Desperdício de medicamentos em ambiente hospitalar : identificação dos pontos críticos no circuito, impacto no consumo de recursos e estratégias de controlo

RESUMO - Numa época de constrangimento orçamental, os hospitais do SNS vêm-se na obrigação de melhorar a eficiência de utilização dos recursos disponíveis, por forma a contribuir para o seu equilíbrio financeiro. Cabe a cada prestador analisar a sua posição, avaliar as suas oportunidades e adoptar estratégias que a curto, médio ou longo prazo se traduzam numa efetiva melhoria na eficiência. A análise e o controlo do desperdício associado à prestação de cuidados de saúde apresentam-se, globalmente, como uma dessas oportunidades. Neste trabalho são exploradas oportunidades de redução de desperdício em medicamentos, numa perspectiva meramente operacional, a nível das funções desempenhadas pelos Serviços Farmacêuticos (SF). No hospital em estudo acompanhou-se as diferentes linhas de produção dos SF, nomeadamente as tarefas envolvidas no processo de Distribuição Individual Diária em Dose Unitária, na distribuição de medicamentos para o Serviço de Urgências (SU) e na preparação de citotóxicos e imunomoduladores para o Hospital de Dia de Oncologia. Durante o ano de 2013, os SF devolveram aos fornecedores 0,07% e abateram 0,05% da despesa em medicamentos. A análise dos erros de medicação registados reflete o tipo de distribuição adotado para a maioria dos serviços de internamento do hospital. As melhorias encontradas a este nível passam pelo reforço de recursos humanos a desempenhar as tarefas de dispensa de medicamentos mas também pela implementação de uma cultura de registo de erros e acidentes, baseada no sistema de informação, para que se consiga quantificar o desperdício associado e agir com vista à optimização do circuito. A relação entre o método de distribuição adotado para o SU e a utilização do medicamento neste serviço foi apenas investigada para os medicamentos de registo individual de administração. Foi determinado um índice de eficiência de utilização de 67,7%, entre o dispensado e o administrado. Às discrepâncias encontradas está associado um custo de 32 229,6 € para o ano de 2013. Constatou-se também que, a nível do consumo de citotóxicos e imunomoduladores houve, durante o mês de abril de 2013, um índice de desperdício médio de 14,7%, entre o prescrito e o consumido, que se traduziu num custo do desperdício mensal de 13 070,9 €. Com base no desperdício mensal estimou-se que o desperdício anual associado à manipulação de citotóxicos e imunomoduladores deverá corresponder a 5,5% da despesa anual do serviço com estes medicamentos. Não obstante as limitações encontradas durantes o trabalho, e parte do desperdício apurado ser inevitável, demonstrou-se que o desperdício em medicamentos pode traduzir-se numa fatia não negligenciável mas controlável da despesa do hospital em estudo. No seguimento do seu conhecimento, a sua contenção pode ter um impacto na redução de despesa a curto-médio prazo, sem a necessidade de racionamento da utilização de medicamentos e sem alterar os padrões de qualidade assistencial exigidos pela tutela e pelos doentes. Por último, são apresentadas recomendações para a redução do desperdício em medicamentos, adequadas a cada uma das dimensões analisadas.

Reduction of catheter-associated bloodstream infections through procedures in newborn babies admitted in a university hospital intensive care unit in Brazil

INTRODUCTION: Catheter-associated bloodstream infection (CA-BSI) is the most common nosocomial infection in neonatal intensive care units. There is evidence that care bundles to reduce CA-BSI are effective in the adult literature. The aim of this study was to reduce CA-BSI in a Brazilian neonatal intensive care unit by means of a care bundle including few strategies or procedures of prevention and control of these infections. METHODS: An intervention designed to reduce CA-BSI with five evidence-based procedures was conducted. RESULTS: A total of sixty-seven (26.7%) CA-BSIs were observed. There were 46 (32%) episodes of culture-proven sepsis in group preintervention (24.1 per 1,000 catheter days [CVC days]). Neonates in the group after implementation of the intervention had 21 (19.6%) episodes of CA-BSI (14.9 per 1,000 CVC days). The incidence of CA-BSI decreased significantly after the intervention from the group preintervention and postintervention (32% to 19.6%, 24.1 per 1,000 CVC days to 14.9 per 1,000 CVC days, p=0.04). In the multiple logistic regression analysis, the use of more than 3 antibiotics and length of stay >8 days were independent risk factors for BSI. CONCLUSIONS: A stepwise introduction of evidence-based intervention and intensive and continuous education of all healthcare workers are effective in reducing CA-BSI.

How to improve Sonae's processes of suppliers of services' management?

Sonae is one of the greatest retailers in Portugal. As the business got bigger, it centralized operations. Direcção de Serviços Administrativos processes all invoices sent by suppliers. However, there are many which deliver errors and are not processed automatically. As a result, there are lost invoices and suppliers who are not paid, while the company’s accountability becomes less transparent. Such is due to a lack of proactive attitude towards suppliers as well as to a lack of incentives for employees to perform well. Great savings may be achieved with little effort, if the right things are measured so that the right tools may be applied.

How to monitor and improve Unilever JM Supply Chain processes to become the best of Portugal’s sector in 2015?

Unilever Jerónimo Martins is a Portuguese joint-venture leading firm in what concerns the supply chain industry of fast-moving consumer goods in Portugal. The scope of analysis of this Work Project is focusing on Unilever-JM operations and services in the Portuguese market regarding quality, efficiency and effectiveness over B2B customers. It will be analysed the possibility of development and implementation of a performance measurement system, Tableau de Bord, which will be crucial for the identification of potential opportunities of improvement with impact in the supply chain processes. This will be completed through the establishment of KPI’s to monitor and manage periodically logistics, planning and customer service processes’ performance, which are the ones where the bottlenecks are impacting more in the supply chain. In this work project the nexus causality for the problems will also be discussed and some recommendations will be prepared to tackle the inefficiencies found through the monitoring of the previous core processes, in order to improve efficacy and quality service of the supply chain.

Impact of an intervention in the use of sequential antibiotic therapy in a Brazilian university hospital

INTRODUCTION: Sequential antibiotic therapy (SAT) is safe and economical. However, the unnecessary use of intravenous (IV) administration usually occurs. The objective of this work was to get to know the effectiveness of an intervention to implement the SAT in a teaching hospital in Brazil. METHODS: This was a prospective and interventional study, historically controlled, and was conducted in the Hospital de Clínicas, Universidade Federal de Uberlândia, State of Minas Gerais, Brazil, a high complexity teaching hospital having 503 beds. In each of the periods, from 04/04/05 to 07/20/05 (pre-intervention) and from 09/24/07 to 12/20/07 (intervention), 117 patients were evaluated. After the pre-intervention period, guidelines were developed which were implemented during the intervention period along with educational measures and a reminder system added to the patients' prescription. RESULTS: In the pre-intervention and intervention periods, the IV antibiotics were used as treatment for a average time of 14.8 and 11.8 days, respectively. Ceftriaxone was the antibiotic most prescribed in both periods (23.4% and 21.6% respectively). Starting from the first prescription of antibiotics, the average length of hospitalization time was 21.8 and 17.5 days, respectively. The SAT occurred only in 4 and 5 courses of treatment, respectively, and 12.8% and 18.8% of the patients died in the respective periods. CONCLUSIONS: Under the presented conditions, the evaluated intervention strategy is ineffective in promoting the exchange of the antibiotic administration from IV to oral treatment (SAT).

The economic valuation of noise reduction projects: A cost-benefit analysis approach

The main purpose of this Work Project consists in performing a practical Cost-Benefit Analysis from a social perspective of two noise reduction projects in industrial sites that aim at complying with the existing regulation. By doing so, one may expect a more comprehensive view of the benefits and costs of both projects, as well as relevant insight to the way noise exposure regulation must be optimally defined in Portugal and within the EU area.

Optimal design and operation of compact simulated moving bed processes for enantioseparations

Simulated moving bed (SMB) chromatography is attracting more and more attention since it is a powerful technique for complex separation tasks. Nowadays, more than 60% of preparative SMB units are installed in the pharmaceutical and in the food in- dustry [SDI, Preparative and Process Liquid Chromatography: The Future of Process Separations, International Strategic Directions, Los Angeles, USA, 2002. http://www. strategicdirections.com]. Chromatography is the method of choice in these ¯elds, be- cause often pharmaceuticals and ¯ne-chemicals have physico-chemical properties which di®er little from those of the by-products, and they may be thermally instable. In these cases, standard separation techniques as distillation and extraction are not applicable. The noteworthiness of preparative chromatography, particulary SMB process, as a sep- aration and puri¯cation process in the above mentioned industries has been increasing, due to its °exibility, energy e±ciency and higher product purity performance. Consequently, a new SMB paradigm is requested by the large number of potential small- scale applications of the SMB technology, which exploits the °exibility and versatility of the technology. In this new SMB paradigm, a number of possibilities for improving SMB performance through variation of parameters during a switching interval, are pushing the trend toward the use of units with smaller number of columns because less stationary phase is used and the setup is more economical. This is especially important for the phar- maceutical industry, where SMBs are seen as multipurpose units that can be applied to di®erent separations in all stages of the drug-development cycle. In order to reduce the experimental e®ort and accordingly the coast associated with the development of separation processes, simulation models are intensively used. One impor- tant aspect in this context refers to the determination of the adsorption isotherms in SMB chromatography, where separations are usually carried out under strongly nonlinear conditions in order to achieve higher productivities. The accurate determination of the competitive adsorption equilibrium of the enantiomeric species is thus of fundamental importance to allow computer-assisted optimization or process scale-up. Two major SMB operating problems are apparent at production scale: the assessment of product quality and the maintenance of long-term stable and controlled operation. Constraints regarding product purity, dictated by pharmaceutical and food regulatory organizations, have drastically increased the demand for product quality control. The strict imposed regulations are increasing the need for developing optically pure drugs.(...)

A decision- theoretic model for M&A sale processes

A Work Project, presented as part of the requirements for the Award of a Masters Double Degree in Economics and International Business from the NOVA – School of Business and Economics and Insper Instituto de Ensino e Pesquisa

Engineering bio-based polymers using alternative solvents and processes

The work presented in this thesis explores novel routes for the processing of bio-based polymers, developing a sustainable approach based on the use of alternative solvents such as supercritical carbon dioxide (scCO2), ionic liquids (ILs) and deep eutectic solvents (DES). The feasibility to produce polymeric foams via supercritical fluid (SCF) foaming, combined with these solvents was assessed, in order to replace conventional foaming techniques that use toxic and harmful solvents. A polymer processing methodology is presented, based on SCF foaming and using scCO2 as a foaming agent. The SCF foaming of different starch based polymeric blends was performed, namely starch/poly(lactic acid) (SPLA) and starch/poly(ε-caprolactone) (SPCL). The foaming process is based on the fact that CO2 molecules can dissolve in the polymer, changing their mechanical properties and after suitable depressurization, are able to create a foamed (porous) material. In these polymer blends, CO2 presents limited solubility and in order to enhance the foaming effect, two different imidazolium based ILs (IBILs) were combined with this process, by doping the blends with IL. The use of ILs proved useful and improved the foaming effect in these starch-based polymer blends. Infrared spectroscopy (FTIR-ATR) proved the existence of interactions between the polymer blend SPLA and ILs, which in turn diminish the forces that hold the polymeric structure. This is directly related with the ability of ILs to dissolve more CO2. This is also clear from the sorption experiments results, where the obtained apparent sorption coefficients in presence of IL are higher compared to the ones of the blend SPLA without IL. The doping of SPCL with ILs was also performed. The foaming of the blend was achieved and resulted in porous materials with conductivity values close to the ones of pure ILs. This can open doors to applications as self-supported conductive materials. A different type of solvents were also used in the previously presented processing method. If different applications of the bio-based polymers are envisaged, replacing ILs must be considered, especially due to the poor sustainability of some ILs and the fact that there is not a well-established toxicity profile. In this work natural DES – NADES – were the solvents of choice. They present some advantages relatively to ILs since they are easy to produce, cheaper, biodegradable and often biocompatible, mainly due to the fact that they are composed of primary metabolites such as sugars, carboxylic acids and amino-acids. NADES were prepared and their physicochemical properties were assessed, namely the thermal behavior, conductivity, density, viscosity and polarity. With this study, it became clear that these properties can vary with the composition of NADES, as well as with their initial water content. The use of NADES in the SCF foaming of SPCL, acting as foaming agent, was also performed and proved successful. The SPCL structure obtained after SCF foaming presented enhanced characteristics (such as porosity) when compared with the ones obtained using ILs as foaming enhancers. DES constituted by therapeutic compounds (THEDES) were also prepared. The combination of choline chloride-mandelic acid, and menthol-ibuprofen, resulted in THEDES with thermal behavior very distinct from the one of their components. The foaming of SPCL with THEDES was successful, and the impregnation of THEDES in SPCL matrices via SCF foaming was successful, and a controlled release system was obtained in the case of menthol-ibuprofen THEDES.

Unilever food solutions new digital CRM platform- what is the combination of tools, processes and content that will help Unilever food solutions grow his business?

Unilever Food Solutions new digital CRM1 Platform - What is the combination of tools, processes and content that will help Unilever Food Solutions grow his business? Unilever Food Solutions (UFS) intend to create a new online platform to enable it to communicate with segments of the markets, which have previously been too difficult to reach. Specifically targeted at Chefs and other food professionals, the aim is to create an interactive website, which delivers value to its intended users by providing a variety of relevant content and functions, while simultaneously opening up a potential transactional channel to those same users.

Removal of organic contaminants from wastewater using the electrodialytic process

Pharmaceuticals and personal care products (PPCPs) are widely used on a daily basis. After their usage they reach the wastewater treatment plants (WWTPs). These compounds have different physico-chemical characteristics, which makes them difficult to completely remove in the WWTPs, througth conventional treatments. Currently, there is no legislation regarding PPCPs thresholds in effluent discharge. But, even at vestigial concentrations, these compounds enclose environmental risks due to, e.g., endocrine disruption potential. There is a need of alternative techniques for their removal in WWTPs. The main goal of this work was to assess the use of electrodialytic (ED) process to remove PPCPs from the effluent to be discharged. A two-compartment ED cell was used testing (i) the effluent position in the cell (anode and cathode compartment); (ii) the use of anion (AEM) and cation exchange membrane (CEM); (iii) the treatment period (6, 12 and 24 hours); (iv) effluent recirculation and current steps; (v) the feasibility of sequential treatments. Phosphorus (P) removal from effluent and energetic costs associated to the process were also evaluated. Five PPCPs were studied – caffeine (CAF), bisphenol A (BPA), 17 β-estradiol (E2), ethinyl estradiol (EE2) and oxybenzone (MBPh). The ED process showed to be effective in the removal when effluent is in the anode compartment. Oxidation is suggested to be the main removal process, which was between 88 and 96%, for all the compounds, in 6 hours. Nevertheless, the presence of intermediates and/or by-products was also observed in some cases. Effluent recirculation should have a retention time in the ED cell big enough to promote removal whereas the current steps (effluent in anode compartment) slightly increased removal efficiencies (higher than 80% for all PPCPs). The sequential set of ED treatment (effluent in anode compartment) showed to be effective during both periods with a removal percentage between 80 and 95% and 73 to 88% in the case of AEM and CEM, respectively. Again, the main removal process is strongly suggested to be oxidation in the anode compartment. However, there was an increase of BOD5 and COD, which might be explained by effluent spiking, these parameters limiting the effluent discharge. From these treatments, the use of AEM, enhanced the P removal from effluent to minimize risk of eutrophication. Energetic costs of the best set-up (6 hours) are approximately 0,8€/m3 of wastewater, a value considered low, attending to the prices of other treatment processes.

A educação para a saúde em meio escolar como veículo construtor para a mudança de comportamentos alimentares

Relatório de estágio de mestrado em Educação Pré-Escolar e Ensino do 1º Ciclo do Ensino Básico

Prevention in underground construction with sequential excavation method

This paper aims to describe the Sequential Excavation Method, used for excava-tion in underground works, as well as the related risks and preventive measures. This method has characteristics that differentiate it from other tunnelling techniques: it uses a larger number of workers and equipment; it has a high concurrency of tasks with various workers and equip-ment quite exposed to hazards; and it uses many potentially aggressive chemicals. Firstly, it is given a broad overview of this issue. Afterwards, it will be presented the results of a survey to a sample of experienced technicians, aimed at gauging the relevance of a set of guidelines relat-ing to the design and work phases, applicable to the domestic market and prepared following technical visits to works abroad.

Assessment of national parks affected by naturbanization processes in Southern Europe

This paper assesses land-use changes related to naturbanization processes on three biosphere reserves in Southern Europe. A comparative analysis has been done on the National Parks in Peneda-Ger^es in North Portugal, C_evennes in South France and Sierra Nevada in South Spain, using Corine Land Cover data from 1990 until 2006. Results indicate that the process of land-use intensification is taking place in the frame of naturbanization dynamics that could jeopardize the role of Protected Areas. Focusing on the trends faced by National Parks and their surrounding territories, the analysis demonstrates, both in quantitative and spatial terms, the intensification processes of land-use changes and how it is important to know them for coping with increasing threats. The article concludes that in the current context of increasing stresses, a broader focus on nature protection, encompassing the wider countryside, is needed if the initiatives for biodiversity protection are to be effective.

Combining data mining and evolutionary computation for multi-criteria optimization of earthworks

Earthworks tasks aim at levelling the ground surface at a target construction area and precede any kind of structural construction (e.g., road and railway construction). It is comprised of sequential tasks, such as excavation, transportation, spreading and compaction, and it is strongly based on heavy mechanical equipment and repetitive processes. Under this context, it is essential to optimize the usage of all available resources under two key criteria: the costs and duration of earthwork projects. In this paper, we present an integrated system that uses two artificial intelligence based techniques: data mining and evolutionary multi-objective optimization. The former is used to build data-driven models capable of providing realistic estimates of resource productivity, while the latter is used to optimize resource allocation considering the two main earthwork objectives (duration and cost). Experiments held using real-world data, from a construction site, have shown that the proposed system is competitive when compared with current manual earthwork design.