Avaliação dos riscos assistenciais relacionados ao uso de equipamentos hospitalares na unidade de terapia intensiva de adultos de um hospital público da cidade de São Paulo, Brasil

Pós-graduação em Bases Gerais da Cirurgia - FMB

Therapeutic Project at Extra-Hospital Mental Health Services: a critical reflection on the elaboration and management of services' therapeutic projects

Based on a study conducted in Ribeirao Preto, SP, Brazil in extra-hospital mental health services that addressed the organization of these services, therapeutic projects and the inclusion of psychosocial rehabilitation in health actions available, a theoretical-critical reflection concerning the development process of the therapeutic projects by the services' teams is presented. The qualitative study was conducted in an outpatient clinic and a Psychosocial Care Center. Data were collected through semi-structured interviews and focal groups. Data analysis was based on the hermeneutic dialectic philosophy of Jurgen Habermas according to the techniques of reconstruction and interpretation. Data analysis revealed that professionals have difficulty developing and managing therapeutic projects. Health actions are made available without being concretely supported by a proposal guiding the service's practical activities. The therapeutic projects are referred by professionals as the result of guidelines provided by management levels or technical orientations inherent to each profession but not as an activity that represents a philosophy of work of the health team. When the therapeutic project is focused on as a type of consensus that results from a communicative action directed to a mutual and intersubjective understanding among the members of the mental health extra-hospital team, the difficulties of the services' team dialogically organizing themselves to collectively construct the therapeutic project is evidenced.

Framing the difficulties resulting from implementing a Participatory Management Model in a public hospital

Objective: This study aims to address difficulties reported by the nursing team during the process of changing the management model in a public hospital in Brazil. Methods: This qualitative study used thematic content analysis as proposed by Bardin, and data were analyzed using the theoretical framework of Bolman and Deal. Results: The vertical implementation of Participatory Management contradicted its underlying philosophy and thereby negatively influenced employee acceptance of the change. The decentralized structure of the Participatory Management Model was implemented but shared decision-making was only partially utilized. Despite facilitation of the communication process within the unit, more significant difficulties arose from lack of communication inter-unit. Values and principals need to be shared by teams, however, that will happens only if managers restructure accountabilities changing job descriptions of all team members. Conclusion: Innovative management models that depart from the premise of decentralized decision-making and increased communication encourage accountability, increased motivation and satisfaction, and contribute to improving the quality of care. The contribution of the study is that it describes the complexity of implementing an innovative management model, examines dissent and intentionally acknowledges the difficulties faced by employees in the organization.

Pediatric pain: prevalence, assessment, and management in a teaching hospital

The goal of this study was to examine the prevalence, assessment and management of pediatric pain in a public teaching hospital. The study sample consisted of 121 inpatients (70 infants, 36 children, and 15 adolescents), their families, 40 physicians, and 43 nurses. All participants were interviewed except infants and children who could not communicate due to their clinical status. The interview included open-ended questions concerning the inpatients’ pain symptoms during the 24 h preceding data collection, as well as pain assessment and pharmacological/non-pharmacological management of pain. The data were obtained from 100% of the eligible inpatients. Thirty-four children/adolescents (28%) answered the questionnaire and for the other 72% (unable to communicate), the family/health professional caregivers reported pain. Among these 34 persons, 20 children/adolescents reported pain, 68% of whom reported that they received pharmacological intervention for pain relief. Eighty-two family caregivers were available on the day of data collection. Of these, 40 family caregivers (49%) had observed their child’s pain response. In addition, 74% reported that the inpatients received pharmacological management. Physicians reported that only 38% of the inpatients exhibited pain signs, which were predominantly acute pain detected during clinical procedures. They reported that 66% of patients received pharmacological intervention. The nurses reported pain signs in 50% of the inpatients, which were detected during clinical procedures. The nurses reported that pain was managed in 78% of inpatients by using pharmacological and/or non-pharmacological interventions. The findings provide evidence of the high prevalence of pain in pediatric inpatients and the under-recognition of pain by health professionals.

[Adapted and Standardised Patient Management in the Treatment of Neovascular AMD in the Outpatient Setting of a University Eye Hospital.]

Visual results in treating neovascular age-related macular degeneration (AMD) using intravitreal injected anti-VEGF (IVT) clearly depend on injection frequency. Regarding to the European approval Ranibizumab has to be used only in cases of recurrent visual loss after the loading phase. In contrast monthly treatment--as also provided in the ANCHOR and MARINA studies--is generally allowed in Switzerland. However, it is commonly tried to reduce the injection frequency because of the particular cost situation in all health systems and of cause also due to the necessary strict monitoring and reinjection regimes, which raise management problems with increasing patient numbers. In this article the special treatment regimes of our University Eye Hospital is presented, in which a reduced injection frequency basically leads to the same increased and stable visual results as in ANCHOR and MARINA; however, needing significantly more injections as generally provided in other countries of Europe. The main focus for achieving this in a large number of patients is placed on re-structuring our outpatient flow for IVT patients with particular emphasis on patient separation and standardisation of treatment steps leading to significantly reduced time consumption per patient. Measurements of timing and patient satisfaction before and after restructuring underline its importance in order to be able to treat more patients at a high quality even in the future. The exceptional importance of spectral domain OCT measurements as the most important criterium for indicating re-treatment is illustrated.

Entramado de politicidad en un ámbito estatal de trabajo : La experiencia de los trabajadores del Hospital Provincial Neuquén (2005-2013)

La presente investigación analiza el entramado de politicidad en un ámbito estatal de trabajo, a partir de la experiencia de los trabajadores del Hospital Provincial Neuquén Dr. Castro Rendón (HN) entre los años 2005 y 2013. Se propone un abordaje relacional que atienda a la configuración y redefinición de los escenarios de disputa, retomando la perspectiva de Norbert Elías. Se ha diseñado una estrategia metodológica cualitativa basada en la realización de observaciones participantes, entrevistas semi-estructuradas en profundidad y en el análisis de materiales gráficos. Se realizó un muestreo teórico de tipo no probabilístico, y las unidades de la muestra fueron seleccionadas de acuerdo a criterios relativos a la participación política y a las características de las labores hospitalarias. Los principales hallazgos de esta tesis refieren a la conceptualización de los ámbitos estatales de trabajo. Se los caracteriza como espacios donde se relacionan y se expresan múltiples grupos, resaltando los procesos socio-culturales que están implicados en las disputas políticas de los trabajadores. Se analizan la articulación entre demandas sectoriales y la disputa más general por la gestión de las políticas públicas, las regulaciones especiales que legislan el trabajo hospitalario, las distintas temporalidades de los conflictos, la vinculación con organizaciones externas, la jerarquización del espacio laboral, y la permeabilidad de lo estatal y lo no-estatal. Estos resultados permiten aportar de manera más general a las teorías sociológicas de la acción colectiva en lo que respecta a la utilización de las categorías de clase y a las identidades de los trabajadores

Entramado de politicidad en un ámbito estatal de trabajo : La experiencia de los trabajadores del Hospital Provincial Neuquén (2005-2013)

La presente investigación analiza el entramado de politicidad en un ámbito estatal de trabajo, a partir de la experiencia de los trabajadores del Hospital Provincial Neuquén Dr. Castro Rendón (HN) entre los años 2005 y 2013. Se propone un abordaje relacional que atienda a la configuración y redefinición de los escenarios de disputa, retomando la perspectiva de Norbert Elías. Se ha diseñado una estrategia metodológica cualitativa basada en la realización de observaciones participantes, entrevistas semi-estructuradas en profundidad y en el análisis de materiales gráficos. Se realizó un muestreo teórico de tipo no probabilístico, y las unidades de la muestra fueron seleccionadas de acuerdo a criterios relativos a la participación política y a las características de las labores hospitalarias. Los principales hallazgos de esta tesis refieren a la conceptualización de los ámbitos estatales de trabajo. Se los caracteriza como espacios donde se relacionan y se expresan múltiples grupos, resaltando los procesos socio-culturales que están implicados en las disputas políticas de los trabajadores. Se analizan la articulación entre demandas sectoriales y la disputa más general por la gestión de las políticas públicas, las regulaciones especiales que legislan el trabajo hospitalario, las distintas temporalidades de los conflictos, la vinculación con organizaciones externas, la jerarquización del espacio laboral, y la permeabilidad de lo estatal y lo no-estatal. Estos resultados permiten aportar de manera más general a las teorías sociológicas de la acción colectiva en lo que respecta a la utilización de las categorías de clase y a las identidades de los trabajadores

Entramado de politicidad en un ámbito estatal de trabajo : La experiencia de los trabajadores del Hospital Provincial Neuquén (2005-2013)

La presente investigación analiza el entramado de politicidad en un ámbito estatal de trabajo, a partir de la experiencia de los trabajadores del Hospital Provincial Neuquén Dr. Castro Rendón (HN) entre los años 2005 y 2013. Se propone un abordaje relacional que atienda a la configuración y redefinición de los escenarios de disputa, retomando la perspectiva de Norbert Elías. Se ha diseñado una estrategia metodológica cualitativa basada en la realización de observaciones participantes, entrevistas semi-estructuradas en profundidad y en el análisis de materiales gráficos. Se realizó un muestreo teórico de tipo no probabilístico, y las unidades de la muestra fueron seleccionadas de acuerdo a criterios relativos a la participación política y a las características de las labores hospitalarias. Los principales hallazgos de esta tesis refieren a la conceptualización de los ámbitos estatales de trabajo. Se los caracteriza como espacios donde se relacionan y se expresan múltiples grupos, resaltando los procesos socio-culturales que están implicados en las disputas políticas de los trabajadores. Se analizan la articulación entre demandas sectoriales y la disputa más general por la gestión de las políticas públicas, las regulaciones especiales que legislan el trabajo hospitalario, las distintas temporalidades de los conflictos, la vinculación con organizaciones externas, la jerarquización del espacio laboral, y la permeabilidad de lo estatal y lo no-estatal. Estos resultados permiten aportar de manera más general a las teorías sociológicas de la acción colectiva en lo que respecta a la utilización de las categorías de clase y a las identidades de los trabajadores

Influência da reutilização na biocompatibilidade de materiais médico-hospitalares de uso único

A prática da reutilização de produtos médico-hospitalares de uso único vem sendo aplicada desde meados da década de setenta. A principal razão que tem contribuído para disseminação desta conduta pelas instituições hospitalares radicadas tanto nos países em desenvolvimento como naqueles considerados ricos, tem sido a aparente economia de custos. Apesar dos riscos relacionados com a prática da reutilização, como reações pirogênicas, danos ocasionados por bactérias consideradas patogênicas em pacientes imunologicamente comprometidos, danos na integridade fisica dos produtos, assim como aumento do período de permanência dos pacientes no hospital, têm despertado o interesse em avaliar aspectos fisicos e biológicos dos produtos médico-hospitalares reutilizados. Baseando-se nestas considerações foram aplicados desafios com esporos de Bacillus Subtilis varo niger ATCC 9372 e endotoxina bacteriana E. coli 055:B5. Os produtos desafiados foram cateteres intravenosos, torneira três vias e tubos de traqueostomia. A possível presença microbiana foi investigada após contaminação intencional dos esporos de B. Subtillis (107 ufc/unid.) com submissão das unidades contaminadas à limpeza e posterior esterilização, utilizando óxido de etileno/CFC na proporção 12:88. Os ciclos de reprocessamentos simulados de produtos médico-hospitalares consistiram de contaminação de cada unidade teste com carga microbiana, lavagem com detergente enzimático, secagem e esterilização. Ao término de cada ciclo de reprocessamento foram separadas unidades representativas para avaliação por contagem microbiana (pour plate), testes de esterilidade por inoculação direta e indireta, citotoxidade por cultura de células e microscopia eletrônica de varredura. A eficiência da esterilidade foi avaliada tanto por contagem microbiana como pelos testes de esterilidade, que resultaram em níveis microbianos de 103 ufc/unid. e detecção de contaminação até o 6° ciclo de reprocessamento nos cateteres intravenosos, tubos de traqueostomia e torneiras três vias. A segurança dos reprocessamentos dos produtos médico-hospitalares foi avaliada pela cultura de células de fibroblastos de camundongo (NCTC clone 929), as quais não apresentaram toxicidade. Entretanto, os resultados obtidos durante microscopia eletrônica de varredura comprovaram presença de carga microbiana após 10° ciclo de reprocessamento, assim como danos na superficie polimérica. Durante desafio com endotoxina bacteriana, que consistiu em contaminar as unidades com 200 UE, secagem e exposição ao ciclo de esterilização com óxido de etileno/CFC (12:88), verificou-se que após ciclos de reprocessamentos simulados, totalizando dez ciclos, foi possível detectar valores de recuperação de endotoxina em torno de 100%. Os cateteres-guia que foram adquiridos em instituição hospitalar após quatro reutilizações, apresentaram níveis de contaminação de 105 ufc/unid., assim como presença de bactérias consideradas patogênicas em pacientes comprometidos imunologicamente, já a detecção de endotoxina bacteriana nestes cateteres não foi considerada significativa. Logo, as avaliações aplicadas nas unidades submetidas aos ciclos de reprocessamentos simulados, assim como nos cateteres-guia reprocessados e reutilizados quatro vezes, refletiram a realidade de algumas instituições no âmbito nacional e internacional que praticam a reutilização de produtos médico-hospitalares de uso-único. Os resultados obtidos vêm enfatizar objeções quanto à prática da reutilização, considerando que a ausência de segurança pode ocasionar em danos ao paciente.

The Identification of Best Management Practices in a Materials Recovery Facility to Increase Solid Waste Diversion in the Department of Defense (DoD) Installations along the Front Range of Colorado to Satisfy the DoD Solid Waste Diversion Goal of 40 Percent

The five installations operated by the Department of Defense (DoD) in the Front Range region of Colorado do not meet the DoD non-hazardous solid waste diversion goal of 40 percent, further impacting landfills and generating greenhouse gases. This applied capstone project identifies and evaluates best management practices of a Materials Recovery Facility (MRF), qualitatively and quantitatively, to increase solid waste diversion at a DoD MRF. An environmental benefits model quantified the externalities of increasing solid waste diversion at the installations. By implementing best management practices at a MRF, the DoD would divert an additional 1,400 tons of solid waste per year, resulting in the equivalent of 1,502,567 gallons of gasoline being saved, among many benefits presented in this capstone.

Time-differentiated target temperature management after out-of-hospital cardiac arrest: a multicentre, randomised, parallel-group, assessor-blinded clinical trial (the TTH48 trial): study protocol for a randomised controlled trial

BACKGROUND The application of therapeutic hypothermia (TH) for 12 to 24 hours following out-of-hospital cardiac arrest (OHCA) has been associated with decreased mortality and improved neurological function. However, the optimal duration of cooling is not known. We aimed to investigate whether targeted temperature management (TTM) at 33 ± 1 °C for 48 hours compared to 24 hours results in a better long-term neurological outcome. METHODS The TTH48 trial is an investigator-initiated pragmatic international trial in which patients resuscitated from OHCA are randomised to TTM at 33 ± 1 °C for either 24 or 48 hours. Inclusion criteria are: age older than 17 and below 80 years; presumed cardiac origin of arrest; and Glasgow Coma Score (GCS) <8, on admission. The primary outcome is neurological outcome at 6 months using the Cerebral Performance Category score (CPC) by an assessor blinded to treatment allocation and dichotomised to good (CPC 1-2) or poor (CPC 3-5) outcome. Secondary outcomes are: 6-month mortality, incidence of infection, bleeding and organ failure and CPC at hospital discharge, at day 28 and at day 90 following OHCA. Assuming that 50 % of the patients treated for 24 hours will have a poor outcome at 6 months, a study including 350 patients (175/arm) will have 80 % power (with a significance level of 5 %) to detect an absolute 15 % difference in primary outcome between treatment groups. A safety interim analysis was performed after the inclusion of 175 patients. DISCUSSION This is the first randomised trial to investigate the effect of the duration of TTM at 33 ± 1 °C in adult OHCA patients. We anticipate that the results of this trial will add significant knowledge regarding the management of cooling procedures in OHCA patients. TRIAL REGISTRATION NCT01689077.

Available information materials on solid waste management : total listing, 1966 to 1979.

"SW-203."