Impact of telemedicine in hospital culture and its consequences on quality of care and safety.

OBJECTIVE: To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice. METHODS: The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein. RESULTS: Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis. CONCLUSION: The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.

Impact of telemedicine in hospital culture and its consequences on quality of care and safety / Impacto da telemedicina na cultura hospitalar e suas consequências na qualidade e segurança do cuidado

ABSTRACT Objective To describe the impact of the telemedicine application on the clinical process of care and its different effects on hospital culture and healthcare practice. Methods The concept of telemedicine through real time audio-visual coverage was implemented at two different hospitals in São Paulo: a secondary and public hospital, Hospital Municipal Dr. Moysés Deutsch, and a tertiary and private hospital, Hospital Israelita Albert Einstein. Results Data were obtained from 257 teleconsultations records over a 12-month period and were compared to a similar period before telemedicine implementation. For 18 patients (7.1%) telemedicine consultation influenced in diagnosis conclusion, and for 239 patients (92.9%), the consultation contributed to clinical management. After telemedicine implementation, stroke thrombolysis protocol was applied in 11% of ischemic stroke patients. Telemedicine approach reduced the need to transfer the patient to another hospital in 25.9% regarding neurological evaluation. Sepsis protocol were adopted and lead to a 30.4% reduction mortality regarding severe sepsis. Conclusion The application is associated with differences in the use of health services: emergency transfers, mortality, implementation of protocols and patient management decisions, especially regarding thrombolysis. These results highlight the role of telemedicine as a vector for transformation of hospital culture impacting on the safety and quality of care.

RESUMO Objetivo Analisar o impacto da aplicação de telemedicina no processo clínico de cuidado e seus diferentes efeitos sobre a cultura hospitalar e na prática assistencial. Métodos O conceito de telemedicina, por meio de uma cobertura integral em tempo real, foi implementada em dois hospitais diferentes em São Paulo, um secundário e público, o Hospital Municipal Dr. Moysés Deutsch, e um terciário e privado, o Hospital Israelita Albert Einstein. Resultados Os dados foram obtidos a partir de 257 teleconsultas registradas ao longo de um período de 12 meses e comparados a igual período antes da implementação. Em 18 pacientes (7,1%), a telemedicina influenciou no diagnóstico e, para 239 pacientes (92,9%), a consulta contribuiu para o manejo clínico. Após a implementação da telemedicina, o protocolo de trombólise para acidente vascular cerebral foi aplicado em 11% dos pacientes com acidente vascular cerebral. A introdução da telemedicina reduziu a necessidade de transferir pacientes para avaliação neurológica externa em 25,9%. O protocolo de sepse foi adotado, sendo observada redução da mortalidade em 30,4% nos casos de sepse grave. Conclusão A aplicação da telemedicina está associada com diferenças na utilização dos serviços de saúde: transferências, mortalidade, implementação de protocolos e apoio à decisão médica, especialmente em relação à trombólise. Estes resultados destacam o papel da telemedicina como um vetor de transformação da cultura hospitalar e seu impacto sobre a segurança e na qualidade assistencial.

Stroke epidemiology, patterns of management, and outcomes in Fortaleza, Brazil: a hospital-based multicenter prospective study.

BACKGROUND AND PURPOSE: Little information exists on the epidemiology and patterns of treatment of patients admitted to Brazilian hospitals with stroke. Our objective was to describe the frequency of risk factors, patterns of management, and outcome of patients admitted with stroke in Fortaleza, the fifth largest city in Brazil. METHODS: Data were prospectively collected from consecutive patients admitted to 19 hospitals in Fortaleza with a diagnosis of stroke or transient ischemic attack from June 2009 to October 2010. RESULTS: We evaluated 2407 consecutive patients (mean age, 67.7±14.4 years; 51.8% females). Ischemic stroke was the most frequent subtype (72.9%) followed by intraparenchymal hemorrhage (15.2%), subarachnoid hemorrhage (6.0%), transient ischemic attack (3%), and undetermined stroke (2.9%). The median time from symptoms onset to hospital admission was 12.9 (3.8-32.5) hours. Hypertension was the most common risk factor. Only 1.1% of the patients with ischemic stroke received thrombolysis. The median time from hospital admission to neuroimaging was 3.4 (1.2-26.5) hours. In-hospital mortality was 20.9% and the frequency of modified Rankin Scale score≤2 at discharge was less than 30%. Older age, prestroke disability, and having a depressed level of consciousness at admission were independent predictors of poor outcome; conversely, male gender was a predictor of good outcome. CONCLUSIONS: The prevalence of stroke risk factors and clinical presentation in our cohort were similar to previous series. Treatment with thrombolysis and functional independency after a stroke admission were infrequent. We also found long delays in hospital admission and in evaluation with neuroimaging and high in-hospital mortality.

Social project and infant mortality: the Paraisópolis case / Projeto social e mortalidade infantil: o caso Paraisópolis

Objective: To evaluate the impact of the Einstein Program in the Paraisópolis Community, using the infant mortality rate as an indicator that synthesizes and expresses the quality of life in the community. Methods: The study was carried out at Paraisópolis neighborhood, in Vila Andrade District, Campo Limpo Borough in the city of São Paulo. To compare infant mortality rate in Paraisópolis Community with other selected districts of the city of São Paulo, data from the Municipal Health Secretariat of São Paulo, from 2000 to 2007, were used; other social data were compared with those of selected districts of São Paulo according to social indicators gathered by the Sistema Estadual de Análise de Dados (SEADE). Results: From 2000 to 2007, the infant mortality rate of Vila Andrade district, decreased from 18.1 deaths per 1,000 live births to 8.2/1,000 live births while in the city of São Paulo, it decreased from 15.8/1,000 to 12,2/1,000 live births. The district ranking in infant mortality rate dropped from 77 to 22. During the study period, healthcare services provided were improved in Campo Limpo by 74%, for outpatients procedures, and 71% for first outpatient visits. Conclusions: The observed reduction in the infant mortality rate in the Andrade District was definitely an exception and other variables, different from those common to the city, might have influenced the results. The hypothesis that more effective medical services and an increase in that population income could have boosted such result is tangible, and part of this achievement can be attributed to Hospital Israelita Albert Einstein social project.

Objetivo: Avaliar o impacto do Programa Einstein na Comunidade Paraisópolis por meio da evolução do coeficiente de mortalidade infantil como indicador sintetizador da qualidade de vida de uma comunidade. Métodos: O estudo foi realizado na Comunidade de Paraisópolis, localizada no distrito de Vila Andrade, da subprefeitura de Campo Limpo do Município de São Paulo. Para comparação dos dados do coeficiente de mortalidade infantil da Comunidade de Paraisópolis com os de outros distritos selecionados do Município de São Paulo, foi utilizado como fonte os dados de mortalidade infantil do Município no período de 2000 a 2007. Os dados da Comunidade de Paraisópolis foram ainda cruzados com os de outros distritos selecionados por meio de indicadores sociais, obtidos pelo Sistema Estadual de Análise de Dados (SEADE). Resultados: No período de 2000 a 2007, o coeficiente de mortalidade infantil de Vila Andrade passou de 18,1 mortes por 1.000 nascidos vivos para 8,2/1.000 nativivos, enquanto que para o município passou de 15,8/1.000 para 12,2/1.000 nativivos. No ranking do coeficiente de mortalidade infantil, Vila Andrade evoluiu do 77º para o 22º lugar. Verificou-se ainda, no período do estudo, uma expansão de oferta de serviços de saúde no Campo Limpo, da ordem de 74% para procedimentos ambulatoriais e 71% para concentração de consultas de primeira vez. Conclusões: A evolução do coeficiente de mortalidade infantil da Vila Andrade é positivamente uma exceção e os fatores não comuns ao conjunto do município podem ter influenciado para o acontecimento. A hipótese de que a maior efetividade dos serviços médicos, e que uma variação positiva na renda naquela comunidade tenha impulsionado tal resultado, é factível, permitindo creditar ao projeto social do Hospital Israelita Albert Einstein uma parcela dessa conquista.

[High expenditure on a private healthcare plan: for whom and in what]. / Gastos elevados em plano privado de saúde: com quem e em quê

OBJECTIVE: To assess expenditures and the profile of beneficiaries of a private health plan and the impact of these expenditures on the finances of both the plan and of beneficiaries. METHODS: Descriptive study including 64,219 customers of a health insurance plan of the State of São Paulo in the year of 2003. The characteristics of high spenders were assessed according to age group, gender, type of expenditure, and related diseases. RESULTS: Among all customers, 642 beneficiaries (1%) were the highest spender in the year, accounting for 36% of the total. Among these beneficiaries, 45% were elderly, over 60 years old. Greatest expenditure was with medical supplies and drugs. Circulatory diseases, cancer, musculoskeletal diseases, respiratory tract diseases and the external causes were most frequently associated with these expenditures. CONCLUSIONS: Age is an important factor associated with high expenditures, being closely connected with chronic degenerative diseases. Thus, ageing of the population points out to the need for strategic changes in the management of private health care plans.

Gastos elevados em plano privado de saúde: com quem e em quê / High expenditure on a private healthcare plan: for whom and in what

OBJETIVO: Analisar os gastos e o perfil de beneficiários de um plano de saúde privado e o impacto desses gastos nas finanças do plano e dos beneficiários. MÉTODOS: Estudo descritivo, incluindo 64.219 clientes de um plano de saúde que opera no Estado de São Paulo, no ano de 2003. Foram analisadas as características dos clientes de gastos elevados segundo a distribuição etária, por sexo, natureza dos gastos e doenças relacionadas. RESULTADOS: Dentre todos os clientes, 642 beneficiários (1 por cento) produziram os maiores gastos no ano, responsáveis por 36 por cento do total. Dentre esses beneficiários, 45 por cento eram idosos acima de 60 anos. O maior gasto foi com material e medicamento. As doenças do aparelho circulatório, neoplasias malignas, do sistema osteomuscular, do aparelho respiratório e as causas externas foram as mais freqüentemente relacionadas a esses gastos. CONCLUSÕES: A idade é um importante fator associado aos gastos elevados, tendo estreita relação com as doenças crônico-degenerativas. Assim, o envelhecimento da população aponta a necessidade de mudanças estratégicas na gestão dos planos de saúde privados.

OBJECTIVE: To assess expenditures and the profile of beneficiaries of a private health plan and the impact of these expenditures on the finances of both the plan and of beneficiaries. METHODS: Descriptive study including 64,219 costumers of a health insurance plan of the State of São Paulo in the year of 2003. The characteristics of high spenders were assessed according to age group, gender, type of expenditure, and related diseases. RESULTS: Among all customers, 642 beneficiaries (1 percent) were the highest spender in the year, accounting for 36 percent of the total. Among these beneficiaries, 45 percent were elderly, over 60 years old. Greatest expenditure was with medical supplies and drugs. Circulatory diseases, cancer, musculoskeletal diseases, respiratory tract diseases and the external causes were most frequently associated with these expenditures. CONCLUSIONS: Age is an important factor associated with high expenditures, being closely connected with chronic degenerative diseases. Thus, ageing of the population points out to the need for strategic changes in the management of private health care plans.

Informaçöes hospitalares: relatório do grupo de trabalho / Hospital records: work group report

O relatório versa sobre a necessidade de se estudar a utilizaçäo das informaçöes hospitalares e de propor mudanças no sistema de coleta de dados. Apresenta como proposta, um novo Boletim que engloba os dados contidos nos boletins 101 e 102 da Coordenadoria de Assistência Hospitalar, com inclusäo de cada variável, de uma proposta de análise dos dados e de um manual de orientaçäo e de instruçäo para o preenchimento, a ser distribuido a cada hospital