Dissertations / Theses on the topic 'Quality care in intensive care units'

Sleep deprivation is a multifactorial phenomenon, occurring frequently in the intensive care unit (ICU) and linked to adverse patient healthcare outcomes. The key practice question of this project focused on determining if retiming of routine laboratory and imaging testing outside of the designated “quiet time” can improve sleep quality among adult patients in the ICU. The purpose was to evaluate the effectiveness of implementing an evidence-based intervention to improve sleep quality in the ICU setting. The theoretical framework was the plan-do-study-act model, which offered a process for implementing a practice change and reevaluation of the intervention’s sustainability within the organization. A thorough literature search of over 100 scholarly journal articles, book references, and expert scholarly reports was completed to gain an understanding of this phenomenon in the ICU setting. The Richards-Campbell Sleep Questionnaire (RCSQ) was the data collection tool used to measure improvement in sleep quality. There were 72 participants that are included in the project. The Wilcoxon rank sum and chi square tests were used for the statistical analysis. The findings did not show statistical significance in the improvement in the RCSQ scores after implementation of the intervention. The recommendations include sleep deprivation training for nursing staff and providers, routine use of the RCSQ for data collection, and repeating the study with an increased number of participants and redefined inclusion and exclusion criteria to be more representative of the ICU patient population. The implication for social change is that this project empowers nursing to embrace a leadership role in using evidence-based practice to change clinical guidelines and improve patient outcomes.

Thesis (MScPhysio(Interdisciplinary Health Sciences. Physiotherapy))--University of Stellenbosch, 2005.<br>Objectives: This study forms part of a baseline study conducted on patients admitted to an adult surgical ICU between June and October 2003. The survival rate and health related quality of life (HRQoL) of patients 12months following ICU discharge was determined. The correlation of selected demographic and ICU variables to survival and HRQoL was determined. Design: Prospective observational cohort study. Setting: Tenbed closed public tertiary adult surgical ICU. Patients: 180 subjects obtained from a previous baseline study. Measurements: The baseline study provided the demographic data and ICU variables. Survival rate was determined from a Kaplan Meier survival curve. A self-developed questionnaire was used to obtain other selected variables for comparison. A modified Short-Form 36 version 2 (SF-36v2) was use to measure HRQoL perceptions of patients. Results: The survival rate was 62% at 12 months following ICU admission. None of the selected variables were significantly correlated to the long-term survival outcome except for APACHE II which was negatively correlated to this outcome (p<0.01). Forty-six subjects took part in the HRQoL study. The mean HRQoL scores ranged between 43% and 53% for each of the SF-36 HRQoL domains. The physical functioning (43.5%), role play (44.5%) and role emotion (43.1%) domains had the lowest scores. APACHE II had a significantly negative correlation to the physical functioning domain of HRQoL (p=0.02). Age was positively correlated to social functioning (p<0.01) and role emotion (p=0.03). Patients employed after ICU had significantly higher scores for general health (p<0.01) than those who were not. Patients unsure of their TB status and HIV status had significantly lower scores in general health (p=0.02) and role emotion (p=0.05) respectively. ICU length of stay was negatively correlated to role play (p=0.05) and role emotion (p<0.01). Intubation period was negatively correlated to general health (p=0.04). Conclusion: APACHE II was the only variable significantly correlated to both long-term survival and the physical functioning domain of HRQoL. Although the long-term survival was comparable to that of international ICU populations the HRQoL outcomes were slightly lower. Similar to international studies and a South African study evaluating the HRQoL of aids sufferers and police, the current ICU population presented more limitation in the physical functioning, role play and role emotion domains of HRQoL.

Background: Recent focus on quality and patient safety has underlined the need to involve patients in improving healthcare. “Experience-based Co-design” (EBCD) is an approach to capture and understand patient and staff (i. e. users) experiences, identifying so called “touch points” and then working together equally in improvement efforts. Purpose: This article elucidates patient (defined as the mother-newborn couple with next of kin) and staff experiences following improvement work carried out according to EBCD in a maternity ward and neonatal intensive care unit (NICU) in a small, acute hospital in Sweden. Method: An experience questionnaire, derived from the EBCD approach tool set, was used for continuously evaluating each event of the EBCD improvement project. Furthermore, a focus group interview with staff and in-depth interviews with mother-father couples were held in order to collect and understand the experiences of working together according to EBCD. The analysis and interpretation of the interview data was carried through using qualitative, problem-driven content analysis. Themes, categories and sub-categories presented in this study constitute the manifest and latent content of the participants’ experiences of Experience-based Co-design. Results: The analysis of the experience questionnaires, prior to the interviews, revealed mostly positive experiences of the participation. Both staff and patient participants stated generally happy, involved, safe, good and comfortable experiences following each event of the improvement project so far. Two themes emerged during the analysis of the interviews. For staff participants the improvement project was a matter of learning within the microsystem through managing practical issues, moving beyond assumptions of improvement work and gaining a new way of thinking. For patients, taking part of the improvement project was expressed as the experience of involvement in healthcare through their participation and through a sense of improving for the future. Discussion: This study confirms that, despite practical obstacles for participants, the EBCD approach to improvement work provided an opportunity for maternity ward /NICU care being explored respectfully at the experience level, by assuring the sincere sharing of useful information within the microsystem continuously, and by encouraging and supporting the equal involvement of both staff and patients. Staff and patients wanted and were able to contribute to the EBCD process of gathering information about their experiences, analyzing and responding to collected data, and engaging themselves in improving the same. Furthermore, the EBCD approach provided staff and patients the opportunity of learning within the microsystem. Nevertheless, the responsibility of the improvement work remained the responsibility of the healthcare professionals. Keywords: Quality Improvement, Maternity Care, Neonatal Intensive Care, Experience-based Co-design

Estudo transversal, descritivo, de natureza quantitativa, realizado com o objetivo de correlacionar o tempo médio de assistência dispensado pelos profissionais de enfermagem em uma Unidade de Terapia Intensiva (UTI) de um hospital privado de um município do interior do estado de São Paulo, com indicadores de qualidade assistencial: incidência de flebite, incidência de extubação orotraqueal (extot) não planejada, incidência de úlcera por pressão (UP), incidência de saída não planejada de sonda nasoenteral (SNE) para aporte nutricional, densidade de incidência de infecção do trato urinário (ITU) e densidade de incidência de pneumonia associada à ventilação mecânica (PAV). O período de análise foi de 01 de janeiro de 2011 a 31 de dezembro de 2013 e os dados foram obtidos de um sistema de registro eletrônico que armazena e gerencia as informações na unidade investigada, além da escala diária do pessoal de enfermagem. Para a análise dos dados, foi utilizada a correlação de Pearson para as variáveis número médio de horas dispensadas e a razão de horas dispensadas por requeridas (p-valor < 0.001) e, para as variáveis resposta, foram usados os Modelos Lineares Generalizados, com nível de significância de 5% (?=0,05). A amostra desse estudo foi composta por 1.717 pacientes, sendo 61% com idade acima de 65 anos, submetidos a tratamento clínico (70%) e média de internação de 3,85 dias, sendo a maioria proveniente da emergência (48,7%). O índice de gravidade SAPS 3 observado foi de 48,6 pontos e a mortalidade no período foi de 18,7%. O tempo médio de assistência de enfermagem dispensado aos pacientes correspondeu a 12,21 horas, sendo que, dessas, os enfermeiros ministraram um mínimo de 23% e um máximo de 30%. Obteve-se um valor de NAS médio de 54,87 pontos, o que equivale a 13,17 horas de assistência de enfermagem requeridas. A média da razão de horas dispensadas por requeridas foi de 0,87. Na análise correlacional entre os indicadores assistenciais e o tempo de assistência de enfermagem dispensado, obteve-se que a incidência de flebite, extot não planejada e de densidade de incidência de PAV apresentou significância estatística, indicando que, quanto maior a razão das horas dispensadas por requeridas, menor a probabilidade da ocorrência desses eventos, segundo modelo ajustado. Os achados desse estudo apontam para a importância da análise das necessidades quanti-qualitativas de profissionais de enfermagem, na medida em que se constroem evidências do impacto do dimensionamento de pessoal e resultados da assistência prestada. A limitação da presente investigação reside no fato de ter sido realizada em uma única UTI de um hospital privado, com um perfil de pacientes diferenciado, o que traz, portanto, restrições para sua generalização. A escassez de estudos na literatura sobre a temática limita, ainda, o confronto dos dados obtidos.<br>Transversal, descriptive and of quantitative approach study, developed with the aim of to correlate the assistance average time spent by nursing professionals in an Intensive Care Unit (ICU) of a private hospital of a city from Sao Paulo State, with the nursing assistance indicators: phlebitis incidence, unplanned orotracheal extubation (OTE) incidence, incidence of pressure ulcer (PU), unplanned output incidence of nasogastric tube (NGT) for nutritional support, incidence density of urinary tract infection (UTI) and incidence density of mechanical ventilation-associated pneumonia (VAP). The analysis period was from 1 January 2011 to 31 December 2013 and the data were obtained from an electronic registry system that stores and manages information in the investigated unit, in addition to daily scale of nursing staff. For data analysis, it was used the Pearson correlation for the variables average number of hours provided and the ratio of hours provided by required (p <0.001), and, for the response variables, the Generalized Linear Models with significance level of 5% (? = 0.05) were used. This study sample consisted of 1.717 patients, 61% aged over 65 years, undergoing medical treatment (70%) and average length of stay of 3.85 days, most of them from emergency (48.7%). The severity index SAPS 3 observed was 48.6 points and mortality in the period was 18.7%. The average time of nursing care provided to patients was 12.21 hours, and, of these, nurses ministered a minimum of 23% and a maximum of 30%. There was obtained an average value NAS of 54.87 points, which is equivalent to 13.17 hours required of nursing care. The mean ratio of hours provided by required was 0.87. In the correlation analysis between the care indicators and provided nursing care time, it was obtained that the incidence of phlebitis, unplanned OET and incidence density of VAP were statistically significant, indicating that the higher the ratio of hours provided by required, the lower the probability of occurring these events, according to the adjusted model. Our findings point to the importance of quantitative and qualitative needs analysis of nursing professionals in so far as they build evidence of the impact of staff dimensioning and delivery of care results. The limitation of this research lies in the fact that it was made in a single ICU of a private hospital, with a distinctive patients profile, which brings, therefore, restrictions to its generalization. Lack of studies in the literature about this subject also limits a comparison of obtained data.

Submitted by Maria Creuza Silva (mariakreuza@yahoo.com.br) on 2013-10-02T19:18:46Z No. of bitstreams: 1 Diss. MP Luciana Pimentel Final. 2013.pdf: 1924251 bytes, checksum: 246448230682abc45da65ba9925918ea (MD5)<br>Approved for entry into archive by Maria Creuza Silva(mariakreuza@yahoo.com.br) on 2013-10-02T19:33:48Z (GMT) No. of bitstreams: 1 Diss. MP Luciana Pimentel Final. 2013.pdf: 1924251 bytes, checksum: 246448230682abc45da65ba9925918ea (MD5)<br>Made available in DSpace on 2013-10-02T19:33:49Z (GMT). No. of bitstreams: 1 Diss. MP Luciana Pimentel Final. 2013.pdf: 1924251 bytes, checksum: 246448230682abc45da65ba9925918ea (MD5) Previous issue date: 2013<br>Este estudo objetivou analisar o grau de implantação da gestão de qualidade desenvolvida na UTI Geral I de um hospital filantrópico de alta complexidade, considerando o contexto e as estratégias, métodos e instrumentos utilizados. O estudo foi realizado em três fases: primeiramente elaborou-se o Modelo Lógico (ML) da gestão de qualidade desenvolvida na referida UTI; em seguida, foi elaborada a matriz de análise que permitiu estimar seu grau de implantação a partir de critérios definidos no ML. Na última fase, para compreender o contexto em que se deu a implantação da gestão da qualidade e os principais métodos utilizados, foram realizadas entrevistas semiestruturadas com informantes-chave, análise documental e observação direta. Essas entrevistas foram analisadas mediante a técnica de análise de conteúdo da forma proposta por Bardin (1977). A classificação da UTI Geral I foi de grau pleno de implantação, com 88,8% de adequação aos indicadores descritos no ML. A análise das entrevistas permitiu concluir que a direção do hospital definiu a gestão de qualidade bem-sucedida como meta institucional, sendo que, para sua implantação, foi decisivo o apoio da alta administração e a escolha pela metodologia de acreditação.<br>Salvador

Este estudo objetivou investigar a qualidade de vida e a satisfação profissional de enfermeiras de Unidades de Terapia Intensiva (UTIs) e examinar suas relações. A amostra consistiu de 190 enfermeiras de 19 UTIs. Foi utilizado um questionário auto-aplicável para coletar os dados sociodemográficos, ocupacionais, de saúde, percepções e estados em relação à vida e ao trabalho. A versão genérica do Índice de Qualidade de Vida (IQV) foi utilizada para medir tanto a satisfação quanto a importância de quatro domínios da vida: saúde e funcionamento, psicológico e espiritual, social e econômico, e família. A qualidade de vida total também foi medida. O nível de satisfação profissional em relação a seis componentes do trabalho (autonomia, status profissional, remuneração, interação, requisitos do trabalho e normas organizacionais) foi medido através do Índice de Satisfação Profissional (ISP). Os dados foram analisados através da análise de conteúdo, Coeficiente de Correlação de Pearson, Qui-quadrado, Teste de Fisher, análise da variância, análise de agrupamentos e análise de componentes principais. Os resultados mostraram que as enfermeiras obtiveram escores mais elevados nos domínios família, psicológico e espiritual, social e econômico, saúde e funcionamento, respectivamente. Elas valorizaram os componentes do trabalho autonomia, interação e remuneração mais do que status profissional, requisitos do trabalho e normas organizacionais, e estavam mais satisfeitas com status profissional, interação, remuneração, requisitos do trabalho e normas organizacionais. Adicionalmente, foram encontradas correlações significativas entre os domínios da qualidade de vida e os componentes da satisfação profissional. Quanto à análise das percepções e estados de vida e trabalho, os resultados sugerem que eles são indicadores potenciais de qualidade de vida e satisfação profissional. Esses achados confirmam as relações entre os domínios da vida no trabalho e da vida fora do trabalho das enfermeiras, e demonstraram o significado das características do trabalho em UTI na discussão da qualidade de vida das enfermeiras.<br>This study aimed to investigate quality of life and job satisfaction among intensive care nurses and to examine its relationships. The sample consisted of 190 intensive care nurses, representing 19 Intensive Care Units (ICUs). A self-administered questionnaire was used to collect sociodemographic, occupational, health data, perceptions and states of life and work. The generic version of Quality of Life Index (QLI) was used to measure both satisfaction and importance of four domains of life: health and functioning, psychological and spiritual, social and economic, and family. The overall quality of life was also measured. The level of job satisfaction towards six job components (autonomy, professional status, pay, interaction, task requirements and organizational policies) was measured using the Index of Work Satisfaction (IWS). Data were analyzed using content analysis, Pearson product-moment correlation, Chi-Square, Fisher’s Test, analysis of variance, cluster analysis and principal component analysis. Results showed that nurses had higher scores in family, psychological and spiritual, social and economic, health and functioning domains, respectively. They valued the job components of autonomy, interaction and pay more than professional status, task requirements and organizational policies, and were more satisfied with professional status, interaction, autonomy, pay, task requirements and organizational policies. Additionally, significant correlations were found among quality of life domains and job satisfaction components. Regarding the analysis of perceptions and states of life and work the results suggest that they were found to be significant potential indicators of quality of life and job satisfaction. These findings support the relationships between the work and nonwork domains of nurses’ lives and demonstrated the significance of ICU’ work characteristics in discussing the quality of life of nurses.

Objetivos Avaliamos a incidência de infecção hospitalar no CTI clínico-cirúrgico de um hospital escola no sul do Brasil. Foram utilizadas taxas ajustadas para o tempo de permanência dos pacientes e para o tempo de exposição aos procedimentos invasivos. Também investigamos a influência da causa básica de internação (trauma, neurológico e clínico-cirúrgico) nas taxas de infecções. Material e Métodos Os pacientes internados no CTI Clínico-cirúrgico de março a dezembro de 1999, foram prospectivamente seguidos para a detecção de infecção hospitalar. Para o diagnóstico de infecção hospitalar utilizou-se as definições do Centro de Controle e Prevenção de Doenças dos EUA (CDC) e as taxas foram calculadas de acordo com a metodologia NNIS (Sistema Nacional de Vigilância Epidemiológica). Resultados Foram acompanhados 686 pacientes (4201 pacientes-dia). Ocorreram 125 infecções hospitalares, sendo que a incidência global foi de 18,2% ou 29,8 infecções por 1000 pacientes-dia. Os sítios de infecção mais freqüente foram: pneumonia (40%), infecção urinária (24%) e septicemia primária (12,8%). As taxas de infecções hospitalares, associadas aos procedimentos invasivos, foram as seguintes: 32,2 pneumonias por 1000 ventiladores mecânico-dia, 9,7 infecções urinárias por 1000 sondas vesicais-dia e 7 septicemias por 1000 cateteres venosos centrais-dia. A incidência global de infecção nos pacientes com trauma (26,8) e neurológicos (20,7%) foi superior quando comparada com o grupo clínico-cirúrgico (12,2%), p < 0,001. Conclusões Encontramos altas taxas de infecções relacionadas com os procedimentos invasivos neste CTI. A causa básica de internação influenciou as taxas de infecção, sugerindo a necessidade de analisar-se estratificadamente os pacientes em CTI clínico-cirúrgico.<br>Objectives The incidence of nosocomial infections in the General ICU of the Hospital São Vicente de Paulo was evaluated using adjusted rates for patients’ lenght of stay and time of device exposure. We also determined the differences in the rates of infections according basic reason for admission (trauma, neurological, and medical-surgical). Material and Methods From March 1 to December 31 1999, patients in the General ICU were prospectively followed for detection of nosocomial infection during their stay. Diagnosis of nosocomial infection was made according to the Centers for Disease Control e Prevention (CDC) definitions and the rates were calculated according to the methods of the National Nosocomial Infections Surveillance (NNIS) System. Results Six hundred eighty-six patients (4,201 patient-days) were followed. One hundred twenty-five nosocomial infections occurred and the overall rate was 18.2% or 29.8 infections per 1,000 patient-days. The most commonly found infection sites were: pneumonia (40%), urinary tract infection (24%), and primary bloodstream infections (12.8%). Device-associated nosocomial infection rates were as follows: 32.2 pneumonias per 1,000 ventilator-days, 9.7 urinary infections per 1,000 indwelling urinary catheter-days, and 7 bloodstream infection per 1,000 central venous catheter-days. Overall incidence of infection in trauma (26.8) and neurological (20.7%) groups was higher than in the medical-surgical group (12.2%), p<0.001. Conclusions Our study found a high incidence of pneumonia and high rates of nosocomial infections associated with use of an invasive device in this ICU. The basic cause for admission affected infection rates, suggesting the need for a stratified analysis of patients in the General ICU by basic reason for admission.

Introdução: Sono de qualidade ruim é uma situação frequentemente descrita em pacientes críticos. A etiologia das alterações do sono nesta população é multifatorial. Dentre os fatores modificáveis citam-se ruído, iluminação, dor, interações decorrentes dos cuidados ao paciente e medicamentos. O sono de má qualidade pode relacionar-se com mudanças no metabolismo, na função endócrina, em disfunção do sistema imunológico e ventilatório e em distúrbios cardiovasculares. Também acarreta consequências psicológicas como disfunção cognitiva e delírio. Objetivo: Avaliar o efeito de um protocolo para promoção da qualidade do sono em pacientes internados em uma unidade de cuidados coronarianos (UCC). Metodologia: Este estudo consistiu em um estudo quase-experimental, realizado em duas fases. Durante a primeira fase, o grupo controle (n = 58 pacientes) recebeu cuidados habituais e informações relativas ao sono foram coletadas por meio do Questionário do Sono de Richards-Campbell (RCSQ) - escala analógica visual de 100 mm, com pontuações mais altas representando sono de melhor qualidade - e do Questionário do Sono na Unidade de Cuidados Intensivos (SICUQ) - escala discreta de 10 pontos, com maiores escores indicando maior interrupção do sono. Durante a segunda fase (n = 55 pacientes), um protocolo para promoção do sono foi implementado. As intervenções incluíram ações para redução do ruído e luminosidade, cuidados com analgesia, além de medidas gerais. Os dados relativos ao sono foram novamente coletados para avaliar o impacto dessas intervenções. Resultados: As principais barreiras ao sono identificadas pelo SICUQ foram dor 1 (1-5,5), luminosidade 1 (1-5) e ruído 1 (1-5). Dentre as fontes de ruído, as que apresentaram maiores escores foram alarmes dos monitores cardíacos 3 (1- 5,25), alarmes das bombas de infusão intravenosa 1,5 (1- 5) e alarmes dos ventiladores mecânicos 1 (1-5). Estas últimas significativamente reduzidas no grupo intervenção. Em relação ao RCSQ, o grupo intervenção obteve melhorias nos escores de profundidade do sono 81 (65-96,7) vs. 69,7 (50-90); p=0,046); fragmentação do sono 90 (65-100) vs. 69 (42,2-92,7); p=0,011); tempo para retomada do sono 90 (69,7 - 100] vs. 71,2 (40,7-96,5); p=0,007); qualidade do sono 85 (65-100) vs. 71,1 (49-98,1); p=0,026) e no escore global de qualidade do sono 83 (66-94) vs. 66,5 (45,7-87,2); p=0,002 em relação ao grupo controle. Conclusão: A implementação de um protocolo para promoção do sono foi factível e eficaz na melhora de vários parâmetros de qualidade do sono e na redução de algumas de suas barreiras em pacientes internados em uma UCC.<br>Introduction: Poor sleep is a frequent occurrence in the acute care unit. The etiology of disrupted sleep in this population is thought to be multifactorial. Modifiable factors include noise, light, pain, patient care interactions and medications. Disrupted sleep can be related to changes in metabolism and endocrine function, immune system dysfunction, ventilatory and cardiovascular disturbances and also psychological consequences like cognitive dysfunction and delirium. Objective: To evaluate the effect of a multi-intervention sleep care protocol in improving sleep quality in coronary care unit (UCC) patients. Methodology: This trial consisted in a quasi-experimental study, carried out in two phases. During the first phase the control group (n=58 patients) received usual care, and baseline sleep data was collected through the Richards-Campbell Sleep Questionnaire (RCSQ) - visual analog scale of 100 mm, with higher scores representing higher quality sleep - and the Sleep in the Intensive Care Unit Questionnaire (SICUQ) - 10-point discrete scale, higher scores indicate greater sleep interruption. During the second phase (n=55 patients), a sleep promoting protocol was implemented. Interventions included actions to promote analgesia, to reduce noise and brightness and other general measures. Sleep data were collected again to assess the impact of these interventions. Results: The main barriers to sleep in the SICUQ were pain [median (interquartile range)] [1 (1.0-5.5)], light [1 (1.0-5.0)] and noise [1 (1.0-5.0)]. The most rated sources of sleep-disturbing noise were heart monitor alarm [3 (1.0-5.25)], intra venous pump alarm [1.5 (1.0-5.00)] and ventilator alarm [1 (1.0-5.0)]. All of the latter were significantly lower in the intervention group than in the baseline group. According to the RCSQ, the intervention group had better scores in overall sleep depth [median (interquartile range)] [81 (65-96.7) vs. 69.7 (50-90); p=0.046]; sleep fragmentation [90 (65-100) vs. 69 (42.2-92.7); p=0.011]; return to sleep [90 (69.7 - 100) vs. 71.2 (40.7-96.5); p=0.007]; sleep quality [85 (65-100) vs. 71.1 (49-98.1); p=0.026] and mean RCSQ score [83 (66-94) vs. 66.5 (45.7-87.2); p=0.002] medians than the baseline group. Conclusion: A multi-intervention protocol was feasible and effective in improving different sleep quality parameters and in reducing some barriers to sleep in CCU patients.

Introducció. La satisfacció de la família amb la qualitat de l'atenció als malalts crítics és un indicador de qualitat que precisa que s’avaluï. Per això és necessari disposar d'instruments vàlids. Una iniciativa promovida per autors d'Holanda i Dinamarca és el desenvolupament del Qüestionari Europeu de Qualitat per a medir la satisfacció de la família amb l'assistència, amb la presa de decisions i amb l'assistència al pacient en situació d'últims dies a les UCIs d'Europa. Les diferències culturals i lingüístiques entre els diferents països significa que un instrument no es pot utilitzar sense l'adaptació cultural i la verificació de les seves propietats mètriques. Objectius. Adaptar i validar al castellà el European Quality Questionnaire (EuroQ2). Metodologia. Disseny de caràcter mètric i descriptiu. L'estudi es va realitzar a la Unitat de Cures Intensives de l'Hospital Universitari de Sabadell. La població d'estudi va ser tots els familiars de pacients ingressats des del 15 de novembre de 2016 fins l’1 de maig de 2017. Mostreig consecutiu amb 132 familiars. L'estudi es va realitzar en dues fases. En la primera fase es va realitzar la traducció, traducció inversa i adaptació cultural, en la segona fase es va realitzar l'anàlisi de la fiabilitat i de la validesa. Per a la validació del qüestionari es va utilitzar l'anàlisi de consistència interna mesura amb l'alfa de Cronbach i l’estabilitat temporal. La validesa convergent amb el qüestionari de Necesidades de los Familiares de Pacientes de Cuidados Intensivos versión breve i la validesa de constructo mitjançant l'anàlisi factorial confirmatori. Resultats. La fiabilitat del qüestionari va ser de 0.935 i els 2 factors van obtenir valors de 0,73 i 0,923. El coeficient de correlació intraclasse de l'escala total va ser de 0,818 indicatiu d'una bona estabilitat temporal. La validesa convergent presentava una correlació positiva de 0.661 i la validesa de constructo presentava un ajust adequat i una estructura factorial en 2 factors. Conclusions. El qüestionari EuroQ2 ha estat adaptat al castellà i validat amb dues dimensions: la satisfacció amb l'assistència (el tracte) i amb la informació. Es necessita d'estudis posteriors per validar la dimensió presa de decisions i recomanar el seu ús en la pràctica clínica.<br>Introducción. La satisfacción de la familia con la calidad de la asistencia a los enfermos críticos es un indicador de calidad que precisa que se evalúe. Para ello es necesario disponer de instrumentos validados. Una iniciativa promovida por autores de Holanda y Dinamarca es el desarrollo del European Quality Questionnaire para medir la satisfacción de la familia con la asistencia, con la toma de decisiones y con la asistencia al paciente en situación de últimos días en las UCIs de Europa. Las diferencias culturales y linguísticas entre los diferentes países significa que un instrumento no puede utilizarse sin la adaptación cultural y la verificación de sus propiedades métricas. Objetivos. Adaptar y validar al castellano el European Quality Questionnaire (EuroQ2). Metodología. Diseño de carácter métrico y descriptivo. El estudio se realizó en la Unidad de Cuidados Intensivos del Hospital Universitario de Sabadell. La población de estudio fue todos los familiares de pacientes ingresados desde el 15 de noviembre de 2016 al 1 de mayo de 2017. Muestreo consecutivo con 132 familiares. El estudio se realizó en dos fases. En la primera fase se realizó la tradución, traducción inversa y adaptación cultural, en la segunda fase se realizó el análisis de la fiabilidad y de la validez. Para la validación del cuestionario se utilizó el análisis de consistencia interna medida con el alfa de Cronbach y la estabilidad temporal test-retest. La validez convergente con el Cuestionario de Necesidades de los Familiares de Pacientes de Cuidados Intensivos versión breve y la validez de constructo mediante el análisis factorial confirmatorio. Resultados. La fiabilidad del cuestionario fue de 0,935 y los 2 factores obtuvieron valores de 0,73 y 0,923. El Coeficiente de Correlación intraclase de la escala total fue de 0.818 indicativo de una buena estabilidad temporal. La validez convergente presentó una correlación positiva de 0.661 y la validez de constructo presentó un ajuste adecuado y una estructura factorial en 2 factores. Conclusiones. El cuestionario EuroQ2 ha sido adaptado al castellano y validado con dos dimensiones: la satisfacción con la asistencia (el trato) y con la información. Se necesita de estudios posteriores para validar la dimensión toma de decisiones y recomendar su uso en la práctica clínica.<br>Introduction. The satisfaction of the family with the quality of care for critically ill patients is an indicator of quality that needs to be assessed. For this, it is necessary to have validated instruments. An initiative promoted by authors from the Netherlands and Denmark is the development of the European Quality Questionnaire to measure family satisfaction with care, decision making and care for dying patients in Europa UCI. Cultural and linguistic differences between different countries mean that an instrument can not be used without cultural adaptation and verification of its metric properties. Aims. Adapt and validate the European Quality Questionnaire (EuroQ2) in Spain. Methodology. Psychometric and transversal quantitative design. The study was carried out at the Intensive Care Unit of the University Hospital of Sabadell. The study population was all relatives of patients admitted from November 15, 2016 to May 1, 2017. Consecutive sampling with 132 relatives. The study was carried out in two phases. In the first phase the translation, back translation and cultural adaptation were carried out, in the second phase the reliability and validity analysis was performed. For the validation of the questionnaire, we used the internal consistency analysis measured with the Cronbach's alpha and the temporary stability test-retest. The convergent validity with the Family Needs Questionnaire for Intensive Care Patients short version and construct validity through confirmatory factor analysis. Results. The reliability of the questionnaire was 0.935 and the 2 factors obtained values of 0.73 and 0.923. The intraclass correlation coefficient of the total scale was 0.818 indicative of good temporal stability. The convergent validity had a positive correlation of 0.661. The construct validity presented an adequate fit and a factorial structure in 2 factors. Conclusions. The EuroQ2 questionnaire has been adapted to Spanish and validated with two dimensions: satisfaction with care (treatment) and with information. Further studies are needed to validate the decision-making dimension and recommend its use in clinical practice.

Apesar da importância das unidades de terapia intensiva pediátricas e neonatais (UTIP/UTIN) na assistência à criança criticamente enferma, pouco se conhece da estrutura destas unidades no município de São Paulo (SP). No período de agosto/00 a julho/02 foi realizado estudo descritivo da estrutura das UTIP/UTIN do município de SP. Das 107 unidades identificadas, 85 (79,4%) concordaram em participar através do preenchimento de questionário. Observou-se uma distribuição desproporcional das UTIs e dos leitos (1 leito/604 crianças - 1 leito/6.812 crianças; média: 1 leito/2.085 crianças). As 85 unidades totalizaram 1067 leitos, dos quais 969 estavam em atividade. A média do número de leitos por unidade foi 11,7 (4-60). Em relação a recursos materiais, equipamentos essenciais para o funcionamento de uma UTI estavam indisponíveis. Quanto aos recursos humanos, mais de 70% dos critérios mínimos foram cumpridos. Observou-se diversidade na distribuição dos leitos de UTIP/UTIN no município de SP<br>Despite the importance of pediatric and neonatal intensive care units (PICU/NICU) to the care of severally ill children, the knowledge of the structure of these units is scarce in Sao Paulo. From Aug/00 to July/02 it was conducted a descriptive study about structure of PICU/NIUC in the city of Sao Paulo. We identified 107 PICU/NICU and 85 (79.4%) agreed to participate. We noticed an irregular distribution of the ICU in relation to the pediatric population in each district (1bed/604 children - 1 bed/6.812 children, mean 1 bed/2.085 children). The 85 units made a total of 1067 beds of which 969 were considered active. The mean number of beds per ICU was 11.7 (4-60). Some basic requirements for a PICU were found to be unavailable in quite a number of units. Regarding human resources, more than 70% of standards were accomplished. We concluded that exists a substantial diversity in PICU/NICU structure in Sao Paulo

The doctoral dissertation investigates changes in health-related quality of life for long-term intensive care patients prior to ICU admission and 6 months after ICU discharge, exploring into the causes of impaired quality of life and the relationship between the quality of life and post-ICU mortality. It has already been established that the quality of life decreases after treatment in the intensive care unit. However, factors that have the strongest effect on the quality of life in ICU patients have not been identified. Information on post-ICU quality of life in long-term intensive care patients is particularly scarce. The findings of our research confirmed that long term treatment in the intensive care unit has major implications for the physical domains of health-related quality of life. The findings evidence that severity of illness on the first day in the ICU, number of therapeutic interventions upon ICU discharge and severe critical illness neuromuscular abnormalities are associated with impaired quality of life, while duration of mechanical ventilation is the factor with the strongest effect on reduced quality of life. Likewise, the findings demonstrate that usual systems for identification of severity of illness are not useful for predicting mortality in patients after discharge from the intensive care unit. Yet, identification of pre-ICU physical activity allows predicting post-ICU mortality.<br>Disertacijoje tiriant ligonių, ilgai gydytų intensyviosios terapijos skyriuje, su sveikata susijusios gyvenimo kokybės skirtumus iki gydymo ir praėjus 6 mėnesiams po gydymo vertinamos gyvenimo kokybės pablogėjimo priežastys bei gyvenimo kokybės ir mirštamumo po iškėlimo iš intensyviosios terapijos skyriaus ryšys. Jau anksčiau nustatyta, kad gyvenimo kokybė po gydymo intensyviosios terapijos skyriuje pablogėja. Tačiau neaišku, kokie veiksniai turi didžiausios įtakos intensyviosios terapijos skyriaus ligonių gyvenimo kokybei. Ypač mažai duomenų apie ligonių, ilgai gydytų intensyviosios terapijos skyriuje, gyvenimo kokybę po iškėlimo iš intensyviosios terapijos skyriaus. Tyrimo rezultatai patvirtino, kad ilgas gydymas intensyviosios terapijos skyriuje turi didžiausios įtakos fizinėms su sveikata susijusioms gyvenimo kokybės sritims. Tyrimo rezultatai įrodo, kad būklės sunkumas pirmą gydymo intensyviosios terapijos skyriuje parą, terapinių intervencijų skaičius iškėlimo iš intensyviosios terapijos skyriaus metu ir sunkus kritinių būklių neuroraumeninis pažeidimas susiję su pablogėjusia gyvenimo kokybe, o dirbtinės plaučių ventiliacijos trukmė – veiksnys turintis didžiausią įtaką gyvenimo kokybės blogėjimui. Taip pat nustatyta, kad įprastos sistemos būklės sunkumui įvertinti netinka numatyti ligonių mirštamumui po gydymo intensyviosios terapijos skyriuje, o nustačius fizinį aktyvumą iki gydymo intensyviosios terapijos skyriuje tai galima atlikti.

O avanço tecnológico nas unidades de terapia intensiva pediátricas (UTIPs) tornou-as aptas ao atendimento de casos de alta complexidade e elevado custo. Porém, a tecnologia disponível nem sempre tem conseguido melhorar a qualidade de atendimento aos pacientes e a própria capacidade de prolongar o tempo de vida torna-se um instrumento que potencializa a dor e o sofrimento. Sendo assim, tornou-se necessário caracterizar o estágio de gravidade da doença, que reflete a magnitude das comorbidades e distúrbios fisiológicos, no momento da internação. Esse procedimento pode ser realizado através dos escores prognósticos de mortalidade que quantificam a gravidade da doença, estimando a probabilidade de óbito de acordo com seu estágio clínico. Atualmente os escores prognósticos fazem parte das metodologias de controle de qualidade e de pesquisa. O Pediatric Risk of Mortality escore (PRISM) é um dos escores mais utilizados na unidade de terapia intensiva pediátrica (UTIP). O objetivo desse estudo foi avaliar a utilização do PRISM quanto a sua capacidade de discriminação entre sobreviventes e não-sobreviventes e determinar os fatores de prognóstico para óbito em uma UTIP terciária. Foi realizado um estudo retrospectivo na UTIP do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, que é considerada de nível de atendimento terciário. Foi anotado o valor do PRISM correspondente às primeiras 24 horas de internação; dados demográficos e da internação, para melhor caracterização da amostra. Foram incluídos 359 pacientes; as variáveis encontradas como fatores de prognóstico para óbito foram: presença de síndrome de disfunção de múltiplos órgãos e sistemas (SDMOS) à admissão, ventilação mecânica (VM), uso de fármacos vasoativos, infecção hospitalar, terapia nutricional parenteral (TNP) e duração da internação (p < 0,0001 para todas as variáveis). Cinquenta e quatro pacientes (15%) evoluíram a óbito; a mediana do PRISM foi significativamente maior nos pacientes que evoluíram para óbito (p= 0,0001). A curva ROC do PRISM mostrou um valor de 0.76 (IC 95% 0,690,83) e a calibração, calculada pelo teste qui-quadrado de Hosmer-Lemeshow, evidenciou x2 = 12,96 com p=0,11, sendo que para este teste é considerado significativamente estatístico um valor de p > 0,05. É importante a implantação de controle estrito de qualidade nas UTIPs para identificar grupos de risco para óbito e medir a eficácia do tratamento. Embora alguns autores já tenham enfatizado que o PRISM superestima a mortalidade e não seria apropriado em populações pediátricas específicas, esse estudo mostrou que o PRISM apresenta capacidade discriminatória adequada em diferenciar sobreviventes dos não-sobreviventes e constitui ferramenta útil para avaliar o prognóstico dos pacientes admitidos em UTIP terciária.<br>Technological advances in pediatric intensive care units (PICU) has made them suitable for the treatment of high complexity cases and high cost. However, the technology available has not always succeeded in improving the quality of patient care and their own ability to prolong the life becomes a tool that leverages the pain and suffering, sometimes prolonging the dying process. Thus, it became necessary to characterize the stage of disease severity, which reflects the magnitude of comorbidities and physiological disorders, at admission. These procedures can be performed by way of the mortality prognostic scores that quantify the severity of the disease, estimating the probability of death according to their clinical state. Nowadays the prognostic scores make part of the methodology of quality control and research. The Pediatric Risk of Mortality score (PRISM) is one of the main scores used in the PICU. The purpose of this study was to evaluate the use of PRISM for their ability to discriminate between survivors and non-survivors and to determine the prognostic factors for death in a tertiary PICU. Retrospective cohort study was conducted in the PICU of Instituto da Criança do Hospital das Clinicas of University São Paulo, which is considered a PICU of a tertiary care level. The PRISM scores (corresponding to the first 24 hours of hospitalization), demographic and hospitalization data were noted to better characterize the study population. We included 359 patients and the variables that were found to have prognostic factors for death were multiple organ dysfunction syndrome (MODS) on admission, mechanical ventilation (MV), use of vasoactive drugs, hospital-acquired infection, parenteral nutrition therapy (PNT) and longer period of hospitalization (p < 0,0001 for all variables). Fifty-four patients (15%) died; median PRISM score was significantly higher in patients who died (p= 0,0001). The ROC curve for PRISM yielded a value of 0.76 (CI 95% 0,690,83) and the calibration, calculated using the Hosmer-Lemeshow chi-square test, was shown x2 = 12,96 with p=0,11, being that for this test is considered a statistically significant p > 0.05 . It is imperative for PICU to implement strict quality controls to identify groups at greatest risk of death and to ensure the adequacy of treatment. Although some authors have shown that the PRISM score overestimates mortality and that it is not appropriate in specific pediatric populations, in this study PRISM showed satisfactory discriminatory performance in differentiating between survivors and non-survivors and constitutes a useful tool for the assessment of prognosis for pediatric patients admitted to a tertiary PICU.

Considerando a importância de identificar fatores do ambiente de trabalho que afetam a saúde física e mental de enfermeiros em Unidades de Terapia Intensiva (UTI) este estudo teve como objetivos: avaliar a qualidade de vida relacionada à saúde (QVRS) de enfermeiros de UTI em relação a componentes físicos e mentais, descrever as condições do ambiente de trabalho e analisar as associações entre QVRS e condições de trabalho de enfermeiros em UTIs. Um estudo descritivo, com delineamento transversal foi realizado em 31 UTIs de adultos, de 18 hospitais selecionados aleatoriamente nas cinco regiões do município de São Paulo, com uma amostra de 180 enfermeiros (68,9% do sexo feminino, idade média de 35,6 anos (dp=7,0), tempo médio de trabalho em UTI de 7 anos (dp=5,2), 68,0% trabalhando até 40 horas semanais). O instrumento Nursing Work Index-Revised (NWI-R) foi utilizado para identificar as condições do ambiente de trabalho percebidas pelos enfermeiros (autonomia, controle sobre o ambiente, relacionamento médico-enfermeiro e suporte organizacional) e o Medical Outcomes Study 12 Item Short Form Health Survey (SF-12), para avaliar a QVRS em seus componentes físico (CF) e mental (CM). Nas análises bivariadas utilizaram-se os testes Qui-Quadrado de Pearson, teste t-Student, ANOVA e o teste pos hoc de Tukey. Análise de Regressão Linear Múltipla, método stepwise forward, foi realizada para examinar o efeito de variáveis selecionadas sobre os CF e CM do SF-12. Na avaliação da QVRS, os escores médios do CF e do CM foram, respectivamente, de 49 (dp=7,6) e 46 (dp=10), valores próximos aos de referência para a população geral americana (50 pontos). O escore total médio do NWI-R foi de 2,0 (dp=0,5) e dos domínios entre 2,0 e 2,1 (dp entre 0,5 e 07), o que sugere condições adequadas de trabalho. Correlações significativas (p<0,05) e de fraca magnitude (-0,18 a -0,34) foram encontradas entre os escores do SF-12 (CF e CM) e os do NWI-R (total e domínios), indicando associação entre QVRS e condições de trabalho dos enfermeiros. Na análise de regressão linear múltipla, o CF esteve associado com gênero masculino, com proporção maior que 8 leitos por enfermeiro e com a subescala suporte organizacional do NWI-R. No CM, foram encontradas associações com idade e com a subescala controle sobre o ambiente do NWIR. Os resultados obtidos sugerem que a QVRS e as condições de trabalho dos enfermeiros deste estudo encontravam-se relativamente preservadas. Gênero masculino, menor idade, maior suporte organizacional e controle sobre o ambiente de trabalho foram fatores independentemente associados à melhor QVRS dos enfermeiros deste estudo.<br>Considering the importance of identifying factors that affect the physical and mental health of nurses in Intensive Care Units (ICU), this study aimed to assess the health-related quality of life (HRQOL) physical and mental components of ICU nurses, to describe the conditions of the work environment and to examine the associations between HRQOL and working conditions of ICU nurses. A descriptive and cross-sectional study was performed in 31 adult ICUs, of 18 hospitals randomly selected in the five regions of Sao Paulo city, Brazil, with a sample of 180 nurses (68.9% female, mean age 35.6 years (SD = 7.0), average working time in the ICU for 7 years (SD= 5.2), 68.0% up to 40 working hours per week). The instrument Nursing Work Index-Revised (NWIR) was used to identify the nurses perceptions of the working environment (autonomy, control over the environment, physician-nurse relationship and organizational support) and the Medical Outcomes Study 12 - Item Short Form Health Survey (SF-12) to assess the physical (PC) and mental (MC) HRQOL components. The chi-square Pearson test, Students t-test, ANOVA and post hoc Tukey test were used in bivariate analyzes. Multiple Linear Regression Analysis, stepwise forward method, was performed to examine the effect of selected variables on the SF-12 PC and MC. In the assessment of HRQOL, the average scores of PC and CM were, respectively, 49 (SD = 7.6) and 46 (SD = 10), values close to that of reference for the general U.S. population (50 points). The mean total score of NWI-R was 2.0 (SD=0.5) and between 2.0 and 2.1 for the subscales (SD from 0.5 to 07), suggesting adequate work conditions. Significant correlations (p <0.05) and of low magnitude (r= -0.18 to -0.34) were found between the scores of the SF-12 and NWI-R (total and subscales), indicating association between HRQOL and working conditions of nurses. In the Multiple Linear Regression Analysis, the PC was associated with male gender, ratios beds per nurse greater than 8 and with the organizational support subscale of the NWI-R. For the MC, significant associations were found with age and the subscale control over the environment. The results of this study suggest that the HRQOL and the working conditions of nurses were relatively preserved. Male gender, younger age, greater organizational support and control over the work environment were factors independently associated with better HRQOL of the nurses in this study.

Este estudo teve como objetivos: analisar as propriedades psicométricas dos instrumentos de avaliação de qualidade de vida WHOQOL-bref e SF-36 aplicados a pacientes adultos após a internação em Unidades de Terapia Intensiva e a seus familiares e, avaliar a concordância entre pacientes e familiares como seus substitutos. A amostra foi composta por 71 pares paciente-famíliar. A confiabilidade foi avaliada pela consistência interna através do Coeficiente Alfa de Cronbach. A validade convergente foi avaliada através das correlações interdomínios dos instrumentos e a validade divergente pelas correlações entre os domínios e o número de comorbidades através da Correlação de Spearman. A concordância entre os pares foi verificada pelo Coeficiente de Correlação Intraclasse e pela estatística kappa ponderado. Os resultados mostraram que o SF-36 quanto à confiabilidade apresenta valores aceitáveis (0,70) para a maioria dos domínios tanto para pacientes como para os familiares. Quanto ao WHOQOL-bref o coeficiente foi inferior a 0,70 para todos os domínios, em ambos os casos. A maioria das correlações interdomínios do SF-36 foram positivas e significativas para pacientes e familiares. O WHOQOL-bref quando aplicado aos pacientes apresentou correlações interdomínios positivas e significativas, mas o mesmo não ocorreu com os familiares. As correlações entre os domínios e número de comorbidades, tanto para o SF-36 e o WHOQOL–bref não foram significativas. A concordância entre os pares foi melhor quando o familiar foi o pai ou a mãe, filho e cônjuge, nessa ordem. Domínios e itens que avaliam condições objetivas são os que apresentam valores de concordância mais elevados entre os pares. O SF-36 apresentou maior número de concordâncias moderadas. O domínio Aspectos Físicos do SF-36 foi o que apresentou concordância substancial para todos os familiares. O domínio Físico do WHOQOL-bref apresentou concordância moderada para a maioria dos familiares. Para o SF-36, a concordância foi melhor quando os pacientes tinham duas ou mais comorbidades, Para o WHOQOL-bref foi melhor quando o paciente tinha uma ou duas comorbidades, mas apresentou maior número de concordâncias inconsistentes. De forma geral, os domínios previstos como aqueles que avaliam construtos similares não se correlacionaram. Esses resultados confirmam que no contexto do tratamento intensivo o SF-36 é mais adequado como instrumento de avaliação de qualidade de vida relacionado à saúde. Esses achados são similares aos da literatura internacional.<br>This aims this study were: to analyze the psychometric properties of the instruments for the evaluation of Quality of Life WHOQOL-bref and Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) applied to adult patients after discharged from Intensive Care Units and their families and to evaluate the agreement between patients and their families as proxies. The sample consisted of 71 patient-family pairs. The internal consistency reliability was evaluated by the Cronbach’s Alfa Coefficient. The convergent validity was evaluated by the inter-domain correlations of the instruments and a divergent validity was evaluated by Spearman correlation between domains and number of comorbidities. Intraclass Correlation Coefficient and weighted kappa were used to analise the agreement between the pairs. Cronbach’s Alpha Coefficient was acceptable (0.70) for the majority of SF-36 domains for patients and their families. For the WHOQOL-bref, the coefficients were below 0, 70 for all domains in both cases. The majority of inter-domains correlation of SF-36 for patients and proxies were positive and significant. WHOQOL-bref inter-domain correlations were positive and significant when applied to the patients but not for the families. For the correlations between domains and number of comorbidities, the majority of SF-36 and WHOQOL-bref domains did not correlate for either the patients or their families. The divergent validity was not supported in both instruments. Agreement between the pairs was better when the relatives were the parents or sons. Domains and items that evaluated objective conditions presented much higher values of agreement between the pairs. The SF-36, showed a larger number of domains with moderate agreement. The Physical Role domains of SF-36 were what showed a substantial agreement for all of the families. The Physical domain of WHOQOL-bref, showed moderate agreement between each of the family members. The agreement SF-36, was better when the patients had 2 or more comorbidities, regarding the WHOQOL-bref, it was better when a patiente had 1 or 2 comorbities, however it showed a greater number of inconsistent agreements. In general, domains hypothesized to measure similar constructs do not correlated. These results confirm that the SF-36 is more suitable for the evaluation of quality of life in the intensive care context. These findings are similar to from international literature.

<p>The present thesis follows an intensive care unit during four year of hard work and demanding organisational changes (1998-2001). The changes were mainly initiated by diminishing resources and a legislative claim to pay regard to the quality aspect of health care service. The process of implementing a quality system was the main focus for the thesis. Triangulation was used aiming at explore the process from different views. Two interviews studies were conducted one with the staff and another with the leadership. Both interviews were analysed thematically combined with a phenomenographic technique (e.g. using the how, and what aspect). A longitudinal quasi experimental time-series study was also accomplished. The correlation between staff variables and workload were measured once a year. The result show a 20 % increase in workload per staff and year. The staff judged the organisational climate for innovativeness stable over the period. Sick leave increased, and more so, than the general trend in the society. In spite of this increase the prevalence of stress related symptoms was the same. Two different systems emerged, a complex adaptive system and a mechanical system. The two systems exist and functions intertwined. Because of the construction of the patient register it is possible to see that the situation around a patients being admitted ≥ 5 days functions according to the complex systems character while the situation around the acute patients functions according to a mechanical system. Sick leave correlated with number of patient admitted ≥ 5 days (P=,000). It seemed the problem found had its root in the unawareness of the existing of a complex system. The result has implications for a need of increased awareness about how to manage the situation when the ICU is functioning according to the complex adaptive system.</p>

Made available in DSpace on 2014-07-29T15:04:41Z (GMT). No. of bitstreams: 1 Eunice Pereira Salles.pdf: 490170 bytes, checksum: 0c155f2455a42c85e413c5e3e4b5cd70 (MD5) Previous issue date: 2005-04-04<br>The speed of the changes which has occurred in the globalized world has interfered with Quality of Life (QOL) of the majority of people and it tends to influence on their performance as workers People who care of human beings can be affected and have their attending quality compromised The purpose of this research was to assess the QOL of nursing paraprofessionals of Intensive Care Units (ICUs) It is a descriptive and exploratory study developed in ICUs of four public hospitals in Goiânia, Brazil A number of 125 nursing paraprofessionals were submitted to quality of life assessment using the World Health Organization instrument named WHOQOL 100 This specific version covers six domains: physical health psychological level of independence social relations environment spirituality / religion / personal beliefs The statistical analysis used the Kruskal Wallis Jonckhere Terpstra and Median tests The subjects were in the majority female young adults married and with two children catholics They also have more than two jobs and have been working more than five years in ICUs The analysis of each domain score showed that almost all of them had an average score higher than the medium point (12) The mean highest score was the Spirituality/Religiousness/Personal beliefs Domain (17,18) followed by the Level of Independence Domain (16,53) by the Personal Relations Domain (14,85) by the Psychological Domain (14,55) by the Physical Health Domain (13,55) and finally by the Environment Domain (11,95) The answers which evaluated the General Quality of Life got the average score of 14,27 The score of the Environment Domain was influenced by the dissatisfaction with the financial situation and the public transportation system as well as worries concerning to their physical safety They considered themselves satisfied with their home environment and their opportunities to get new skills and information The pain manifestations and the physical discomfort contributed to the reduction of the mean score of the Physical Health Domain but it did not interfere in the amount of energy used to perform everyday activities nor the sleeping quality The catholics considered themselves more worried with pain and physical discomfort than the evangelical ones In the Psychological Domain evaluation the self-esteem and physical appearance were positively determining The women had higher scores than men regarding positive thoughts In the Social Relation Domain the satisfaction with the family support and friends as well as with the sexual activity were evident mainly among the married ones<br>A velocidade nas mudanças que têm ocorrido no mundo globalizado tem interferido na Qualidade de Vida (QV) da maioria das pessoas e tendem a influenciar no seu desempenho como trabalhador Aquelas que têm como objeto de trabalho o cuidado ao ser humano em especial podem ser afetadas e ter a qualidade de seu atendimento comprometida Este estudo teve por objetivo avaliar a qualidade de vida dos auxiliares e técnicos de enfermagem em UTIs Trata-se de um estudo descritivo e exploratório realizado em UTIs de quatro hospitais públicos de Goiânia-GO Participaram deste estudo 125 Auxiliares e Técnicos de Enfermagem que responderam ao questionário elaborado pela OMS denominado WHOQOL-100 composto de seis domínios: Físico Psicológico de independência Relações Sociais Ambiente Espiritualidade/Religião/Crenças Pessoais Os resultados foram codificados e digitados no programa estatístico SPSS versão 11 sendo aplicados os testes da mediana de Kruskal-Wallis H e de Jonckheere-Terpstra Os sujeitos são na maioria do sexo feminino adulto-jovens casados com dois filhos católicos são técnicos de enfermagem com mais de dois empregos e trabalham há mais de cinco anos em UTIs A análise do comportamento dos escores dos domínios do WHOQOL-100 revelou que quase todos apresentaram média acima do ponto médio (12) A mais alta média do escore foi obtida pelo Domínio Espiritualidade/Religiosidade/Crenças Pessoais (17,18) seguida do Domínio Nível de Independência (16,53) do Domínio Relações Pessoais (14,85) do Domínio Psicológico (14,55) do Domínio Físico (13,55) e do Domínio Ambiente (11,95) As respostas às questões que avaliaram a Qualidade de Vida Geral obtiveram escore médio de 14,27 O escore obtido pelo Domínio Ambiente foi influenciado pela insatisfação com a situação financeira preocupação com segurança física e com os meios de transporte Consideraram-se satisfeitos com o ambiente do lar e com suas oportunidades de adquirir novas habilidades e informações As manifestações de dor e desconforto físico colaboraram para redução da média do escore do Domínio Físico mas não prejudicou a quantidade de energia para as atividades diárias nem a qualidade do sono Os católicos consideraram-se mais preocupados com a dor e desconforto físico que os evangélicos Na avaliação do Domínio Psicológico a auto-estima e aparência física foram positivamente determinantes As mulheres tiveram escores mais altos que os homens em relação aos pensamentos positivos No Domínio Relações Sociais destacaram-se a satisfação com o apoio familiar e dos amigos bem como com a atividade sexual principalmente dentre os casados O fato de não terem dificuldades para locomoção, não depender de medicação e tratamentos bem como a satisfação com a capacidade para o trabalho influenciaram para aumentar a média do escore do Domínio Nível de Independência Observou-se que quanto maior o tempo de serviço nas UTIs maior a capacidade para o trabalho

Syftet med litteraturstudien var att beskriva hur patienter som vårdats på IVA upplever sin livskvalitet efter att ha kommit hem. Vidare var syftet att bedöma och beskriva kvaliteten på de ingående artiklarna utifrån den metodologiska aspekten urval och bortfall. Litteraturstudien hade en deskriptiv design med kvalitativ ansats. Till litteraturstudien analyserades 14 kvalitativa artiklar som hittades genom sökning i Pubmed, Cinahl och PsycINFO samt manuell sökning. Upplevelsen av livskvalitet relaterades till tre huvudkategorier. Huvudresultatet visade att patienter upplevde sin livskvalitet som försämrad när de kommit hem efter utskrivning från sjukhus, men att den vanligtvis förbättrades succesivt med tiden. Hur livskvaliteten höjdes eller sänktes var beroende av patienternas copingstrategier. Typ av urval beskrevs tydligt i tio artiklar, resterande fyra beskrev inte urvalstyp. Bortfall beskrevs i elva artiklar. Slutsatsen var att relationer och samspel med närstående var betydelsefulla copingstrategier och inverkade på patienternas livskvalitet. Information om realistiska förväntningar ansågs saknas i omvårdnaden. Författarna ansåg att mer information och stöd behövs till patienter och närstående angående realistiska förväntningar efter IVA. Författarna anser vidare att patienterna bör erbjudas personligt uppföljningsstöd.<br>The aim of this study was to describe how patients admitted to ICU experience their quality of life (QOL) after coming home. A further aim was to assess and describe the quality of the included articles according to the methodological aspect selection and nonresponse bias. The literature study had a descriptive design with a qualitative approach. For the literature study 14 articles were analyzed. The articles were found by searching Pubmed, Cinahl, PsycINFO and by manual search. The experience of quality of life was related to three main categories. The main results showed that patients experienced their QOL as impaired after coming home from the hospital, but usually improved gradually with time. How the QOL was raised or lowered, depended on the patients' coping strategies. Type of selection was described clearly in ten articles, the remaining four described no type of selection. Nonresponse bias was described in eleven articles. The conclusion was that relationships and interactions with relatives were important coping strategies and had an impact on patients QOL. Information about realistic expectations was found missing in nursing. The authors felt that more information and support to patients and relatives is needed about realistic expectations after ICU. The authors consider that patients should be offered a personal follow up support.

FUNDAMENTO: análisis de la aplicación de un ciclo de garantía de calidad sobre las tasas de infección nosocomial (IN) en una UCI polivalente de nivel II. MÉTODO: Estudio prospectivo de cohortes, de dos años de duración, sobre 568 pacientes; Grupo A (n=281), observacional y Grupo B (n=287), en el que se aplicaron medidas de mejora (administración de sucralfato, correcta profilaxis antibiótica quirúrgica y medidas estrictas de asepsia) Se comparan las tasas de IN asociada a ventilación mecánica (NAVM), sonda uretral, catéter venoso central e infección de herida quirúrgica en ambos grupos, así como la estancia y mortalidad intra-UCI. RESULTADOS Tras la aplicación del ciclo de mejora de calidad mediante el cumplimiento de criterios de calidad, obtuvimos una reducción significativa de las tasas de incidencia de todas las infecciones controladas. No apreciamos diferencias en la mortalidad global intra-UCI entre ambos grupos, aunque sí en los que desarrollaron una IN. Los pacientes con NAVM, mostraron una reducción no significativa de la mortalidad. El subgrupo de pacientes que recibió sucralfato presentó una disminución de la frecuencia de IN y mortalidad relacionada. Sin embargo, el grado de incumplimientos del protocolo de mejora se mostró elevado (diagrama de Pareto). CONCLUSIONES: La instauración de un sistema de vigilancia y la aplicación de medidas de mejora han logrado reducir tanto la incidencia como la mortalidad de la IN, no así la mortalidad global intra-UCI.<br>BACKGROUND: To analyze the effects of implementation of a quality assurance cycle on rates of nosocomial infection (NI) in a level II intensive care unit (ICU.) METHOD: Prospective cohort study of two years on 568 patients divided in Group A (n = 281, cohort observational control group) and Group B (n = 287; experimental cohort group), which were implemented improvement measures (administration of oral sucralfate, surgical prophylaxis and aseptic measures). We compare the rates of follow aspects: ventilator-associated pneumonia (VAP), urethral catheter, central venous catheter and surgical wound infections, length and ICU mortality in both groups. RESULTS: After the implementation of quality improvement cycle by meeting quality criteria, we obtained a significant reduction in incidence rates of all infections under control. We found no differences in overall mortality ICU between the two groups, except in those who developed one NI. Patients with VAP showed a non significant reduction in mortality. The subgroup of patients receiving sucralfate showed a decrease in the frequency of NI and related mortality. However, the degree of improvement protocol violations was high (analyzed by Diagram’ s Pareto). CONCLUSIONS: The establishment of a surveillance system and implementation of improvement measures have reduced both the incidence and mortality of NI, but not the overall ICU mortality.

A redução da mortalidade é um objetivo fundamental das unidades de terapia intensiva pediátrica (UTIP). O estágio de gravidade da doença reflete a magnitude das comorbidades e distúrbios fisiológicos no momento da internação e pode ser avaliada pelos escores prognósticos de mortalidade. Os dois principais escores utilizados na UTIP são o Pediatric Risk of Mortality (PRISM) e o Pediatric Index of Mortality (PIM). O PRISM utiliza os piores valores de variáveis fisiológicas e laboratoriais nas primeiras 24 horas de internação enquanto o PIM2 utiliza dados da primeira hora de internação na UTIP e apenas uma gasometria arterial. Não há consenso na literatura, entre PRISM e PIM2, quanto à utilidade e padronização na admissão na terapia intensiva para as crianças e adolescentes, principalmente em uma UTI de nível de atendimento terciário. O objetivo do estudo foi estabelecer o escore de melhor performance na avaliação do prognóstico de mortalidade que seja facilmente aplicável na rotina da UTIP, para ser utilizado de forma padronizada e contínua. Foi realizado um estudo retrospectivo onde foram revisados os escores PRISM e PIM2 de 359 pacientes internados na unidade de terapia intensiva pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da USP, considerada uma unidade de atendimento de nível terciário. A mortalidade foi de 15%, o principal tipo de admissão foi clinico (78%) sendo a principal causa de internação a disfunção respiratória (37,3%). Os escores dos pacientes que foram a óbito mostraram-se maiores do que o dos sobreviventes. Para o PRISM foi 15 versus 7 (p = 0,0001) e para o PIM2, 11 versus 5 (p = 0,0002), respectivamente. Para a amostra geral, o Standardized Mortality Ratio (SMR) subestimou a mortalidade tanto para o PIM2 quanto para o PRISM [1,15 (0,84 - 1,46) e 1,67 (1,23 - 2,11), respectivamente]. O teste de Hosmer-Lemeshow mostrou calibração adequada para ambos os escores [x2 = 12,96 (p = 0,11) para o PRISM e x2 = 13,7 (p = 0,09) para o PIM2]. A discriminação, realizada por meio da área sob a curva ROC, foi mais adequada para o PRISM do que para o PIM2 [0,76 (IC 95% 0,69 - 0,83) e 0,65 (IC 95% 0,57 - 0,72), respectivamente, p= 0,002]. No presente estudo, a melhor sensibilidade e especificidade para o risco de óbito do PRISM foi um escore entre 13 e 14, mostrando que, com o avanço tecnológico, o paciente precisa ter um escore mais elevado, ou seja, maior gravidade clínica do que a população original, para um maior risco de mortalidade. Os escores de gravidade podem ter seus resultados modificados em consequência: do sistema de saúde (público ou privado), da infraestrutura da UTIP (número de leitos, recursos humanos, parque tecnológico) e indicação da internação. A escolha de um escore de gravidade depende das características individuais da UTIP, como o tempo de espera na emergência, presença de doença crônica complexa (por exemplo, pacientes oncológicos) e como é realizado o transporte para a UTIP. Idealmente, estudos multicêntricos têm maior significância estatística. No entanto, estudos com populações maiores e mais homogêneas, especialmente nos países em desenvolvimento, são difíceis de serem realizados<br>The decrease in mortality is a fundamental goal of the pediatric intensive care unit (PICU). The disease severity reflects the magnitude of comorbidities and physiological disorders on admission and can be assessed by the mortality prognostic scores. The two main scores used in the PICU are the Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM). PRISM uses the worst values of physiological and laboratory variables in the first 24 hours of hospitalization while PIM2 uses data from the first hour after admission to the PICU and only one arterial blood gas. There is no consensus in the literature, between PRISM and PIM2, about usefulness and standardization on admission to intensive care for children and adolescents, especially in a tertiary care level ICU. The aim of the study was to establish the score of best performance in assessing the mortality prognosis that is easily applicable in routine PICU, to be used in a standardized and continuously manner. A retrospective study was conducted and PRISM and PIM2 scores of 359 patients were reviewed. All of them were admitted to the pediatric intensive care unit of the Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, considered a tertiary care unit. Mortality was 15%, the main type of admission was clinical (78%) being the main cause of hospitalization, respiratory dysfunction (37.3%). The scores of the patients who died were higher than that of survivors. For PRISM was 15 versus 7 (p = 0.0001) and the PIM2, 11 versus 5 (p = 0.0002), respectively. For the overall sample, the Standardized Mortality Ratio (SMR) underestimated mortality for both PIM2 and PRISM [1.15 (0.84 to 1.46) and 1.67 (1.23 to 2.11), respectively]. The Hosmer-Lemeshow test showed adequate calibration for both scores [x2 = 12.96 (p = 0.11) for the PRISM and x2 = 13.7 (p = 0.09) for PIM2]. The discrimination performed by the area under the ROC curve was more than adequate for the PRISM than for PIM2 [0.76 (95% CI 0.69 - 0.83) and 0.65 (95% CI 0, 57 - 0.72), respectively, p = 0.002]. In this study, the greatest sensitivity and specificity for this risk would be a PRISM score between 13 and 14, showing that with technological advances, the patient needs a score that is higher and indicates greater clinical severity compared with the original population to reflect an increased risk of mortality. The severity scores may have their results changed as a result: the health system (public or private), the infrastructure PICU (number of beds, human resources, technology park) and statement of admission. The choice of a severity score depends on the individual characteristics of the PICU, as the waiting time in the emergency, the presence of complex chronic disease (for example, oncological patients) and how the transport to the PICU is carried out. Ideally, multicenter studies have greater statistical significance. However, studies with larger and more homogeneous populations, especially in developing countries, are difficult to perform

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2017-04-18T18:10:40Z No. of bitstreams: 1 Angelo Mario Vieira Amorim.pdf: 2335865 bytes, checksum: df9aabae9bafbeac8b01885ccf1ccf83 (MD5)<br>Made available in DSpace on 2017-04-18T18:10:40Z (GMT). No. of bitstreams: 1 Angelo Mario Vieira Amorim.pdf: 2335865 bytes, checksum: df9aabae9bafbeac8b01885ccf1ccf83 (MD5) Previous issue date: 2017-01-06<br>Health is a complex system of service rendering, which has among its basic premises the search for quality and the guarantee of safety to users and patients. However, some hospital institutions have difficulty in diagnosing what should be implemented to meet these requirements. As a result, evaluate the level of health care provided in an ICU in public hospitals - through the domains of quality: safety, effectiveness, efficiency and centrality in the patients. The purpose of the present study was to analyze the quality and safety of patients in an adult intensive care unit (ICU) of a public hospital located in the city of São Paulo, and provides subsidies for the evaluation of their performance, enabling the institution to question its own results for decision making. As a methodological procedure, quality indicators related to the dimensions of safety, effectiveness, efficiency and centrality in the patient were surveyed, as well as the application of a questionnaire using sub-dimensions of patient safety assurance in 52 workers from different professional categories, who work on the unit searched. As results, it was possible to observe high rates of bloodstream infection associated with central venous catheters. In addition, with the use of analysis of variance (ANOVA), it was possible to identify that the variables associated with dimensions - management support and non-punitive responses - were the most relevant from the point of view of statistical significance (p> 0.05) as conditioners for a safe care to patient.<br>Saúde constitui um sistema complexo de prestação de serviços, que tem entre suas premissas básicas a busca pela qualidade e a garantia da segurança aos usuários e pacientes. No entanto, algumas instituições hospitalares têm dificuldade em diagnosticar o que deve ser implementado para o atendimento destes requisitos. Em decorrência, avaliar o nível da assistência à saúde prestada em uma UTI em hospitais públicos – por meio dos domínios da qualidade: segurança, efetividade, eficiência e centralidade no paciente. O propósito do presente estudo foi analisar a qualidade e a segurança de pacientes em uma Unidade de Terapia Intensiva (UTI) de adultos de um hospital público localizado na cidade de São Paulo e oferecer subsídios para a avaliação de seu desempenho, possibilitando à instituição questionar seus próprios resultados para tomadas de decisão. Como procedimento metodológico, houve o levantamento de indicadores de qualidade relacionados às dimensões de segurança, efetividade, eficiência e centralidade no paciente, bem como a aplicação de um questionário utilizando subdimensões da garantia da segurança do paciente em 52 trabalhadores de diversas categorias profissionais, atuantes na unidade pesquisada. Como resultados, foi possível a observação de altos índices de infecção de corrente sanguínea associada a cateteres venosos centrais. Ademais, com a utilização de análise de variância (ANOVA), foi possível identificar que as variáveis associadas às dimensões – apoio à gestão e respostas não punitivas – foram as mais relevantes do ponto de vista de significância estatística (p>0,05) como condicionantes de uma cultura para a assistência segura aos pacientes.

Submitted by PPG Pediatria e Sa?de da Crian?a (pediatria-pg@pucrs.br) on 2018-05-17T17:07:44Z No. of bitstreams: 1 DISSERTAC?A?O_ALESSANDRA Homologada.pdf: 2515370 bytes, checksum: ad16338aa10d94f13cf00eb3c4fe55c1 (MD5)<br>Approved for entry into archive by Caroline Xavier (caroline.xavier@pucrs.br) on 2018-05-28T18:42:00Z (GMT) No. of bitstreams: 1 DISSERTAC?A?O_ALESSANDRA Homologada.pdf: 2515370 bytes, checksum: ad16338aa10d94f13cf00eb3c4fe55c1 (MD5)<br>Made available in DSpace on 2018-05-28T18:44:59Z (GMT). No. of bitstreams: 1 DISSERTAC?A?O_ALESSANDRA Homologada.pdf: 2515370 bytes, checksum: ad16338aa10d94f13cf00eb3c4fe55c1 (MD5) Previous issue date: 2018-03-08<br>Coordena??o de Aperfei?oamento de Pessoal de N?vel Superior - CAPES<br>Introduction: Measures of quality assessment in Pediatric Intensive Care Units (PICUs) are generally related to clinical parameters. However, parental satisfaction is also considered an important indicator. Satisfaction surveys are already carried out frequently, but the questionnaires are not evaluated in relation to validity and reliability. In the Netherlands, the Empowerment of Parents in the Intensive Care 30 (EMPATHIC-30) questionnaire was developed to assess parental satisfaction in UTIO. In Brazil, validated questionnaires were not found for this purpose, so our aim is to translate, culturally adapt and validate the content of EMPATHIC-30 to evaluate parents' satisfaction in Brazilian PICUs. Methods: : the translation and cultural adaptation was carried out according to the protocol of the translation and cultural adaptation group of the International Society for Pharmacoeconomic Research - ISPOR 2005. The content validation was carried out by a committee of experts. After that, the mean and standard deviation (SD) for all items were calculated, and the content validity coefficient (CVC) for each item and for the instrument as a whole. Conclusion: EMPATHIC-30 was translated and adapted culturally to the Brazilian population. Validation demonstrated a total above-average CVC, confirming the validity of the instrument content.<br>Introdu??o: As medidas de avalia??o da qualidade em Unidades de Terapia Intensiva Pedi?tricas (UTIP) s?o geralmente relacionadas a par?metros cl?nicos. Contudo, a satisfa??o dos pais tamb?m ? considerada um indicador importante. Pesquisas de satisfa??o j? s?o realizadas com frequ?ncia, por?m os question?rios n?o s?o avaliados em rela??o ? validade e ? confiabilidade. Na Holanda, foi desenvolvido o question?rio Empowerment of Parents in the Intensive Care 30 (EMPATHIC-30) para avaliar a satisfa??o dos pais em UTIP. No Brasil, n?o foram encontrados question?rios validados para este fim, desta forma, nosso objetivo ? traduzir, adaptar culturalmente e validar o conte?do do EMPATHIC-30 para avaliar a satisfa??o dos pais em UTIP brasileiras. M?todos: a tradu??o e adapta??o cultural foi realizada conforme protocolo do grupo de tradu??o e adapta??o cultural da Sociedade Internacional para Pesquisas Farmacoecon?micas ? ISPOR 2005. A valida??o do conte?do foi realizada por uma comiss?o de especialistas. Ap?s foram calculadas a m?dia e Desvio Padr?o (DP) para todos os itens, e o coeficiente de validade de conte?do (CVC) para cada item e para o instrumento como um todo. Resultados: na fase de adapta??o transcultural, as frases foram adaptadas de acordo com a sintaxe brasileira e sofreram poucas modifica??es. Na valida??o de conte?do, o CVC foi abaixo da m?dia em tr?s itens, dois foram mantidos no instrumento e um foi exclu?do. Conclus?o: o EMPATHIC-30 foi traduzido e adaptado culturalmente para a popula??o brasileira. A valida??o demonstrou um CVC total acima da m?dia, confirmando a validade do conte?do do instrumento.

Nursing Care for Terminal Patients in Intensive Care Units by Pervell Dunbar Project Submitted in Partial Fulfillment of the Requirements for the Degree of Doctor of Nursing Practice Walden University August 2015 Although the goal of the ICU has always been to save lives, ICU now additionally provides end-of life (EOL) care. The objective of this project was to provide ICU nurses with a comprehensive awareness of physical, emotional, and spiritual EOL care issues of patients and their families in order to be better equipped to handle EOL care. The framework used was Jean Watson's Caring model (10 Caritas). A literature review revealed a poster previously used by a major health organization as a conversation starter to facilitate decision-making among ICU nurses, EOL patients, and their families related to EOL issues. The purpose of this quality improvement initiative was to introduce and implement an educational EOL tool that would engage patients and family members in meaningful and useful conversations with ICU nurses. Twenty seven ICU nurses were selected by the unit's director to attend a PowerPoint presentation on the use of the EOL educational poster. Four ICU nurses were chosen by the director to be champions for this project. After the presentation, there was a period for questions and answers, and the ICU nurses were requested to give feedback on the presentation. The result from the feedback revealed that EOL care is outside previous practice and may require extra education and support. These comments substantiated similar conclusions from other researchers as described in this paper. With an increase in EOL training for ICU nurses and the implementation of EOL teaching tools like the poster used in this study, ICU nurses may be better able to have conversations with EOL patients and families, thus improving patient care.

Objectives: The aim of the study is to investigate the relationship between risk of mortality at admission to a paediatric intensive care unit (PICU) and health status at six months post discharge from PICU in the United Kingdom (UK). Patients and Methods: Prospective follow-up study of children aged 6 months or more at admission to PICU between 2001 and 2002, who were discharged alive. Health status was measured using the Health Utility Index Mark II (HUI2). Risk of mortality was measured using the Paediatric Index of Mortality (PIM and PIM2) and the Pediatric Risk of Mortality (PRISM and PRISM III). The relationship between H U 12 outcomes (individual dimensions and overall Disability) and mortality risk measures was investigated using generalised ordered regression, adjusted for PICUs effect. Results: Eighty six percent (1221/1414) of children had complete data on all HUI2 dimensions. Nearly two thirds (803/1221) of the children had moderate to severe disability. PIM was significantly associated with disability. The odds ratio of having none/mild vs. moderate or severe disability was 1.4, 95% Cl 1.2 to 1.7 for each unit increase in log PIM. More than three quarters of children with severe disability were correctly classified by PIM with good discrimination (c-index = 0.60, p-value < 0.001). PIM also showed a significant relationship to the following individual HUl2 dimensions: Sensation, Mobility, Emotion, Cognition, Self-care, and Pain. Conclusions: Mortality risk tools may be adequate for predicting mortality as outcome following admission to PICU, but of these only PIM showed the potential for predicting long term health status in these children based on c-index and misclassification rate.

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação.<br>Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.

PONTIFÍCIA UNIVERSIDADE CATÓLICA DO RIO DE JANEIRO<br>COORDENAÇÃO DE APERFEIÇOAMENTO DO PESSOAL DE ENSINO SUPERIOR<br>CONSELHO NACIONAL DE DESENVOLVIMENTO CIENTÍFICO E TECNOLÓGICO<br>PROGRAMA DE SUPORTE À PÓS-GRADUAÇÃO DE INSTS. DE ENSINO<br>A Unidade de Terapia Intensiva (UTI) é um departamento importante dentro do Hospital visto que lida majoritariamente com casos de alta complexidade e gera elevados custos administrativos, o que requer um controle adequado de seus processos. Inconformidades tais como erros em atividades de tratamento e falta de comunicação entre os funcionários são comumente responsáveis pelo baixo desempenho de UTIs e devem ser ajustados para reduzir possíveis danos ao tratamento do paciente. Para avaliar a eficiência de uma UTI, a literatura propõe que sejam estabelecidas métricas que considerem quatro perspectivas - médica ou clínica, econômica, social e institucional – que oferecem uma visão abrangente das atividades (administrativas ou de tratamento) dentro da unidade e seus impactos no pós-tratamento. Entretanto, a avaliação de desempenho em uma UTI não é uma tarefa simples, pois há diversas variáveis a serem consideradas e que podem ser potenciais causas de um mau desempenho. Além disso, não há uma métrica ou indicador padrão-ouro que consegue reter de forma adequadas as informações, sendo que diversas perspectivas devem ser consideradas. Os indicadores mais comuns são A Taxa de Mortalidade Padronizada (Standardized Mortality Ratio, SMR) e o Taxa de Uso de Rescursos Padronizada (Standardized Resource Use, SRU), que contabilizam desfechos de mortalidade (clínicos) e de uso de recursos (econômicos), junto de metodologias propostas para viabilizar a comparação entre diferentes UTIs, identificar de grupos de desempenho e analisar os riscos de mortalidade dos pacientes dentro da unidade, tais como os conceitos de Rankability e Perfis de Risco (Risk Profiles). Além disso, é necessário definir corretamente os desfechos a serem contabilizados em indicadores. Nesse contexto, recomenda-se a combinação de diferentes indicadores e metodologias de forma a complementar e elevar a confiabilidade da análise de desempenho e benchmarking. Com isso, este estudo tem como objetivo analisar um conjunto de UTIs em termos de desempenho quanto à mortalidade e uso de recursos, associando-os com as características das unidades e seus fatores institucionais, para identificar possíveis correlações. A análise foi feita em uma amostra composta por 12.100 pacientes que foram hospitalizados em 116 UTIs, considerando um desfecho em até 60 dias de interação. Este estudo teve como contribuição a combinação de diferentes técnicas e indicadores, e uma discussão a respeito da variabilidade do SMR em comparação à metodologia tradicional. Para este propósito, combinou-se as técnicas da Matriz de Eficiência, Rankability – índice de confiabilidade de um indicador de desfecho, e Perfis de Risco, de forma a obter e avaliar o desempenho de grupos de UTIs. Como resultados, verificou-se que UTIs cuja administração é de domínio Público e que destinam a maioria dos seus leitos ao Sistema Único de Saúde (SUS) brasileiro tiveram mortalidade significativamente alta em relação àquelas de dominínio privado (p-valor menor que 0.05). Além disso, realizou-se um agrupamento das UTIs utilizando quatro diferentes técnicas de clusterização de forma a garantir a máxima confiabilidade do indicador para comparação (Rankability), o que resultou na presença de clusters extremos contendo uma UTI cada, sendo elas a de maior e a de menor SMR, apesar de ambas apresentarem o mesmo conjunto de severidades. Para cada grupo, estimou-se o seu perfil de risco, e verificou-se que pacientes com menor gravidade apresentaram maior variabilidade nos riscos de morte, sendo estes maiores nos grupos com alto SMR e menores em grupos de menor mortalidade, sendo que a dispersão tendeu a ser menor quanto menor for o risco, o que poderia influenciar diretamente no cálculo do SMR. Com isso, por meio de equações matemáticas e simulação por meio de reamostragem, verificou-se que o SMR possui uma limitação em sua escala, que depende diretamente do espectro de gravidade dos pacientes em cada UTI ou grupo de desempenho analisado. O S<br>Intensive Care Unit (ICU) is an important department within a hospital since it deals mostly with complex cases and it generates the highest amount of costs, thus requiring adequate control on its care treatments. Nonconformities such as poor communication and treatment errors are commonly responsible for a bad performance in ICUs. However, evaluating the performance of an ICU is not an easy task and there are no gold-standard indicators. The most common metrics are the Standardized Mortality Ratio (SMR) and the Standardized Resource Use (SRU), which measure mortality and resource utilization, respectively. Hence, this study aims to analyze different ICUs in terms of mortality, resource use, and institutional factors, combining the methods Efficiency Chart, Rankability and Risk Profile. The analysis was performed considering a total of 12,100 patients in 116 ICUs provided by a clinical trial study. As results, it was verified that most ICUs were from hospitals with public administration (47.41 per cent), which had significantly high lethality rate compared to private hospitals. Four different clustering approaches were tested, which identified similar case-mixes between the best and lower performance groups of ICUs, and a high variability in expected risks for low severity patients. Using a resampling approach, it was evidenced that the mortality indicator varies strongly on low-risk groups of patients, while high-risk patients had a smaller range of SMR values, which may lead to biased conclusions when comparing ICUs with similar mortality and different case-mixes.

Background: Neonates who require specialized care and life-saving therapies in neonatal intensive care units (NICUs) and neonatal special care units (NSCUs) can be exposed to separation from their parents and families. Consequently, establishing a parental-neonate bond can be difficult. However, addressing this problem of separation through involving parents and families in neonatal care to improve parent-professional collaboration can result in positive outcomes for neonates and their families. Family-centred care (FCC) has developed over decades and is broadly recommended as an ideal model of care in daily clinical practice in NICUs. However, FCC implementation is challenging at individual, organizational, cultural, and healthcare system levels. In particular, developing countries are challenged by the lack of material resources, infrastructure, and staff shortages. In Thailand, the practical incorporation of FCC into daily clinical practice in neonatal care units is difficult, and it has not been sustainably achieved. Furthermore, there has been minimal research reporting on the development, implementation, and evaluation of FCC in the neonatal critical care context within Thailand. Aim and Objectives: The aim of this PhD study has been to develop, implement and evaluate innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. It had three objectives, each representing a distinct phase in the study: (1) to identify perceptions, current practices and FCC strategies; (2) to develop and implement an innovation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU; and (3) to evaluate the FCC innovation developed in Phase 2. Methods and Results Design: The multistage, mixed-methods study design applied the Participatory Intervention Model (PIM) to guide the innovation’s development, implementation, and evaluation to facilitate FCC by improving respect, collaboration, and support in a Thai NICU. Setting and context: This study was conducted in a tertiary care hospital in southern Thailand (February 2020-January 2021). Ethics approval was obtained from the Research Ethics Committee of Hatyai Hospital and Griffith University. Phase 1: Identification of perceptions, current practices, and FCC strategies Phase 1 was planned to include data collection over 3 months. Due to the COVID-19 pandemic, it was reduced to 2 months during the very early stages of the pandemic (February to March 2020). This phase consisted of two parts, including surveys and interviews with parents and the interdisciplinary professionals. Participants: Participants consisted of two groups: parents of neonates (all gestational ages with no life-threatening or life-limiting diagnosis) who had an expected NICU stay of at least 72 hours and visited the study NICU at least once, and interdisciplinary professionals with a permanent position for at least 1 year in the study unit. Part A: Survey of parents and interdisciplinary professionals Surveys of parents and interdisciplinary professionals were conducted using the validated Perceptions of Family Centred Care – Parent (PFCC-P) and Perceptions of Family Centred Care – Staff (PFCC-S) instruments which were translated into Thai. Sample size: Sample size was based on availability of parents and interdisciplinary professionals over the planned 3-month Phase 1 period. Recruiting parent participants in Phase 1 was prior/during the very early stages of the COVID-19 pandemic and needed to be stopped prior to pre-determined sample size of 100 parents due to visitor restriction (n = 85). Eighty-five parents and 20 interdisciplinary professionals completed the surveys. Data analysis: Demographic characteristics of parents, interdisciplinary professionals, and neonates are reported using descriptive statistics. The subscale scores for parents and interdisciplinary professionals were not normally distributed, so medians were calculated for each of the three sub-scales (respect, collaboration, and support). Parents’ and interdisciplinary professionals’ perceptions of FCC (PFCC-P & PFCC-S) were compared using the Mann-Whitney U test to examine differences in medians in the preimplementation phase because they were unpaired groups. Part B: Semi-structured interviews with parents and interdisciplinary professionals Face-to-face, semi-structured, individual interviews were planned to gain information from extended family members and parents and interdisciplinary professionals; however, given the visitation restrictions, only parents and interdisciplinary professionals were recruited to participate (during the first half of February 2020). Sample size: The sample size was determined when data saturation was identified. Eight interdisciplinary professionals and nine parents participated in face-to-face interviews. Data analysis: Thematic analysis was used to analyse the transcribed Thai language interviews. Results: The survey results across the median of three subscales demonstrated that parents and interdisciplinary professionals’ perceptions on the FCC strategies in current practice were 2-3/4 (Interquartile range [IQR] 1.7-3.8) and 3-4/4 (2.85-3.55), respectively. Considering the median subscale scores, the interdisciplinary professionals had significantly higher subscale scores for respect (median 3.00 (95% CI, 2.91-3.24) vs 2.50 (2.37-2.81)), collaboration (median 3.22 (3.10-3.37) vs 2.33 (1.9-2.62)), and support (median 3.20 (3.03-3.39) vs 2.60 (2.03-2.61)) (all p ≤ 0.001). The interview findings highlighted that the interdisciplinary professionals in this study accepted that the three critical elements of FCC (respect, collaboration, and support) were necessary to be implemented into clinical practice. However, they believed that in reality it was not easy in the Thai NICUs context. This finding identified that the challenge to promote parent-healthcare professional partnerships was associated with the structure and processes of the healthcare delivery system. In addition, the individuality of families' readiness and healthcare providers' perceptions of parents’ involvement as obstacles to providing care were found to be challenges to current practices of FCC. Phase 2: Development and implementation of innovation to facilitate FCC This phase was achieved by two different methods: strategy development working group and implementation of the FCC innovation. Strategy development working group: The development of FCC innovations by the strategy development working group (June to August 2020) was based on Phase 1 findings and the reported integrative literature review. In addition, the FCC innovations were considered within the policies and practices of the NICU in the context of COVID- 19 in Thailand. The development working group members were key and high-level stakeholders in the NICU. Educational activities for the healthcare professional team to incorporate the FCC innovations into their clinical practice in NICU were provided. Implementation of the FCC innovation: The FCC innovations were then implemented over 2 months (September to October 2020), during a period of restrictions on parents and staff arising from COVID-19. Results: The working group identified the gaps in the three key elements (respect, collaboration, and support) to providing FCC in a Thai NICU through the analysis of Phase 1’s results in consort with the findings from the integrative review. A preliminary protocol for the FCC innovations and implementation plan were developed consistent with the challenges associated with COVID-19 in Thailand. FCC practice innovations associated with improving communication were established, including changes and updates to the material within the parent booklet with specific material related to COVID- 19, neonatal updates at bedside or conducted via telephone calls, interdisciplinary family meeting for complex care situations, structured communication checklists, and documentation templates. In addition, although visiting restrictions were limiting, parents were provided with more flexibility as to when they could visit based on individual circumstances. The majority of the healthcare providers in this setting (80%) attended the educational activities to incorporate the FCC innovations into their clinical practice in the NICU. The FCC innovations were incorporated into daily NICU practice by nurses in cooperation with other healthcare providers and ancillary support staff during the pandemic. Phase 3: Evaluation of the FCC innovation Phase 3 (post-implementation) was conducted over 3 months (November 2020-January 2021), and it focused on evaluating the FCC innovations. This phase repeated the collection of data from the validated PFCC-P and PFCC-S surveys of parents and interdisciplinary professionals' perceptions, as per Phase 1, to assess respect, collaboration, and support changes after implementing the FCC innovations in the Thai NICU during the pandemic. Sample size: One hundred parents and 20 interdisciplinary professionals completed the surveys. Data analysis: As per Phase 1 for demographic characteristics. The Mann-Whitney U test was used to analyse parents' perceptions of the items of the PFCC-P pre- and postimplementation given they were two independent groups. Wilcoxon signed-rank test was used to compare the perceptions of the interdisciplinary professionals pre- and postimplementation using the PFCC-S given they were matched samples. Results: The participants consisted of 83 pairs of parents (i.e., mother and/or father of neonate participated) (35 pre; 48 post), which represented 102 neonates (50 pre; 52 post). There were 185 parents; 85 pre-implementation and 100 post-implementation. For the NICU health care team, 20 participated. The median scores of parents' perceptions post-implementation significantly improved for respect (2.50 to 3.50; 95%CI, 3.02-3.53), collaboration (2.33 to 3.33; 2.90- 3.40), support (2.60 to 3.60; 2.84-3.62), and the overall score (2.50 to 3.43) (p < 0.001, 95%CI 2.93-3.51). There was an absolute difference of at least 0.3 in the pre- and postimplementation scores for three subscales and overall score, where 0.3 corresponds to 10% of the rating scale. Comparatively, interdisciplinary professionals' perception of FCC did not significantly change pre- and post-implementation for respect ([median] 3.00 to 2.92; 95%CI, 2.87-3.16), collaboration (3.22 to 3.33; 3.16-3.47), support (3.20 to 3.20; 2.96-3.28) and overall (3.15 to 3.20; 95%CI, 3.10-3.25). Conclusions:Results from this study indicate that incorporating FCC innovations in the NICU appeared to be successful, despite the challenges of COVID-19. The key finding was that the innovations incorporated in the NICU were primarily based on communication strategies, a simple means to support, collaborate with, and respect parents that required low investment within the complex situation arising from COVID-19. These innovations were essential to engage collaborative working between parents and healthcare providers to promote parents as partners in a neonatal critical care team. To successfully implement FCC innovations in different settings, further innovations associated with communication methods need to target the specifics of individuals involved, healthcare settings, and available resources.<br>Thesis (PhD Doctorate)<br>Doctor of Philosophy (PhD)<br>School of Nursing & Midwifery<br>Griffith Health<br>Full Text

Nos locais de trabalho, a qualidade do ar pode interferir na performance dos trabalhadores e no risco de doenças. Sabe-se que a qualidade do ar interior pode ser afetada pelos poluentes gerados no ambiente exterior. Nos hospitais, estes temas têm sido insuficientemente analisados e nas unidades de terapia intensiva eles ainda não foram investigados. Os objetivos deste estudo foram analisar a correlação entre os níveis de poluentes medidos dentro e fora das unidades de terapia intensiva e investigar a associação entre a qualidade do ar nas unidades e a saúde dos trabalhadores. Oito unidades de terapia intensiva localizadas em quatro hospitais diferentes foram incluídas neste estudo. Níveis de poluentes, temperatura e umidade relativa do ar foram medidos dentro e fora das unidades, simultaneamente, durante períodos de sete dias específicos para cada unidade. Monitores automáticos foram usados para o monitoramento do MP2,5, enquanto monitores passivos foram usados para as medidas de NO2 e O3. Um questionário de sintomas foi aplicado a cada trabalhador das unidades de terapia intensiva que concordou em participar do estudo. Para testar diferenças nos poluentes e nas variáveis meteorológicas em cada unidade (dentro e fora) adotamos o teste t de Student ou o teste U de Mann-Whitney. Para testar diferenças entre a unidades nós adotamos o teste de análise de variância para amostras independentes (ANOVA) e o teste HSD-Tukey, quando necessário. Adotamos os coeficientes de correlação de Pearson ou de Spearman para avaliar correlações entre as medidas interiores e exteriores em cada unidade. Para as associações entre os sintomas e o local de trabalho nós adotamos o teste de qui-quadrado de Pearson ou o teste exato de Fisher. A unidade 1 apresentou a maior média interior de MP2,5 (33,9 g/m3; Desvio Padrão - DP = 44,2), estatisticamente diferente das demais unidades (p < 0,05). Além disso, este valor foi quase 16 vezes maior do que a média de MP2,5 observada na unidade 6 (2,1 g/m3; DP = 3,4), a menos poluída. Em cinco unidades, as medidas interiores e exteriores de MP2,5 apresentaram correlações estatisticamente significativas (p < 0,05). Tanto para o NO2 quanto para o O3, os valores exteriores foram maiores do que os interiores e não ouve correlação entre eles. Entre os 18 sintomas investigados, dores nas costas, ombros e pescoço (65%), cefaléia (65%), cansaço e fadiga (62%), tensão e irritabilidade (58%), coriza (51%), espirros (45%), vista cansada (44%), olhos secos (42%), dor de garganta (38%), dificuldade de concentração (35%) e tosse (27%) foram os mais relatados. As freqüências de sintomas foram semelhantes em todas as unidades. Não foram observadas associações entre a qualidade do ar interior e os sintomas relatados. Estes resultados mostraram que o isolamento entre os ambientes internos e externos através dos sistemas de ar condicionado pode variar permitindo altas concentrações de partículas finas interiormente. Além disso, a falta de correlações entre os gases dentro e fora das unidades indica a presença de fontes interiores para os dois poluentes. Potenciais associações entre a qualidade do ar nas unidades e sintomas de doenças requerem investigações adicionais<br>In work facilities, air quality can interfere in workers performance and in diseases´ risk. It is well known that indoor air quality can be affected by pollutants generated outdoor. In hospitals these topics have been insufficiently investigated and in intensive care units they have not been explored yet. The aims of this study were to analyze the correlation between indoor and outdoor levels of air pollutants in intensive care units and investigating the association between indoor air quality and workers health. Eight intensive care units located in four different hospitals were included in this study. Indoor and outdoor levels of air pollutants, temperature and relative humidity were measured simultaneously in each unit along unit-specific seven-day periods. Automatic monitors were used to measure PM2.5 while passive samplers were adopted to measure both NO2 and O3. A questionnaire of symptom was applied to each intensive care unit worker that agreed in participating of the study. In order to test differences in pollutants and weather variables measurements intra-units (inside and outside) we adopted the Student t test or Mann-Whitney U test. To test differences inter-units we adopted one-way analysis of variance for independent samples (ANOVA) and the Tukeys Honestly Significantly Different post-hoc test when necessary. We adopted Pearson correlation coefficients or Spearman correlation coefficients to investigate correlations between indoor and outdoor measures. For associations between symptoms and place of work we adopted qui-square test or Fishers exact test. Unit 1 presented the highest indoor PM2.5 mean (33.9 g/m3; Standard Deviation-SD = 44.2) and it was statistically different from all other indoor measures (p < 0.05). Also, it was almost sixteen fold higher than indoor PM2.5 mean in unit 6 (2.1 g/m3; SD = 3.4), the cleanest one. In five units, indoor and outdoor levels of PM2,5 presented statistically significant correlations (p < 0.05). For both NO2 and O3, outside values were higher than those measured inside and there were no correlations between indoor and outdoor measures. From 18 investigated symptoms, pain in back, shoulders or neck (65%), headache (65%), tiredness or fatigue (62%), tension and irritability (58%), runny nose (51%), sneezing (45%), eyestrain (44%), dry eyes (42%), sore and dry throat (38%), difficult of concentrating (35%) and cough (27%) were the most reported. Frequency of symptoms were similar in all units. There were not associations between indoor air quality and reported symptoms. These results showed that isolation between indoor and outdoor environments through air conditioning systems may vary allowing high indoor concentrations of fine particles. Moreover, the lack of correlation between indoor and outdoor gaseous pollutants indicates the presence of indoor sources of both pollutants. Potential associations between indoor air quality and disease symptoms require additional investigation

<p>Syfte med denna enkätstudie var att undersöka hälsorelaterad livskvalitet (HRQOL) tolv månader efter utskrivning från intensivvårdavdelning mellan kvinnor och män och mellan yngre (< 65 år) och äldre (≥65 år). Huvudresultatet visade att det fanns signifikanta skillnader mellan kvinnor och män hur de skattar HRQOL i delskala smärta. Ingen signifikant skillnad fanns mellan yngre och äldre. Även med ett litet antal patienter är skattad HRQOL för hela undersökningsgruppen jämförbar med större studier inom område som mäter HRQOL med SF-36.</p><br><p>The aim of the study was to assess health-related quality of life (HRQOL) twelve months after discharge from the intensive care unit (ICU) as well as to study if there were differences in HRQOL between younger (<65 years) and older (≥65 years) patients. There were significant differences between women and men in how they estimated HRQOL in the domain pain. No significant differences existed between younger and older patients and the HRQOL overall twelve months after discharge from ICU were consistent with previous HRQOL SF-36 research results even with a small sample of patients.</p>

Objetivos: Este estudo investigou as associações entre características dos médicos e a variabilidade de condutas em fim de vida em UTI. Métodos: Um questionário foi aplicado aos médicos das 11 UTIs do HC-FMUSP, apresentando dois casos clínicos. O primeiro apresentava uma paciente em estado vegetativo persistente, sem familiares ou diretivas antecipadas de vontade, com um choque séptico. O segundo, uma paciente de 88 anos, com disfunção de múltiplos órgãos decorrente de uma pneumonia. Investigou-se através do questionário a associação entre condutas e características pessoais, profissionais e educacionais dos médicos. Resultados: Foram analisados 105 questionários (taxa de resposta 89%). A media de idade foi de 38±8 anos, com 14±7 anos de graduação em medicina. A maioria das decisões envolveu exclusivamente médicos (66%), 21% envolveram também enfermeiros. Na análise multivariada, especialistas em Medicina Intensiva (17/22 vs. 46/83, OR=0,205[0,058-0,716], P=0,013) e médicos mais jovens (38±7 vs. 40±8; OR=0,926[0,858-0,998], P=0,045) mais frequentemente envolveram enfermeiros no processo de decisão. Ordem de não reanimação (ONR) foi estabelecida por 89% dos participantes, sendo 44% exclusivamente verbais. Médicos que atribuíram a si mesmo notas mais altas em relação ao conhecimento sobre cuidados paliativos mais frequentemente estabeleceriam uma ONR na análise multivariada (6±2 vs. 3±2, OR=2,167[1,062-4,420], P=0,034). A maior parte dos participantes (60%) respondeu que limitaria de alguma forma o suporte artificial de vida (SAV) para a primeira paciente, enquanto 21% respondeu que não limitaria nenhum suporte e 19% retiraria o SAV. Na análise de regressão logística, o interesse em discutir sobre fim de vida em UTI permaneceu como variável de associação independente para retirada ou limitação de SAV (20/20 vs. 61/63 vs. 17/22, OR=0,129[0,019-0,894], P=0,038). Quarenta e seis dos 105 médicos avaliados (44%) apresentavam respostas discordantes para as questões sobre a conduta mais provável e a conduta acreditada como a melhor para a primeira paciente. Dentre estes, 45 (98%) acreditavam que a melhor conduta envolveria o uso de menos SAV do que provavelmente fariam. Motivos relacionados a aspectos jurídicos ou legais foram os mais frequentemente apontados como os motivos para a divergência entre estas condutas. A maioria das decisões (58%) envolvendo uma paciente octagenária lúcida na UTI com alto risco de morte ou de baixa funcionalidade em caso de sobrevivência foram decisões paternalistas, e não ofereceram qualquer autonomia à paciente ou a sua família. A análise multivariada observou que médicos mais jovens (39±8 vs. 41±8, OR=0,966[0,9390,994], P=0,016) e que leram mais artigos sobre fim de vida ou cuidados paliativos em UTI (15/44 vs. 12/61, OR=2,404[1,0185,673], P=0,045) estavam associadas de forma independente ao compartilhamento da decisão com a paciente e/ou sua família, provendo assim algum grau de autonomia. Conclusão: Características dos médicos que trabalham em UTIs como idade, interesse e educação em cuidados paliativos em UTI se associam a variabilidade de condutas em fim de vida em UTI. Quarenta e quatro por cento dos médicos investigados não agiriam conforme o que julgam melhor para a paciente, utilizando-se de mais SAV do que julgam melhor. Motivos legais foram os mais citados como a causa desta discrepância de condutas<br>Purpose: To investigate associations between physician education in end-of-life (EOL) care and variability in EOL practice in the ICU, and differences between actual EOL practice and what physicians believe is best for the patient. Methods: Physicians from 11 ICUs at a university hospital completed a survey presenting a patient in a vegetative state with no family or advance directives. Questions addressed approaches to EOL care, and physicians personal, professional and EOL educational characteristics. Results: One-hundred-and-five questionnaires were analyzed (response rate 89%). Respondents mean age was 38±8 years, with a mean of 14±7 years post-graduation. Physicians who applied written do-not-resuscitate (DNR) orders had more often attended EOL classes than those who did not apply DNR orders (31/47 vs. 0/7, OR=1.818[1.456-2.159], P=0.001). Younger physicians (38±7 vs. 40±8 years, OR=0.926[0.858-0.998], P=0.045) and ICU specialists (17/22 vs. 46/83, OR=0.205[0.058-0.716], P=0.013) more often involved nurses in EOL decision-making than did other physicians. Physicians who would withdraw lifesustaining therapies had more often read about EOL (11/20 vs. 3/22, OR=1.306[1.0011.547], P=0.012) and had more interest in discussing EOL (20/20 vs. 17/22, OR=4.717[2.0487.381], P<0.001), than physicians who would apply full code. Forty-four percent of respondents would not do what they believed was best for their patient: 98% of them believed a less aggressive attitude was preferable with legal concerns the leading cited cause for this dichotomy. Conclusions: Physician education about EOL issues is associated with variability in EOL decisions in the ICU. Actual practice may differ from what physicians believe is best for the patient

Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-09T13:38:42Z No. of bitstreams: 1 Gustavo Dias da Silva.pdf: 3137873 bytes, checksum: f82f8f22e1838a52d011f8d20995b925 (MD5)<br>Made available in DSpace on 2015-12-09T13:38:42Z (GMT). No. of bitstreams: 1 Gustavo Dias da Silva.pdf: 3137873 bytes, checksum: f82f8f22e1838a52d011f8d20995b925 (MD5) Previous issue date: 2013<br>Mestrado Profissional em Enfermagem Assistencial<br>O objeto deste estudo é o erro nos processos do sistema de medicação da Unidade de Terapia Intensiva Neonatal (UTIN), tendo como objetivo geral elaborar um processo de reestruturação do sistema de medicação da UTIN, com base nos erros de medicação identificados por meio de incidentes críticos. Os objetivos específicos são descrever os sistemas de medicação e de notificação dos incidentes envolvendo medicamentos na UTIN; caracterizar os erros de medicação na UTIN relatados por profissionais de enfermagem; e discutir as situações, comportamento e consequências envolvendo os erros de medicação na UTIN. Foi realizada uma pesquisa aplicada do tipo descritiva, com uma abordagem quanti-qualitativa adotando-se a técnica dos incidentes críticos com base no referencial metodológico de Flanagan. Os sujeitos do estudo incluíram enfermeiros, técnicos e auxiliares de enfermagem da UTIN de uma maternidade do Rio de Janeiro. A coleta de dados compreendeu duas etapas: observação não-participante e entrevista individual com o uso de um instrumento semi-estruturado. Os incidentes coletados foram categorizados e submetidos à análise estatística e de conteúdo. Foram incluídos no estudo 40 sujeitos, dos quais 13 (32,5%) eram enfermeiros, 26 (65%) técnicos de enfermagem e 1 (2,5%) auxiliar de enfermagem. A média de tempo de experiência profissional foi de 12,6 anos (± 6,6) e de experiência na instituição foi de 8 anos (± 5,3). 65% dos sujeitos eram extra quadro e 77,5% tinham 2 ou mais vínculos de trabalho. Existem três grupos de profissionais diretamente envolvidos nos processos do sistema de medicação: equipe médica, de enfermagem e serviço de farmácia. A caracterização dos relatos dos profissionais de enfermagem revela que o tipo de erro mais freqüente é o de paciente errado (28,2%), seguido de medicamento errado e dose errada (17,0% cada), houve predominância de relatos de incidentes entre os enfermeiros (r=0,98), servidores estatutários, com média de tempo de experiência profissional de 12,6 anos (± 6,6) e tempo de vínculo na instituição de 8,4 anos (± 5,3). Através da análise de conteúdo das entrevistas emergiram 12 temas que foram agrupados nas categorias que compõem o Incidente Crítico: Situações (Sistema de Medicação, Processo de Trabalho e Comunicação); Comportamentos (Proatividade, Admissibilidade, Mestria, Negação); e Conseqüências (Inadequado Gerenciamento do Cuidado, Sofrimento Psíquico, Near miss ou Evento Adverso, Punição e Estratégias de Prevenção). O produto gerado pela análise e interlocução das características peculiares do sistema e do processo de trabalho dos profissionais de enfermagem com as situações, comportamentos e conseqüências dos erros de medicação foi um fluxograma gerencial para reestruturação do sistema de medicação. Os resultados desta pesquisa apontam que a ocorrência de erros e iatrogenias é freqüentemente associada às características sistemáticas e fatores latentes institucionais, sendo a interface destas características do sistema de medicação com o processo de trabalho vivo em ato do profissional de enfermagem, fator determinante para a ocorrência de incidentes críticos negativos envolvendo o uso de medicamentos na UTIN<br>The object of this study is the error in the processes of the medication system of Neonatal Intensive Care Unit (NICU), aiming to propose a general restructuring of the NICU medication system, based on medication errors identified by critical incidents. The specific objectives are to describe the medication systems and notification of incidents involving drugs in the NICU; characterize medication errors reported by the NICU nurses, and discuss situations, behavior and consequences involving medication errors in the NICU. We performed a descriptive type of applied research with a quantitative and qualitative approach adopting the critical incident technique based on the methodological framework of Flanagan. The study subjects included nurses, technicians and nursing assistants of a maternity in Rio de Janeiro. Data collection involved two stages: non-participant observation and individual interviews using a semi-structured instrument. The incidents were categorized collected and subjected to statistical analysis and content. The study included 40 subjects, 13 (32.5%) nurses, 26 (65%) nursing technicians and 1 (2.5%) nursing assistant. The average professional experience was 12.6 years (± 6.6) and experience in the institution was 8 years (± 5.3). 65% of subjects were extra frame and 77.5% had 2 or more working links. There are three groups of professionals directly involved in the processes of the medication system: medical staff, nursing and pharmacy service. The characterization of the reports of nurses reveals that the most frequent type of error is to the wrong patient (28.2%), followed by wrong drug and wrong dose (17.0% each), there was a predominance of reported incidents between nurses (r = 0.98), servers with average professional experience of 12.6 years (± 6.6) and time to bond with the institution of 8.4 years (± 5.3). Through content analysis of the interviews revealed that 12 subjects were grouped in categories of the Critical Incident: Situation (Medication System, Work Process and Communication); Behaviors (Proactivity, Admissibility, Mastery, Denial) and Consequences (Inadequate Management Care, Suffering Psychic, near miss or adverse event, Punishment and Prevention Strategies). The product generated by analysis and dialogue of the characteristics of the system and the working process of nursing with the situations, behaviors and consequences of medication errors was a flowchart for managerial restructuring of the medication system. The results of this study indicate that the occurrence of iatrogenic errors and is often associated with systemic features and latent institutional factors, and the interface of these characteristics of the medication system in the process of work in action nursing professional factor for the occurrence of negative critical incidents involving the use of drugs in the NICU

Patient satisfaction is an outcome of care that represents the patient's judgment on the quality of care. An important aspect of quality affecting patient's judgment can be attributed to patients' expectations and experiences regarding nursing care according to type of unit. The purpose of this study was to examine differences between patients' perceptions of satisfaction with nursing care in critical care units and medical units in one Midwestern hospital.The conceptual framework was "A Framework of Expectation" developed by Oberst in 1984, which asserted that patients have expectations of hospitals and health care professionals regarding satisfaction and dissatisfaction with care. The instrument used to measure patient satisfaction was Risser's Patient Satisfaction Scale, with three dimensions of patient satisfaction: (a) Technical-Professional, (b) Interpersonal-Educational, (c) Interpersonal-Trusting. The convenience sample included 99 patients50 from critical care units and 49 from medical wards. Participation was voluntary. The study design was comparative descriptive and data was analyzed using a t-test.The demographic data showed that the majority of patients had five or more admission. About one-third of the patients were 45-55, 56-65, 66-75, respectively. Findings related to the research questions were that: (a) 84 percent of the respondents rated overall satisfaction in the satisfactory to excellent range, (b) results of a t-test showed significant differences in overall patient satisfaction with patients being more satisfied with care in critical care units. Significant differences were found in three subscales with critical care being more satisfied. No relationship was found between patient satisfaction and age/and/or type of unit.Conclusions were that in both medical and critical care units patients were more satisfied with Technical-Professional and Interpersonal-Trusting than with Interpersonal-Educational. Also noted was that patients in the units where nurse-to-patient ratio was higher participants perceived that nurses had more time, energy and ability to meet patient expectation. Implications call for analysis of nurse/patient ratio in relation to patient satisfaction and nurses in relation to patient education as well as patient's perceptions of getting their needs met.<br>School of Nursing

Submitted by Mariana Dornelles Vargas (marianadv) on 2015-03-26T17:44:12Z No. of bitstreams: 1 recordacoes_mnemicas.pdf: 697532 bytes, checksum: c6d3f6b1ff4b1e1dabe61e4c2a84cc44 (MD5)<br>Made available in DSpace on 2015-03-26T17:44:12Z (GMT). No. of bitstreams: 1 recordacoes_mnemicas.pdf: 697532 bytes, checksum: c6d3f6b1ff4b1e1dabe61e4c2a84cc44 (MD5) Previous issue date: 2010<br>Nenhuma<br>A Unidade de Terapia Intensiva (UTI) é um local responsável por salvar vidas, um ambiente repleto de equipamentos, drogas, alta tecnologia e corpo técnico altamente qualificado. No entanto, medos, fantasias de morte, recordações e sentimentos colocam o paciente diante de um cenário que poderá deixar marcas mnêmicas capazes de gerar efeitos psicológicos importantes como o Transtorno de Estresse Pós-Traumático (TEPT), afetando a qualidade de vida após a alta hospitalar. Diante disso, o objetivo do presente estudo foi avaliar a prevalência de TEPT em pacientes que passaram por internação em UTI, levantar alguns fatores de risco e de proteção para TEPT a partir do registro de memórias trazido pelo paciente seis meses após a alta hospitalar e correlacionar TEPT, qualidade de vida, com recordações mnêmicas, dados sócio-demográficos e variáveis clínicas. Participaram do estudo 41 pacientes adultos que passaram por internação em UTI em um hospital geral de Porto Alegre, com idade média de 59 anos (DP=14,71). Os instrumentos usados foram: Inventário de Katz, Planilha de dados sócio-demográficos e variáveis clínicas, Memory Tool, WHOQOL-breve e SPTSS. A análise descritiva mostrou a prevalência de TEPT na população estudada de 24,4%, usando-se um ponto de corte≥ 5. As mulheres apresentaram mais TEPT do que os homens (X2=6,999, p<0,05) e o teste t mostrou que as lembranças mais significativas para os pacientes foram respectivamente: rostos (t=4,88, p<0,05), pânico (t=11,17, p<0,001), medo (t=6,99, p<0,05) e dor (t=4,02, p<0,05). As memórias afetivas associaram-se de maneira significativa (t=-2,28, p<0,05) ao TEPT, e as memórias delirantes correlacionaram-se de maneira significativa ao tempo de internação (r=0,46, p<0,001). O teste Qui-quadrado mostrou que variável clínica delirium apresentou-se estatisticamente significativa em relação ao TEPT (X2=6,16, p<0,05), as demais variáveis não foram significativas. A qualidade de vida dos pacientes sofreu abalo após internação do ponto de vista geral, apresentando-se estatisticamente significativas em relação ao TEPT em todas as suas dimensões respectivamente: A análise de regressão hierárquica mostrou que as variáveis gênero e memórias afetivas mostraram-se preditoras de TEPT respectivamente: (β=0,44, p<0,01) e (β=0,46, p<0,01). Conclusão: O presente estudo identificou a prevalência de TEPT em pacientes seis meses após a alta hospitalar e concluiu que, apesar de ter identificado dois preditores de TEPT – gênero e memórias afetivas – novos estudos longitudinais são necessários, a fim de conhecer em profundidade os fatores de risco e de proteção em relação ao TEPT.<br>The Intensive Care Unit (ICU) is a site responsible for saving lives, an environment filled with equipment, drugs, high technology and highly qualified technical staff. However, fears, fantasies of death, memories and feelings put the patient in front of a scenario that may leave marks or records mnemonic capable of generating significant psychological effects such as Post Traumatic Stress Disorder (PTSD), affecting the qual ity of life after hospital discharge. Therefore, the purpose of this study was to evaluate the prevalence of PTSD in patients who have ICU stay, raise some risk factors and protective factors for PTSD from record of memories brought by the patient six months after hospital discharge, and correlate PTSD symptoms, quality of life, with mnemonic memories, sociodemographic and clinical variables. Study participants were 41 adult patients who underwent ICU admission in a general hospital in Porto Alegre, mean age 59 years (SD=14,71).The instruments used were: Inventory Katz, Sheet with sociodemographic and clinical variables, Memory Tool, WHOQOL-brief e SPTSS. Descriptive analysis showed the prevalence of PTSD in this population of 24,4%, using a cutoff ≥ 5, women had more PTSD than men (X2=6,99, p<0,05). The t test showed that memories are more meaningful to patients respectively: faces (t=4,88, p<0,05), panic (t=11,17, p<0,001), fear (t=6,99, p<0,05) and pain (t=4,02, p<0,05). The affectionate memories were associated with significantly (t=-2,28, p<0,05) with PTSD and delusional memories correlated significantly to the time of admission (r=0,46, p<0,001). The chi square test showed that delirium clinical variable showed statistical significance relative to PTSD (X2=6,16, p<0,05), the other variables were not significant. The quality of life of patients suffered concussion after admission of the general point of view, presenting – was statistically significant in relation to PTSD in all its dimensions respectively, the hierarchical regression analysis showed that the variables gender and affectionate memories proved to be predictive of PTSD respectively (β=0,44, p<0,01) and (β=0,46, p<0,01). Conclusion: This study identified the prevalence of PTSD in patients six months after discharge and concluded that, despite having identified two predictors of PTSD – gender and affectionate memories – new longitudinal studies are needed in order to know in depth the risk factors and protection in relation to PTSD.

Este estudo transversal teve como objetivos: caracterizar os erros de medicação relatados por profissionais de enfermagem que atuam em UTI; comparar os dados sócio-demográficos, do trabalho e da qualidade de vida relacionada à saúde (QVRS) dos profissionais envolvidos e não envolvidos com erros de medicação em UTI; verificar se os domínios da QVRS são fatores independentes associados aos erros de medicação em UTI. Foram pesquisados 94 profissionais de enfermagem de três UTIs (duas de adultos e uma pediátrica) de um hospital privado do município de São Paulo, sendo 39 enfermeiros (41,5%) e 55 técnicos de enfermagem (58,5%). Os dados socio-demográficos, do trabalho e os relacionados aos erros de medicação foram registrados em instrumentos próprios. A QVRS foi avaliada com a versão em português do instrumento SF-36. Os profissionais foram comparados em dois grupos, segundo o relato de terem ou não cometido erros de medicação nas quatro semanas anteriores à pesquisa. Regressão logística univariada e múltipla foram utilizadas para análise da relação entre as variáveis. A maioria dos profissionais era do sexo feminino (79,8%), com idade média de 33 anos (dp=6,45), casada ou com companheiro (52,1%). A renda familiar per capita foi de R$ 2.024,95 (dp=1.625,00); 52,1% tinham apenas um vínculo empregatício. Entre os 18 profissionais que mencionaram ter cometido erro, seis eram enfermeiros e 12, técnicos de enfermagem. Houve notificação do erro em 61,1% dos casos. Os erros mais freqüentes foram os da fase de administração (67,8%). Entre os profissionais que cometeram erros, todos os escores do SF-36 foram significativamente menores. Na análise múltipla, o domínio Aspectos Emocionais e os turnos de trabalho da tarde e da noite mostraram associação significativa com erro de medicação, como fatores de proteção. Os resultados deste estudo trazem subsídios para a adoção de medidas institucionais especificamente direcionadas às necessidades dos profissionais de enfermagem, contribuindo, desta forma, para uma assistência mais segura aos pacientes<br>This cross-sectional study aimed to characterize the medication errors reported by the nursing professionals who work in ICU; to compare the socio-demographic data of the labor and the health-related quality of life (HRQL) of professionals involved and not involved with medication errors in ICU; and to check whether the domains of HRQL are independent factors associated with medication errors in ICUs. We studied 94 nursing professionals in three ICUs (two adult and one pediatric) in a private hospital in the city of Sao Paulo, with 39 nurses (41.5%) and 55 nursing technicians (58.5%). Socio-demographic data of the labor and the ones related to medication errors were recorded in separate instruments. The HRQL was assessed with the Portuguese version of the SF-36 instrument. The professionals were compared in two groups, according to the report of having committed or not medication errors in the four weeks preceding the survey. Univariable and multiple logistic regressions were used to analyze the relationship between the variables. Most practitioners were female (79.8%) with average age of 33 years (SD = 6.45), married or with partner (52.1%). The per capita income was R$ 2024.95 (SD = 1625.00), 52.1% had only one job. Among the 18 practitioners who reported having committed error, six were nurses and 12 were nursing technicians. There was notification of the error in 61.1% of the cases. The most frequent errors were the ones of the administration stage (67.8%). Among those who committed errors, all of the SF-36 scores were significantly lower. In multiple analysis, the domain Emotional Aspects and the work shifts of the afternoon and night showed significant association with medication errors as factors of protection. The results of this study provide subsidies for the adoption of institutional measures specifically targeted to the needs of nursing professionals, thus contributing to a safer care of patients

Comparisons of the incidence of blood stream infection (BSI) between neonatal intensive care units (NICUs) can promote sharing of potentially better practices for infection control. Comparisons should take into account differences in babies’ vulnerability and the invasive procedures which can introduce infection. I carried out a systematic review of methods reported in the literature, or used by regional monitoring systems, for comparing the incidence of BSI among NICUs. I found substantial variation, especially in the risk factors used to adjust incidence estimates. The use of routinely recorded administrative data would minimize and accelerate staff workload for BSI monitoring. I investigated which risk factors recorded in routine data should be adjusted for when comparing BSI incidence between NICUs. I linked microbiology laboratory records with administrative records collected over four years for three London NICUs. I analysed rates of BSI using various methods, including Poisson regression and logistic regression assuming a matched case control design. With both approaches, National Health Service level of care was the strongest predictor for BSI incidence. Using Poisson regression models, the rate ratio for BSI, adjusted for birth weight, inborn/outborn status and postnatal age, was 3.15 (95% confidence interval (CI) 2.01, 4.94) for intensive care and 6.58 (95% CI 4.18, 10.36) for high dependency care, relative to special care. The case control study gave slightly larger estimates of effect than the Poisson regression models. Total parenteral nutrition was significantly associated with BSI incidence but explained less of the variance among babies than level of care. Using the results from the risk adjustment model, I demonstrated how routine data can be integrated into a method for prospective, risk adjusted monitoring. This method involved standardised infection ratios and a sequential probability ratio test. The method can evaluate changes in BSI rates over time and between NICUs. It could also be used to quantify improvements following infection control interventions.

Today’s intensive care units monitor patients through the use of various medical devices, which generate a high ratio of false positive alarms due to a low alarm specificity. The false alarms have resulted in a stressful working environment for healthcare professionals that are getting more desensitized to triggered alarms and causing alarm fatigue. The patient safety is also compromised by having high noise levels in the patient room, which disturbs their sleep. This thesis has developed an intelligent alarm system with an improved alarm management and the use of 23 intelligent algorithms to minimize the number of false positive alarms. The suggested system is capable of improving the alarm situation and increasing the patient safety in critical care. The algorithms were modeled with fuzzy logics consisting of delays and multi parameter validation. The results were iteratively developed by having focus groups with various experts.

Background and aims Untreated stress-induced hyperglycaemia in critically ill patients has been associated with harmful effects, which can even be fatal. Current evidence about the optimal glycaemic targets, and the most effective and safest methods of glycaemic control (GC) in intensive care units (ICU), is contradictory. GlyCon study aimed to investigate the effectiveness, efficiency and safety of the monitoring and insulin treatment methods for GC implemented in the seven ICUs of an NHS ICU network in the UK. In addition, GlyCon study also aimed to explore the contents of the local protocols for GC of these ICUs, as well as the views of ICU professionals about several aspects of GC. Methodology A multi-method study was undertaken, comprising three sub‑studies: (1) a document review of the protocols for GC designed by and implemented at each of the participating ICUs, using techniques of inductive content analysis and descriptive statistics; (2) an online survey to ICU medical and nursing staff, on their opinion about effective GC, and deviations from protocol instructions, which was analysed using descriptive statistics and logistic regression; (3) A retrospective study about the methods and outcomes of GC, based on a review of electronic and manual medical records of a stratified random sample of 146 patients admitted to the seven participating ICUs during 2012 and 2013. The main analyses of association between the exposures and the primary outcome measure (percentage of time with glycaemic levels of 4‑10mmol/L, or TIR, which was transformed into the odds of being within that range at any time, or odds of IR), were mainly based on generalised estimating equations using the logit link, and autoregressive correlation structure. Secondary outcome measures of time‑efficiency and safety were also investigated, and analysed using univariate statistics and multiple log‑linear regression. Results The protocols for GC implemented in the seven ICUs differed greatly in their target patients, target glycaemic levels, recommended methods for monitoring, and insulin titration algorithms, among others. Most of the 40 respondents to the survey agreed that TIR≥75% constitutes good GC and TIR < 50% constitutes poor GC. Opinions were divided on intermediate levels of TIR, with professionals having more experience in intensive care tending to rate such intermediate TIR as poor GC more often than their less experienced colleagues. Most of the proposed protocol deviations were considered as major by at least two thirds of the respondents. Professionals’ role (nurse vs. physician) and their number of years of experience were significantly associated with different views. The blood glucose (BG) monitoring frequencies and insulin hourly dosages, at each glycaemic status, differed by ICU, and between patients with and without diabetes. Non‑adherence to protocol instructions regarding BG monitoring and insulin infusion rates occurred more often than not. The median (IQR) TIR was 91% (81‑96%) and 56% (34‑71%) among patients without and with diabetes, respectively. A number of time-dependent and time-constant factors were associated with higher odds of IR at any time. Time-constant protective factors included: having spent more than 20% of admission time receiving insulin during hyperglycaemia, certain ICU protocols, and lower levels of severity on admission. Time-dependent protective factors were: the number of hours from admission, and the dobutamine and insulin hourly dosages. Time-dependent detrimental factors were: non‑adherence to protocol insulin instructions, the hourly nutritional energy administered, and the hourly dosage of certain drugs, including adrenaline and hydrocortisone. Conclusions Protocols for GC, practice of GC, and outcomes of GC, all differed significantly across hospitals. Some protocols seemed more effective, time‑efficient or safe than others, but there was a high incidence of non‑adherence to protocol instructions in all ICUs. This contrasts with professionals rating deviations from protocols as major, more often than not. Certain monitoring and insulin treatment methods for GC were more effective, and some were more time‑efficient than others, particularly among patients without diabetes. There is a clear need for protocols to include different recommendations for patients with diabetes, as well as to formally emphasise the importance of GC also in patients without diabetes. ICU multidisciplinary teams should be involved in the development of these protocols, and their views should be accounted for in research studies about the effectiveness of GC in the ICU.

Thesis (S.M.)--Massachusetts Institute of Technology, Sloan School of Management, Operations Research Center, 2010.<br>Cataloged from PDF version of thesis.<br>Includes bibliographical references (p. 135-143).<br>Poor management of the patient flow in intensive care units (ICUs) causes service rejections and presents significant challenges from the standpoint of capacity planning and management in ICUs. This thesis reports on the development of a simulation framework to study admission control polices that aim to decrease the rejection rate in the ICU at Children's Hospital Boston (CHB), and to provide predictions for the future state of the ICU system. To understand the patient flow process, we extensively analyze the arrival and length of stay (LOS) data from the ICU census. The simulation model for the ICU is developed based on the results from this statistical analysis as well as the currently-practiced scheduling and admission policies of the ICU at CHB. The model is validated to provide accurate estimates for important performance metrics such as rejection rates in the ICU. The simulation model is used to study the performance of many admission control policies. The policies of our interest exploit "caps" to control the number of scheduled patients who are allowed to enter the ICU on a single day. In particular, we consider two cap-based policies: the uniform cap policy (UCP), which is the existing policy in CHB, and the service-specific cap policy (SSCP), which is originally proposed in this thesis. While the UCP implements caps on the total census of surgical patients, the SSCP utilizes the service-oriented heterogeneity of surgical patients' LOS and enforces caps on separate groups of surgical patients based on their average LOS. We show that the UCP can reduce the rejection rate in the ICU at the expense of extra waiting time of scheduled patients. The SSCP is shown to further decrease the rejection rate while increasing the waiting time compared to the UCP. We also demonstrate that the performance of both policies depends on the level of system utilization. In order to validate our results theoretically, a discrete-time queueing model for the ICU is developed and verified to provide estimates for performance measures that are consistent with the results from simulation. Finally, we introduce the notion of state-dependent prediction, which aims to identify the likelihood of the future state of the ICU conditional on the information of a current state. Several experiments are conducted by simulation to study the impact of a current state on a state in the future. According to our results, current state information can be useful in predicting the state of the ICU in the near future, but its impact gradually diminishes as the time difference between the present and future grows. Our major finding is that the probability of unit saturation at a certain future time can be determined almost entirely by the number of current patients who will leave the ICU after that time, regardless of the total number of patients who are currently staying in the unit. These results imply the potential development of adaptive cap-based policies that dynamically adjust caps according to the outcomes of state-dependent predictions.<br>by Wongsakorn Chaiwanon.<br>S.M.

Introduction - Maximising efficient and effective use of resources without compromising quality of care is essential in the current healthcare climate. Intensive care unit services are one of the most resource intensive and therefore expensive services within a hospital. Because intensive care unit services comprise a significant portion of hospital costs and resources, appropriate utilisation of intensive care units is imperative. The occurrence of delayed discharges and the reason for the delays is important as they impact on the efficiency and effectiveness of intensive care unit services. Patients who no longer need intensive care unit care block beds for impending admissions, unnecessarily utilise the costly and often scarce resources and by remaining in a stressful environment may experience negative psychological and social effects detrimental to their well being. Study objectives - To determine to what extent delayed discharge from the intensive care unit occurs and ascertain the reasons for these delays. Design - A prospective cross sectional design to determine the number of delayed discharges from the intensive care unit and reasons causing the delay. A discharge was considered to be delayed if the patient was not discharged from the intensive care unit within 8 hours of being deemed suitable for discharge by intensive care unit medical staff. Setting - A level III intensive care unit with 22 beds (12 general and 10 surgical beds in 2 adjacent areas) in a metropolitan tertiary teaching hospital of 955 beds located across two campuses. Sample - A prospective convenience sample of consecutive patients admitted over a 6-month period from September 2000 to March 2001. Exclusions were patients who died whilst in the intensive care unit and those patients who could be discharged prior to commencement of the study. Method. - Intensive care unit medical staff informed nursing shift coordinators when patients could be discharged. The nursing shift coordinators completed the data collection tool on all patients discharged from intensive care unit. Admission and discharge times and APACHE-11 data (a predictive scoring system for ICU patient outcome) were recorded from intensive care unit records. Results - There were 652 discharges, 468 patients were not delayed (71.8%), 176 were delayed (27.0%, 95% CI 23,9%-30.7%) and 8 (1.2%) patients had no delay information available. There were substantial delays in discharging patients from the intensive care unit; for every 5 discharges that were not delayed, 2 patients would be delayed. Unavailable ward beds (81 %) were cited as the main reason for delay in discharge. Delay time from the intensive care unit ranged from 0.2 hours (1 0 minutes) to 617.5 hours (3 weeks, 4 days, 17.5 hours). Mean delay time was 42 hours (I day, 18 hours) and median delay time 21.3 hours. There was a statistical significance difference between-non delayed and delayed patients for APACHE II score on admission (Ɩ = -3.824 {642), p <0.0001) and worst APACHE 11 score in first 24 hours e (Ɩ = -5.123 (642), p <0.0001 ). There was also a statistically significant difference between delay from the intensive care unit and non delayed discharge by admitting diagnosis (Chi sq (12) = 43.235, p < 0.0001); primary organ system failure (chi sq (6) = 14.231, p = 0.027); ward destination (chi sq (7) = -51.486, p < 0.0001 ); specialty (chi sq (23) = -43.371, p = 0.006) and day of eligible discharge (chi sq (6) = 34.008; p < 0.0001 ). Conclusion - Discharge from the intensive care unit is delayed on average by 27% in the study hospital. These delays can be related to how sick the patient was, principle admitting diagnosis, discharge destination and weekend discharge. Reducing these delays would free up beds for other admissions, may result in a cost saving for the health care facility through more efficient resource utilisation and ultimately benefit patients by better managing the discharge process.