativos de desenvolvimento local têm importantes implicações para o futuro sociocultural e econômico da cidade.

Problema da falta de vagas em creches: matriz de loops e a priorização de causas de problemas complexos

Dez milhões de crianças brasileiras deveriam frequentar creches, mas apenas 21% delas estão regularmente matriculadas. O problema da falta de vagas em creches foi o cenário escolhido para evidenciar a utilidade do artefato proposto: procedimentos para análise de problemas complexos, composto pela aplicação integrada entre mapa causal e matriz de loops, duas técnicas associadas aos estudos de padrões de cognição nas organizações. O artefato proposto foi testado junto a três municípios brasileiros, segundo os preceitos da abordagem design science. Causas e associações intercausais foram identificadas e priorizadas pela técnica de mapa causal e, posteriormente, interdependências entre causas foram analisadas pela técnica matriz de loops, o que alterou a priorização inicial. Evidenciou-se que para problemas complexos é fundamental identificar e analisar os loops entre loops de amplificação de desvio (loops "explosivos"). Outro resultado a destacar é a melhor compreensão de um problema complexo e socialmente relevante.

The epidemiologic paradox of low birth weight in Brazil

OBJECTIVE: To examine whether the low birth weight (LBW) paradox exists in Brazil. METHODS: LBW and cesarean section rates between 1995 and 2007 were estimated based on data from SINASC (Brazilian Live Births Database). Infant mortality rates (IMRs) were obtained using an indirect method that correct for underreporting. Schooling information was obtained from census data. Trends in LBW rate were assessed using joinpoint regression models. The correlations between LBW rate and other indicators were graphically assessed by lowess regression and tested using Spearman's rank correlation. RESULTS: In Brazil, LBW rate trends were non-linear and non-significant: the rate dropped from 7.9% in 1995 to 7.7% in 2000, then increased to 8.2% in 2003 and remained nearly steady thereafter at 8.2% in 2007. However, trends varied among Brazilian regions: there were significant increases in the North from 1999 to 2003 (2.7% per year), and in the South (1.0% per year) and Central-West regions (0.6% per year) from 1995 to 2007. For the entire period studied, higher LBW and lower IMRs were seen in more developed compared to less developed regions. In Brazilian States, in 2005, the higher the IMR rate, the lower the LBW rate (p=0.009); the lower the low schooling rate, the lower the LBW rate (p=0.007); the higher the number of neonatal intensive care beds per 1,000 live births, the higher the LBW rate (p=0.036). CONCLUSIONS: The low birth weight paradox was seen in Brazil. LBW rate is increasing in some Brazilian regions. Regional differences in LBW rate seem to be more associated to availability of perinatal care services than underlying social conditions.

Lack of access and continuity of adult health care: a national population-based survey

OBJECTIVE To describe the lack of access and continuity of health care in adults.METHODS A cross-sectional population-based study was performed on a sample of 12,402 adults aged 20 to 59 years in urban areas of 100 municipalities of 23 states in the five Brazilian geopolitical regions. Barriers to the access and continuity of health care and were investigated based on receiving, needing and seeking health care (hospitalization and accident/emergency care in the last 12 months; care provided by a doctor, by other health professional or home care in the last three months). Based on the results obtained by the description of the sample, a projection is provided for adults living in Brazilian urban areas.RESULTS The highest prevalence of lack of access to health services and to provision of care by health professionals was for hospitalization (3.0%), whilst the lowest prevalence was for care provided by a doctor (1.1%). The lack of access to care provided by other health professionals was 2.0%; to accident and emergency services, 2.1%; and to home care, 2.9%. As for prevalences, the greatest absolute lack of access occurred in emergency care (more than 360,000 adults). The main reasons were structural and organizational problems, such as unavailability of hospital beds, of health professionals, of appointments for the type of care needed and charges made for care.CONCLUSIONS The universal right to health care in Brazil has not yet been achieved. These projections can help health care management in scaling the efforts needed to overcome this problem, such as expanding the infrastructure of health services and the workforce.