The reliability and validity of the Therapeutic activity index

Purpose To assess the psychometric properties of the Simplified Therapeutic Intervention Scoring System (TISS 28) scale. Materials and Methods A prospective observational design was used. Patients were recruited from a medical-surgical intensive care unit (ICU) and 4 rehabilitation wards of 2 university-affiliated hospitals in Hong Kong. Results Data necessary for the calculation of the TISS 28, the Therapeutic Intervention Scoring System (TISS 76), and severity of illness scoring system (Simplified Acute Physiology Score [SAPS II]) were recorded for each patient during the first 24 hours after his/her admission to an ICU. A significant positive correlation was found between the TISS 76 and the TISS 28 scores as well as the TISS 28 and the SAPS II scores. There was a significant difference between the TISS 28 scores among ICU patients and patients in rehabilitation wards. A significant correlation was found between the TISS 28 scores of the first and second set of TISS 28 scores. Conclusions Although the findings supported the validity and reliability of the TISS 28, there were limitations of the TISS 28 in measuring nursing workload in ICUs. Hence, continued amendment and validation of the TISS 28 on larger samples in different ICUs would be required so as to provide clinical nurses with a valid and reliable assessment of nursing workload.

Adoption of a sedation scoring system and sedation guideline in an intensive care unit

Aim. The paper presents a study assessing the rate of adoption of a sedation scoring system and sedation guideline. Background. Clinical practice guidelines including sedation guidelines have been shown to improve patient outcomes by standardizing care. In particular sedation guidelines have been shown to be beneficial for intensive care patients by reducing the duration of ventilation. Despite the acceptance that clinical practice guidelines are beneficial, adoption rates are rarely measured. Adoption data may reveal other factors which contribute to improved outcomes. Therefore, the usefulness of the guideline may be more appropriately assessed by collecting adoption data. Method. A quasi-experimental pre-intervention and postintervention quality improvement design was used. Adoption was operationalized as documentation of sedation score every 4 hours and use of the sedation and analgesic medications suggested in the guideline. Adoption data were collected from patients' charts on a random day of the month; all patients in the intensive care unit on that day were assigned an adoption category. Sedation scoring system adoption data were collected before implementation of a sedation guideline, which was implemented using an intensive information-giving strategy, and guideline adoption data were fed back to bedside nurses. After implementation of the guideline, adoption data were collected for both the sedation scoring system and the guideline. The data were collected in the years 2002-2004. Findings. The sedation scoring system was not used extensively in the pre-intervention phase of the study; however, this improved in the postintervention phase. The findings suggest that the sedation guideline was gradually adopted following implementation in the postintervention phase of the study. Field notes taken during the implementation of the sedation scoring system and the guideline reveal widespread acceptance of both. Conclusion. Measurement of adoption is a complex process. Appropriate operationalization contributes to greater accuracy. Further investigation is warranted to establish the intensity and extent of implementation required to positively affect patient outcomes.

The effect of an algorithm-based sedation guideline on the duration of mechanical ventilation in an Australian intensive care unit

To examine the effect of an algorithm-based sedation guideline developed in a North American intensive care unit (ICU) on the duration of mechanical ventilation of patients in an Australian ICU. The intervention was tested in a pre-intervention, post-intervention comparative investigation in a 14-bed adult intensive care unit. Adult mechanically ventilated patients were selected consecutively (n =322) The pre-intervention and post-intervention groups were similar except for a higher number of patients with a neurological diagnosis in the pre-intervention group. An algorithm-based sedation guideline including a sedation scale was introduced using a multifaceted implementation strategy. The median duration of ventilation was 5.6 days in the post-intervention group, compared with 4.8 days for the pre-intervention group (P = 0.99). The length of stay was 8.2 days in the post-intervention group versus 7.1 days in the pre-intervention group (P = 0.04). There were no statistically significant differences for the other secondary outcomes, including the score on the Experience of Treatment in ICU 7 item questionnaire, number of tracheostomies and number of self-extubations. Records of compliance to recording the sedation score during both phases revealed that patients were slightly more deeply sedated when the guideline was used. The use of the algorithm-based sedation guideline did not reduce duration of mechanical ventilation in the setting of this study.

Development of a dosage strategy in patients receiving enoxaparin by continuous intravenous infusion using modelling and simulation

Aim To develop an appropriate dosing strategy for continuous intravenous infusions (CII) of enoxaparin by minimizing the percentage of steady-state anti-Xa concentration (C-ss) outside the therapeutic range of 0.5-1.2 IU ml(-1). Methods A nonlinear mixed effects model was developed with NONMEM (R) for 48 adult patients who received CII of enoxaparin with infusion durations that ranged from 8 to 894 h at rates between 100 and 1600 IU h(-1). Three hundred and sixty-three anti-Xa concentration measurements were available from patients who received CII. These were combined with 309 anti-Xa concentrations from 35 patients who received subcutaneous enoxaparin. The effects of age, body size, height, sex, creatinine clearance (CrCL) and patient location [intensive care unit (ICU) or general medical unit] on pharmacokinetic (PK) parameters were evaluated. Monte Carlo simulations were used to (i) evaluate covariate effects on C-ss and (ii) compare the impact of different infusion rates on predicted C-ss. The best dose was selected based on the highest probability that the C-ss achieved would lie within the therapeutic range. Results A two-compartment linear model with additive and proportional residual error for general medical unit patients and only a proportional error for patients in ICU provided the best description of the data. Both CrCL and weight were found to affect significantly clearance and volume of distribution of the central compartment, respectively. Simulations suggested that the best doses for patients in the ICU setting were 50 IU kg(-1) per 12 h (4.2 IU kg(-1) h(-1)) if CrCL < 30 ml min(-1); 60 IU kg(-1) per 12 h (5.0 IU kg(-1) h(-1)) if CrCL was 30-50 ml min(-1); and 70 IU kg(-1) per 12 h (5.8 IU kg(-1) h(-1)) if CrCL > 50 ml min(-1). The best doses for patients in the general medical unit were 60 IU kg(-1) per 12 h (5.0 IU kg(-1) h(-1)) if CrCL < 30 ml min(-1); 70 IU kg(-1) per 12 h (5.8 IU kg(-1) h(-1)) if CrCL was 30-50 ml min(-1); and 100 IU kg(-1) per 12 h (8.3 IU kg(-1) h(-1)) if CrCL > 50 ml min(-1). These best doses were selected based on providing the lowest equal probability of either being above or below the therapeutic range and the highest probability that the C-ss achieved would lie within the therapeutic range. Conclusion The dose of enoxaparin should be individualized to the patients' renal function and weight. There is some evidence to support slightly lower doses of CII enoxaparin in patients in the ICU setting.

Application of Monte Carlo simulations to identify an appropriate dosage strategy for patients receiving a continuous intravenous infusion of enoxaparin

Aim: To identify an appropriate dosage strategy for patients receiving enoxaparin by continuous intravenous infusion (CII). Methods: Monte Carlo simulations were performed in NONMEM, (200 replicates of 1000 patients) to predict steady state anti-Xa concentrations (Css) for patients receiving a CII of enoxaparin. The covariate distribution model was simulated based on covariate demographics in the CII study population. The impact of patient weight, renal function (creatinine clearance (CrCL)) and patient location (intensive care unit (ICU)) were evaluated. A population pharmacokinetic model was used as the input-output model (1-compartment first order output model with mixed residual error structure). Success of a dosing regimen was based on the percent of Css that is between the therapeutic range of 0.5 IU/ml to 1.2 IU/ml. Results: The best dose for patients in the ICU was 4.2IU/kg/h (success mean 64.8% and 90% prediction interval (PI): 60.1–69.8%) if CrCL60ml/min, the best dose was 8.3IU/kg/h (success mean 65.4%, 90% PI: 58.5–73.2%). Simulations suggest that there was a 50% improvement in the success of the CII if the dose rate for ICU patients with CrCL

A IMPORTÂNCIA DA FAMÍLIA NA RECUPERAÇÃO DE PACIENTES INTERNADOS NA UNIDADE DE TERAPIA INTENSIVA

A Unidade de Terapia Intensiva (UTI) é um setor do hospital destinado ao atendimento de pacientes em estado crítico, que requer cuidados complexos e controles rígidos e, por isso sempre gera um ambiente estressante, não só para a equipe que atende ao paciente mas também aos familiares e portanto induz muitas vezes ao processo de depressão. Estes fatores leva-nos a abordar a necessidade de humanização, no atendimento ao paciente, bem como de seus familiares. A preocupação com a humanização deve estar presente nas equipes de enfermagem como filosofia-diretriz e deve ser um indicador de qualidades desses serviços. Humanizar a UTI significa cuidar do paciente como um todo, englobando o contexto bio-psico-social, incorporando os valores sociais e da família, as esperanças, os culturais e as preocupações pessoais. A humanização deve fazer parte da filosofia da enfermagem. O ambiente físico, os recursos materiais e tecnológicos são importantes, porém não mais significativos do que a natureza humana. O pensamento em ações da equipe de enfermagem, alimentam a reflexão crítica e a construção de uma realidade mais humana e menos agressiva e hostil para as pessoas que diariamente convivem no hospital. A hospitalização altera a rotina não só do paciente mas também dos familiares. De certa forma, a própria hospitalização pode ser vivida como abandono ou morte, à medida que implica um afastamento das pessoas queridas, da casa, como também uma invasão de privacidade. Este trabalho procurou Identificar as necessidades dos familiares ou visitantes, frente à equipe de saúde durante o período de internação na UTI e avaliar o grau de satisfação em relação à qualidade das informações e ao suporte dados à família ou visitante. Os resultados indicam que no Hospital Heliópolis, onde o trabalho foi conduzido, os entrevistados estavam satisfeitos com a equipe multiprofissional pois os pacientes eram bem cuidados, havendo preocupação com os pacientes, e que os médicos, além de compreensivos e competentes, forneceram as informações de modo que eles pudessem compreender,. Porém deve-se ressaltar que 48% dos entrevistados apontam a necessidade de apoio psicológico.(AU)

Performance measurement of intensive care services in hospitals:The case of Barbados

The Intensive Care Unit (ICU) being one of those vital areas of a hospital providing clinical care, the quality of service rendered must be monitored and measured quantitatively. It is, therefore, essential to know the performance of an ICU, in order to identify any deficits and enable the service providers to improve the quality of service. Although there have been many attempts to do this with the help of illness severity scoring systems, the relative lack of success using these methods has led to the search for a form of measurement, which would encompass all the different aspects of an ICU in a holistic manner. The Analytic Hierarchy Process (AHP), a multiple-attribute, decision-making technique is utilised in this study to evolve a system to measure the performance of ICU services reliably. This tool has been applied to a surgical ICU in Barbados; we recommend AHP as a valuable tool to quantify the performance of an ICU. Copyright © 2004 Inderscience Enterprises Ltd.

Application of analytic hierarchy process for measuring and comparing the global performance of intensive care units

Purpose: To develop a model for the global performance measurement of intensive care units (ICUs) and to apply that model to compare the services for quality improvement. Materials and Methods: Analytic hierarchy process, a multiple-attribute decision-making technique, is used in this study to evolve such a model. The steps consisted of identifying the critical success factors for the best performance of an ICU, identifying subfactors that influence the critical factors, comparing them pairwise, deriving their relative importance and ratings, and calculating the cumulative performance according to the attributes of a given ICU. Every step in the model was derived by group discussions, brainstorming, and consensus among intensivists. Results: The model was applied to 3 ICUs, 1 each in Barbados, Trinidad, and India in tertiary care teaching hospitals of similar setting. The cumulative performance rating of the Barbados ICU was 1.17 when compared with that of Trinidad and Indian ICU, which were 0.82 and 0.75, respectively, showing that the Trinidad and Indian ICUs performed 70% and 64% with respect to Barbados ICU. The model also enabled identifying specific areas where the ICUs did not perform well, which helped to improvise those areas. Conclusions: Analytic hierarchy process is a very useful model to measure the global performance of an ICU. © 2005 Elsevier Inc. All rights reserved.

Data envelopment analysis model for the appraisal and relative performance evaluation of nurses at an intensive care unit

The appraisal and relative performance evaluation of nurses are very important and beneficial for both nurses and employers in an era of clinical governance, increased accountability and high standards of health care services. They enhance and consolidate the knowledge and practical skills of nurses by identification of training and career development plans as well as improvement in health care quality services, increase in job satisfaction and use of cost-effective resources. In this paper, a data envelopment analysis (DEA) model is proposed for the appraisal and relative performance evaluation of nurses. The model is validated on thirty-two nurses working at an Intensive Care Unit (ICU) at one of the most recognized hospitals in Lebanon. The DEA was able to classify nurses into efficient and inefficient ones. The set of efficient nurses was used to establish an internal best practice benchmark to project career development plans for improving the performance of other inefficient nurses. The DEA result confirmed the ranking of some nurses and highlighted injustice in other cases that were produced by the currently practiced appraisal system. Further, the DEA model is shown to be an effective talent management and motivational tool as it can provide clear managerial plans related to promoting, training and development activities from the perspective of nurses, hence increasing their satisfaction, motivation and acceptance of appraisal results. Due to such features, the model is currently being considered for implementation at ICU. Finally, the ratio of the number DEA units to the number of input/output measures is revisited with new suggested values on its upper and lower limits depending on the type of DEA models and the desired number of efficient units from a managerial perspective.

Early warnings of heart rate deterioration

Hospitals can experience difficulty in detecting and responding to early signs of patient deterioration leading to late intensive care referrals, excess mortality and morbidity, and increased hospital costs. Our study aims to explore potential indicators of physiological deterioration by the analysis of vital-signs. The dataset used comprises heart rate (HR) measurements from MIMIC II waveform database, taken from six patients admitted to the Intensive Care Unit (ICU) and diagnosed with severe sepsis. Different indicators were considered: 1) generic early warning indicators used in ecosystems analysis (autocorrelation at-1-lag (ACF1), standard deviation (SD), skewness, kurtosis and heteroskedasticity) and 2) entropy analysis (kernel entropy and multi scale entropy). Our preliminary findings suggest that when a critical transition is approaching, the equilibrium state changes what is visible in the ACF1 and SD values, but also by the analysis of the entropy. Entropy allows to characterize the complexity of the time series during the hospital stay and can be used as an indicator of regime shifts in a patient’s condition. One of the main problems is its dependency of the scale used. Our results demonstrate that different entropy scales should be used depending of the level of entropy verified.

The effects of advanced practice nurses (APNs) as intensivists in a surgical intensive care unit (SICU) on patient outcomes, healthcare charges, and apn intensivist services in the SICU

Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, approximately 360,000 deaths, and account for close to 30% of acute care hospital costs. The need for critical care services has increased due to an aging population and medical advances that extend life. The result is efforts to improve patient outcomes, optimize financial performance, and implement models of ICU care that enhance quality of care and reduce health care costs. This retrospective chart review study examined the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on differences in patient outcomes, healthcare charges, SICU length of stay, charges for APN intensivist services, and frequency of APNs special initiatives when the SICU was staffed by differing levels of APN Intensivist staffing over four time periods (T1-T4) between 2009 and 2011. The sample consisted of 816 randomly selected (204 per T1-T4) patient chart data. Study findings indicated reported ventilator associated pneumonia (VAP) rates, ventilator days, catheter days and catheter associated urinary tract infection (CAUTI) rates increased at T4 (when there was the lowest number of APN Intensivists), and there was increased pressure ulcer incidence in first two quarters of T4. There was no statistically significant difference in post-surgical glycemic control (M = 142.84, SD = 40.00), t (223) = 1.40, p = .17, and no statistically significant difference in the SICU length of stay among the time-periods (M = 3.27, SD = 3.32), t (202) = 1.02, p = .31. Charges for APN services increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place. The number of new APN initiatives declined in T4 as the number of APN Intensivists declined. Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU. ^

Características dos programas de residência médica em cardiologia do estado do Rio Grande do Norte

The present study had as goal to evaluate Rio Grande do Norte state’s medical residency programs (MRP) in Cardiology. It’s a descriptive study, including a documental analysis of the program’s accreditation processes (PAP) of cardiology’s medical residency in Rio Grande do Norte state in 2014 and the analysis of the resident’s perception about his professional education as a specialist in Cardiology. Beside the documental analysis of the PAPs, it was applied a semi-structured questionnaire with closed questions Likert style and open questions to all the current and former residents of the MRPs analyzed. Two MRPs in Cardiology were identified in Rio Grande do Norte state, one hosted in a public institution and the other in a private institution. The documental analysis showed a greater amount of preceptors with a good level of ownership on the public institution in comparison with the private one, as well as a bigger number of publications, participation in congresses and in book’s publications. The private institution presents a better Urgency’s infrastructure, with emergency room and cardiologic ICU. It IS clear that the residents are aware of how a good residency must work, as well as the strengths and fragilities of their own residences. Most of Onofre Lopes Universitary Hospital’s residents point out as a strength the organization, participation and quality of the preceptors, practice activities and scientific debates, great amount of patients and the visits and debates with the preceptors on the sickrooms. As the greatest fragilities, they emphasize the lack of a urgency service of their own and a specialized ICU. In Coração Hospital of Natal (HCor), it is listed as weak points the theoretic scheduling and the few ambulatory practices. As positive aspects, they report the preceptors, the agility on the execution of exams, a good number of serious patients and procedures. In both residences, it is seen a certain difficulty in accepting the important and mandatory items imposed by the rules of the Medical Residences’ National Committee, such as: biostatistics, bioethics, medical ethic, epidemiology and research methodology. Besides that, the residents recognize that both hospitals have a good infrastructure and technological support, especially in imaging methods. The evaluation of PRMCs identifies the strengths of each program and the aspects to be improved in both programs. It also allowed the observation of difficulties in accepting some regulations contained in the CNRM resolution by the resident, such as participation in activities such as biostatistics, epidemiology and research methodology as well as the improvement needs of specific technical training, such as in emergency care. Thus, our results make possible to develop strategies for continued improvement of PRMC in RN state. In addition, it enabled the preparation of the resident’s manual in cardiology, containing even a breakdown of resident evaluation system, which could serve as a model for other residency programs.

Gasto com a internação de idosos em unidades de terapia intensiva

Introduction: Population aging in Brazil underscores the need to discuss the proper management of the budget allocated in health field, especially in the sectors of high complexity, where coexist costly procedures, limited resources and the need for cost containment. In the other hand, demand is growing in a way directly proportional to the increase in the number of elderly in country. Objective: In this way, this research had as main objective to analyze the costs resulting from the admission of elderly in intensive care units (ICU) and its associated factors. Methods: This is a cross-sectional study with a quantitative approach and featured as a descriptive and exploratory research. Data were collected from medical records of elderly hospitalized in ICU from a brazilian city called Natal-RN, between november first, 2013 and january, 31 of 2014. The variables collected relate to the socio demographic profile, morbidity framework and characterization of hospitalization. The dependent variable was categorized by quartile 75 in high and low expense of hospitalization and submitted to chi-square test with the independent variables of the survey. Associations with p value <0.20 in the bivariate analysis were submitted to the technique of multiple logistic regression. We opted for the construction of three regression models from the above algorithm: general regression model, composed by all 493 hospitalizations in the study, other made with 181 individuals admitted in health public system (SUS) and a third one related to 312 cases from private service in health area. Results: In the general regression model, the variables respiratory diseases, hospitalizations in the private system, disoriented patient and previous stroke were associated with greater probability of high spending in the ICU. In the other hand, in SUS kind of hospitalizations, this probability was associated with disoriented patient, 80 years old or more, sepsis and admission for clinical reason. In the cases from the private network health, the high expenditure was associated with respiratory disease, mechanical ventilation, hospitalization for clinical reason and disoriented patients. Conclusion: The increased expenditure on hospitalization of elderly in intensive care depends on the clinical conditions of individuals. This highlights the importance of avoiding hospitalizations due to diseases sensitive to primary care by health preventive actions and providing comprehensive care to the elderly. In addition, obtaining different explanatory models, according to kind hospital funding, demonstrates the importance of the organization in health services related to composition of costs of hospitalization among the elderly. Another question founded was the need that to improve the funding, we must use rationally the available resources by avoiding unnecessary hospitalizations of elderly people in the extremes of severity. On this kind of precarious funding, ICU hospitalization of elderly non-critical or in a terminal state can compromise the quality of services provided to those who really need intensive care.

Infecções por enterobacteriaceae resistente aos carbapenêmicos em hospital de ensino: epidemiologia e caracterização molecular

Introduction: The production of KPC (Klebsiella pneumoniae carbapenemase) has become an important mechanism of carbapenem-resistance among Enterobacteriaceae strains. In Brazil, KPC is already widespread and its incidence has increased significantly, reducing treatment options. The “perfect storm” combination of the absence of new drug developmentand the emergence of multidrug-resistant strains resulted in the need for the use of older drugs, with greater toxicity, such as polymyxins. Aims: To determine the occurrence of carbapenemase-producing strains in carbapenem-resistant Enterobacteriaceae isolated from patients with nosocomial infection/colonization during September/2014 to August/2015, to determine the risk factors associated with 30-day- mortality and the impact of inappropriate therapy. Materials and Methods: We performed a case control study to assess the risk factors (comorbidities, invasive procedures and inappropriate antimicrobial therapy) associated with 30-day-mortality, considering the first episode of infection in 111 patients. The resistance genes blaKPC, blaIMP, blaVIM and blaNDM-1 were detected by polymerase chain reaction technique. Molecular typing of the strains involved in the outbreak was performed by pulsed field gel electrophoresis technique. The polymyxin resistance was confirmed by the microdilution broth method. Results: 188 episodes of carbapenem-resistant Enterobacteriaceae infections/colonizations were detected; of these, 122 strains were recovered from the hospital laboratory. The presence of blaKPC gene were confirmed in the majority (74.59%) of these isolates. It was not found the presence of blaIMP , blaVIM and blaNDM-1 genes. K. pneumoniae was the most frequent microorganism (77,13%), primarily responsible for urinary tract infections (21,38%) and infections from patients of the Intensive Care Unit (ICU) (61,38%). Multivariate statistical analysis showed as predictors independently associated with mortality: dialysis and bloodstream infection. The Kaplan-Meier curve showed a lower probability of survival in the group of patients receiving antibiotic therapy inappropriately. Antimicrobial use in adult ICU varied during the study period, but positive correlation between increased incidence of strains and the consumption was not observed. In May and July 2015, the occurrence rates of carbapenem-resistant Enterobacteriaceae KPC-producing per 1000 patient-days were higher than the control limit established, confirming two outbreaks, the first caused by colistin-susceptible KPC-producing K. pneumoniae isolates, with a polyclonal profile and the second by a dominant clone of colistin-resistant (≥ 32 μg/mL) KPC-producing K. pneumoniae. The cross transmission between patients became clear by the temporal and spatial relationships observed in the second outbreak, since some patients occupied the same bed, showing problems in hand hygiene adherence among healthcare workers and inadequate terminal disinfection of environment. The outbreak was contained when the ICU was closed to new admissions. Conclusions: The study showed an endemicity of K. pneumoniae KPC-producing in adult ICU, progressing to an epidemic monoclonal expansion, resulted by a very high antibiotic consumption of carbapenems and polymyxins and facilitated by failures in control measures the unit.

A crença sobre a morte e o coping religioso-espiritual em pacientes internados com doenças crônicas

The human being is understood as an integral being, complex, which has multiple dimensions: social, biological, psychological, anthropological, spiritual and others. As its biological dimension, the man presents the possibility of physical illness, which means that the body requires care. The sick away from humans in health and safety conditions, approaching them directly from the finitude and vulnerability condition, leading us to contact the major uncertainties of life: suffering of disease and death. Religiosity and spirituality are important coping strategy for human when faced with borderline situations. When people turn to religion to cope with stress is the religious and spiritual coping. The objective of this research was to evaluate the relationship between the views on death and the religious-spiritual coping in patients with chronic diseases hospitalized. The study included ten patients hospitalized for chronic disease complications Medical Clinic Unit of a public hospital in the city of Uberlândia/MG. two psychological scales were used: Scale Religious-Spiritual Coping Brief (CRE-Brief Scale) and Scale Brief Diverse Perspectives of Death and a structured interview (audiogravada) on the subject of death and religious and spiritual coping. The results indicated that 80% of the sample (N = 8) consisted of patients hospitalized due to chronic diseases, while 20% accounted for patients with AIDS complications. Analyzing the results of scale CRE-Brief, it emphasizes the use of strategies of religious and spiritual coping by participants as compared to CRE Total, all study participants had average or high scores for this index, with a low utilization CRE negative and average utilization CRE Positive. Regarding views on death, the results obtained by the Different Perspectives Quick Scale on Death suggest that this sample agrees with the view death as something that is part of the natural cycle of life (M8 - Death as a natural end) and features the prospect of death as uncertainty, mystery and ignorance (M4 - death as Unknown). The correlations between the measures the factors and items of CRE-Bref and dimensions of Short scales on different perspectives of Death notes the prevalence of correlations of M4 dimensions - Death as unknown and M8 - Death as a natural order to the creditor scale soon. In the interview analysis revealed a positive influence of religion/ spirituality on health, from the perspective of the respondent, highlighting the protection promoted by religion. It also noticed the use of prayer as a coping strategy of hospitalization and illness. Regarding the interview about the topic of death, there was a predominance of issues related to "afterlife", "unknown" and "abandonment", which are associated with the visions of death and mystery and death as a natural end. In the interviews there belief clues about death as a terrifying mystery connected, so the unknown and the feeling of fear on the same. The experience of illness can therefore be considered as a source of vulnerability, since it is present personal perception of danger (external) - own illness and possible death, especially in those patients undergoing ICU - and where control is insufficient for the sense of security, since the hospital providing care to the patient are delegated to third parties and patients assume a passive role. This fact is important and relevant to health professionals who deal daily with patients hospitalized for chronic diseases, since the recourse to religion and spirituality as a coping strategy that psychic movement was not constituted in a form of negative distance or even denial of health condition. On the contrary, it refers to a movement in search of comfort and security provided by the religion and spirituality.