Circuito del paciente fallecido en el Hospital Garrahan: Implementación de Gestión por procesos y plan de mejora integral / Circuit of the deceased patient at Garrahan Hospital: implementation of process management and a comprensive plan for improvement

Ante circunstancias que concluyen en el fallecimiento de los pacientes, el Hospital Garrahan (HG) debe facilitar el duelo con medidas adecuadas y apropiadas en un contexto de respeto y contención, acompañando preguntas, dudas e incertidumbres familiares, respetando valores, evitando dificultades administrativas y legales. El objetivo fue trabajar sobre el proceso del paciente fallecido para ordenar la normativa histórica, reglamentarla y documentarla agregando avances tecnológicos. Se estableció un circuito que llamamos circuito del paciente fallecido (CPF). Es un proceso que comienza en la inscripción de la defunción, traslado del paciente a la morgue hasta la entrega a la familia. Involucra al hospital de forma transversal. A través del trabajo interdisciplinario, aplicando conceptos y herramientas de gestión, se trabajó un plan de mejora en la gestión del CPF, partiendo de la disposi- ción hospitalaria vigente, adecuando el Protocolo respectivo del Ministerio de Salud del Gobierno de la Ciudad de Buenos Aires, estableciendo registros adecuados en todo el circuito. El diseño metodológico propuesto fue la planificación, desarrollo implementación de un plan de mejora en el CPF de acuerdo a gestión por procesos. Se desarrollaron las siguientes etapas: análisis de la situación de salud que generó la intervención, identificación del proceso en un mapa, identificación de problemas del CPF, revisión y análisis del proceso e implementación del plan de mejora. Este plan de mejora está sustentado en la Disposición N°238/ DME/17

When a patient dies in hospital, Garrahan Hospital should facilitate the process of mourning with adequate and appropriate measures in a context of respect and contention, providing support in case of questions, doubts, and uncertainties of the family, respecting values and avoiding administrative and legal difficulties. The aim of this project was to improve the processes related to the deceased patients organizing historical norms by establishing guidelines and documentation using new technological means. A circuit called circuit of the deceased patient (CDP) was established, consisting of a process that starts at the moment of the registration of death, followed by the transfer of the patient to the morgue, and finishing with the handing over to the family. The process involves the hospital transversally. In an interdisciplinary manner and using different management concepts and tools, a plan of improvement of the management of the CDP was developed, based on the current regulations of the hospital, adapting the protocol of the Ministry of Health of the Government of the City of Buenos Aires, establishing adequate records for the entire circuit. The proposed methodological design consisted of the planning, development, and implementation of a plan for the improvement of the CDP according to process management. The following stages were developed: analysis of the situation that led to the intervention, identification of the process on a map, identification of difficulties in the CDP, process revision and analysis and implementation of the improvement plan. The improvement plan is supported by Disposition N°238/DME/17

Lich-Gregoir technique and routine use of double J catheter as the best combination to avoid urinary complications in kidney transplantation.

INTRODUCTION: Urinary complications in kidney transplantation cause patient morbidity and can decrease graft survival. Most of the complications stem from the vesicoureteric anastomosis. Different techniques for ureteroneocystostomy (UNC) have been designed to avoid these complications. The routine use of a double J catheter after the anastomosis has the same purpose. Our aim was to show our experience and compare the use or non-use of a double J catheter and different techniques for ureteric reimplantation with the rate of urologic complications. MATERIAL AND METHODS: We conducted a retrospective, nonrandomized study of 1011 renal transplantations performed between July 1985 and April 2012. We recorded the surgical techniques for UNC, the use or non-use of a double J catheter, and urinary complications (ureteric fistulae and strictures). The first 700 kidney transplantations (group A) were performed using several UNC techniques (Taguchi, Leadbetter-Politano, and Lich-Gregoir) with a selective use of double J catheter according to the criteria of the surgeon. In the last 311 patients (group B), a surgical technique was established (Lich-Gregoir), as well as the universal use of double J catheters. RESULTS: Urinary fistula occurred in 7% of group A patients and 2% of group B patients (P = .0001). Ureteric stricture occurred in 5.3% of patients in group A and 3% of group B patients (P = .09). In our study, routine prophylactic stenting combined with the Lich-Gregoir UNC technique has decreased the incidence of postoperative fistulae. CONCLUSIONS: Individually, the use of double J catheters seems to lessen the incidence of fistulae, although statistically, the difference is not significant. Accurate knowledge of the complications rates, recommendations of guidelines, and the early diagnosis are essential to attaining reasonable results in kidney transplantation.

[Morbidity and risk factors of transrectal prostate biopsy]. / Morbilidad y factores de riesgo de la biopsia transrectal prostática.

OBJECTIVES: To evaluate the incidence of minor complications that rarely need treatment (haematuria, hematospermia and rectal bleeding) and major complications (fever and shock) in patients undergoing transrectal biopsy of the prostate and to identify risk factors. PATIENTS AND METHODS: We present an analytic and prospective study where we evaluated 146 patients subjected to transrectal biopsy of the prostate from December 2007 to September 2008. Complications rates and variables were analyzed. RESULTS: Eight patients (5,5%) suffered fever and seven (4,8%) of them were admitted. One of the patients (0,7%) suffered shock. The median of time between biopsy and fever was 3.5 days (1-10 days). Haematuria and hematospermia were more frequent in patients younger than 65 years (p<0.05) and fever and sepsis were more frequent in patients with prostate volume smaller than 55mL (p<0.05). CONCLUSIONS: The complications of the transrectal biopsy of the prostate are frequent, autolimited and they rarely suppose a health hazard for the patients. The most frequent are haematuria and hemospermia, specially in younger patients, whereas infectious complications are rarer and in our study are more frequent in patients with smaller prostates. We must take into account that the information to the patient is very important after a prostate biopsy, so we can avoid useless consultations (for example with haematuria) and it will enable to identify important signs like fever earlier.

[Hand-assisted laparoscopic nephrectomy in challenging cases]. / Nefrectomía laparoscópica asistida por la mano en casos difíciles.

OBJECTIVE: To assess the outcome of hand-assisted laparoscopic nephrectomy in patients with significant complicating clinical factors. METHODS: A retrospective assessment was made of 100 laparoscopic nephrectomies performed at a single hospital from 2001 to 2005. Patients with a history of prior abdominal surgery, prior procedures on the involved kidney, evidence of perirenal inflammation, renal lesions 10 cm or more in diameter, or level I renal vein thrombosis were enrolled. RESULTS: Twelve patients were enrolled. Of these, 5 had a lesion at least 10 cm in diameter, 2 had renal vein thrombosis, and 5 reported major abdominal surgery. Most patients had more than one of these findings. Three patients showed inflammatory conditions (staghorn calculi) and a T4 renal tumor was successfully treated without conversion to open surgery. Mean operating time and blood loss were 210 minutes and 310 ml respectively, while mean length of hospital stay was 3 days. No patient required conversion to open surgery. CONCLUSIONS: Hand-assisted laparoscopic nephrectomy is an attractive minimally invasive option for technically challenging tumors and has reasonable operating times, blood losses, and complication rates.

[Does cystocele have a role in bladder outlet obstruction]. / ¿Es realmente el cistocele un factor de obstrucción infravesical?

INTRODUCTION: Controversy exists as to whether cystocele has a causative role in bladder outlet obstruction (BOO). OBJECTIVE: To assess the relationship between cystocele and bladder outlet obstruction. MATERIALS AND METHODS: Two hundred women undergoing a urodynamic study from December 2007 to December 2008 were retrospectively assessed. Patients were divided into two groups: Group A: Patients with no cystocele (Grade 0) and Grade I cystocele Group B: Patients with Grade II-IV cystocele. EXCLUSION CRITERIA: 1. Absence of flowmetry or voided volume < 150 ml. 2. Neurological disorders. 3. History of urogenital surgery. Bladder outlet obstruction was defined as follows: Postvoid residue (PVR) > 20%; peak flow (Qmax) < 15 ml/sec; detrusor pressure at maximum flow (PdetQmax) > 25 cm H2O. RESULTS: Group A included 64% of patients, and Group B the remaining 36%. A pathological PVR > 20% was found in 26.6% and 40.3% of patients in Group A and Group B respectively (p=0.04). A Qmax < 15 mL/sec was seen in 15.6% and 27.8% of Group A and Group B patients respectively (p=0.03). A PdetQmax > 25 cm H2O was found in 26.3% and 47.8% of Group A and Group B patients respectively (p=0.01). CONCLUSIONS: A statistically significant association exists between cystocele and bladder outlet obstruction.

[Clinical efficacy of prostatic biopsy. Experience in our center from 1990 to 2002]. / Eficacia clínica de la biopsia prostática. Experiencia en nuestro centro 1990-2002.

INTRODUCTION: The prostate biopsy is the only valid tool to diagnose the existence of cancer of prostate. The indications of the biopsy, according with EAU, are the existence of high PSA, increased velocity PSA and a rectal suspicious tact. OBJECTIVES: validation of the utility of the prostate biopsy, to know the value of the PSA as a marker of prostate cancer in our way and to value the indication and efficiency of repeated biopsies. MATERIAL AND METHODS: we practice a manual review of the biopsies in our hospital, between the years 1990 and 2002. We study the level of PSA before the biopsy, number of prostatic cores and histologic information of the biopsy. A statistical descriptive and inferencial study has been performed by SPSS 12.0 package. RESULTS: The total number of biopsies registered was a 1202, with 36.96% of biopsy positive. The PSA before the biopsy (available in the biopsies realized between the year 1999 and 2002: 578 biopsies, 48.08% of the whole) was > 10 ng/ml in 55,88% of these patients, 4-10 ng/ml in 39.27% and 0-4 ng/ml in 4.84%. The average and PSA's median is of 19.09 (standard error: 1.87) and 10.6, respectively. The positividad of the biopsy increases with PSA's level: 48,61% with PSA > 10; 25.11% with PSA 4-10 and 21,4% in patients with PSA < 4. There was realized prostate rebiopsy (2 or more biopsies) in 132 patients (21.97% positive) 88,36% of the cancers was diagnosed in the first biopsy, and 6.62% in the second one (94,98% of the diagnoses of cancer of prostate carried out with the first 2 biopsies). CONCLUSIONS: The information obtained in the study by means of the descriptive analysis of our series meets in conformity the published in other studies and publications. There exists a need to increase the diagnostic profitability of the biopsy of prostate, for which we have introduced a protocol of biopsy under local anesthesia in order to be able to increase the number of obtained cylinders.

[Kidney lipomatosis in a transplantation donor]. / Lipomatosis renal en donante cadáver.

OBJECTIVES: The aim of this clinical note is to report one case of incidental superficial renal mass during an organ explantation. METHODS: The renal donor was a 56-years-old male patient death for subaracnoidea haemorrhage without urological history. RESULTS: The anatomopathologic intraoperative study of the renal masses informed about the fatty nature of the tissue, and the renal implantation was performed. CONCLUSIONS: The find of a superficial renal mass during an organ explantatiation determine the necessity of a preoperative biopsy.

[Testicular and paratesticular prepuberal tumors: our experience and update on the topic]. / Tumores testiculares y paratesticulares prepuberales. Experiencia en nuestro centro y revisión de la literatura.

OBJECTIVES: To evaluate the importance of testicular and paratesticular prepubertal tumors in our center and to make an update on the topic. METHODS AND PATIENTS: Data from all patients diagnosed of testicular and paratesticular prepubertal tumors and treated in our pediatric oncology unit from January 1st 1998 to December 31st 2003 have been revised. RESULTS: Seven cases are reported among one hundred and ninety patients (represents 3,68 percent of all treated tumors): five tumors affecting the testis and two cases of paratesticular tumors. Pathology classification was as follows: one yolk sack tumor, one mature teratoma, two nongerminomatous testicular tumors (one Sertoli cell tumor and one unclassifiable), one Burkitt's lymphoma and two paratesticular rhabdomyosarcomas. Primary approach was inguinal radical orchiectomy in all cases except neoadjuvant chemotherapy in the case of lymphoma and partial escrotectomy in one patient previously managed with transcrotal orchiectomy. Rhabdomyosarcoma cases received adjuvant chemotherapy. All patients are alive and well after a follow-up period ranging from 17 to 74 months. CONCLUSIONS: Testicular and paratesticular prepubertal tumors are rare. Except for one patient affected of lymphoma, surgical primary approach have been essential for treatment. The prognoses in this series has been excellent.

[Non obstructive retrocaval ureter]. / Uréter circumcavo no obstructivo.

We report a case on circumcavum ureter without obstruction or type two, according the Batenson and Atkinson's classification, in a forty-nine year old man. It was diagnosticated for a gross haematuria and renoureteral pain, because of a simultaneous urinary tract infection. We emphasize its absence of the typical morphology and obstruction signs. After twelve months the patient is still asymptomatic, without any medical or surgical treatment.

La autopsia clínica: las posibles causas de su declinación y una propuesta multidisciplinaria / Clinical autopsy: possible causes of its declining request and a multidisciplinary proposal

La autopsia constituye el sólido cimiento cientifico dejado durante siglos y es uno de los instrumentos de investigación en que se ha basado la medicina moderna. El objetivo de este trabajo fue analizar las causas de la caída de la tasa de autopsia en el Hospital Garrahan, el grado de concordancia con los diagnósticos clínicos y la opinión del grupo médico acerca de su utilidad. Material y Método: revisamos 120 autopsias completas y consecutivas efectudas en un período de 6 años (1995-2001). Establecimos la tasa de autopsia y la comparamos con las cifras facilitadas por dos Hospitales Pediátricos de Referencia. Mediante una encuesta formulamos 7 preguntas a los médicos del Hospital: 1. ¿Cúal es el % de autopsia óptimo para este Hospital? 2.¿Quién debe solicitar la autopsia? 3.¿La considera un monitor válido de calidad? 4.¿La considera como un instrumento docente y de acreditación hospitalaria? 5. ¿Qué causas relacionadas con aspectos familiares o culturales de negación considera? 6. ¿Qué causas médicas de negación considera? 7. Condición del encuestado. Resultados: La tasa de autopsia disminuyó de un 31,20% en 1988 a un 13.65% en el 2001. La concordancia clinico patológica fue completa en el 70%. Entre las causas principales de muerte predominaron las infecciosas (57.14%) y las malformaciones cardíacas (21%). Contestaron la encuesta 39/50 profesionales (78%) 24 fueron médicos principales. El equipo médico consideró una tasa óptima de autopsia del 70% para este hospital. el 76% opinó que debía ser solicitada por el médico de cabecera. El 60% consideró la solicitud como una situación desagradable y el 34% juzgo no estar familiarizado con la metodología de la solicitud. Discusión y conclusiones: La tasa declinante de autopsias en nuestro hospital es concordante con lo ocurrido en los dos hospitales pediátricos referidos. Las causas de su disminución en general han sido más causa médica que por la negativa de los familiares.

Oat-cell carcinoma of the prostate. Diagnosis, prognosis and therapeutic implications.

BACKGROUND: Any carcinoma of prostatic origin which is not an acinary adenocarcinoma of the prostate is considered to be an atypical carcinoma. One member of this group of atypical prostatic tumors is the oat-cell carcinoma, or small cell carcinoma (SCC) of the prostate. This variety of carcinoma constitutes the histologic basis of <1% of all prostatic neoplasms. METHODS: Between 1992 and 1997, four patients were diagnosed with SCC of the prostate at our hospital. In 3 of the 4 cases, the histopathological diagnosis was pure SCC, and in the 4th case there was a component of prostatic adenocarcinoma associated with the SCC. At the time of diagnosis, extracapsular extension of the tumor was present in all 4 cases, with T3 or higher stages in all of them (T(3A)N(0)M(1), T(3A)N(0)M(0), T(3B)N(0)M(1), and T(4)N(0)M(0)). Because of the presence of extracapsular extension, radiotherapy and radical surgery were ruled out for all 4 patients. They were all offered systemic chemotherapy with cyclophosphamide (1 g/m(2)), doxorubicin (50 mg/m(2)) and vincristine (1.2 mg/m(2)). This therapeutic protocol was carried out in only 2 cases. RESULTS: Survival was <1 year in the 3 patients with pure SCC, and the patient with a mixed tumor is alive with detectable disease 9 months after diagnosis. CONCLUSIONS: This poor vital prognosis in SCC stresses the need for early diagnosis a timely and appropriate therapeutic intervention in this condition.

[Abscess of seminal vesicle: conservative treatment]. / Absceso de vesícula seminal: tratamiento conservador.

OBJECTIVE: To describe a case of primary seminal vesicle abscess that was managed conservatively. METHODS: Antibiotics, according to the urine culture and antibiotic profile, were administered for four weeks. Outpatient follow-up was carried out with digital rectal examination, urine culture and ultrasound. RESULTS: A favorable clinical response was observed at day three. The patient was discharged from hospital on day 7. DRE, urine culture and ultrasound findings were normal after 4 weeks. CONCLUSIONS: Primary abscess of the seminal vesicle can be successfully treated with antibiotics. Percutaneous drainage of the abscess should be reserved for those cases that do not respond to conservative management with antibiotics.

[Can PSA density predict the response to alpha-blockers in benign prostatic hyperplasia?]. / Puede la densidad de PSA predecir la respuesta a los alfa-bloqueantes en la hiperplasia benigna de próstata?

INTRODUCTION AND OBJECTIVES: In BPH there is a growth of both glandular and stromal components. Most of adrenoceptors sites are in the fibromuscular stroma. So the higher is the stromal/epithelial ratio, the more effective will alpha-blockers be. There in an indirect way of stimating this ratio without performing a biopsy. Bearing in mind that PSA is produced by the prostatic epithelium, the lower PSA density (PSAd), the higher the stromal/epithelial ratio and the higher alpha-blocker activity. We pretend to study if PSAd is useful for predicting the response to alpha-blockers in BPH. MATERIAL AND METHODS: We studied 75 patients suffering from prostatism and diagnosed of bladder outlet obstruction secondary to BPH through IPSS symptom score, digital rectal examination, PSA, uroflowmetry, and transrectal ultrasound. All of them received Alfuzosin, 5 mg twice daily during 3 months, and then were evaluated again with IPSS and uroflowmetry. RESULTS: A statistically significant improvement was appreciated of the two studied parameters and in both groups of patient with regard to the pretreatment situation. A statistically significant better answer was also appreciated in the group of patient with smaller PSAd in comparison with the higher PSAd patients. CONCLUSIONS: Our results show that PDAd is usefu to estimate the stroma/epithelium ratio, and therefore the clinical response to alpha-blockers.

[Brucellar orchiepididymitis]. / Orquiepididimitis brucelosa.

The brucellosis is an unusual entity whose incidence has diminished due to the improvement in preventive measures. We have carried out a retrospective study of all the patients admitted in our service between 1996 and 1998, with diagnosis of orchitis. Two of the 31 patients admitted for this reason presented a final diagnosis of brucellar orchiepididymitis. Both patients presented clinic of affectation from the general state accompanied by resistance to habitual antibiotic treatment. The patient's epidemic antecedents, accompanied by the suitable clinical evolution took to the suspicion of orchiepididymitis of brucellar etiology, with change in the antibiotic rule. The diagnosis of the process was obtained by means of serologic tests and blood cultures.

[Malignant melanoma of the penis]. / Melanoma maligno de pene.

OBJECTIVE: To report a case of malignant melanoma of the penis, a rare malignant neoplasm whose aggressive behaviour carries a poor prognosis. METHODS: A 58-year-old male consulted for a pigmented elevated lesion in the balanopreputial sulcus. The biopsy was positive for melanoma. Complementary studies did not demonstrate disseminated disease. RESULTS: Partial resection of the penis and bilateral inguinal lymphadenectomy were performed. Histological analysis showed two positive nodes in the same lymphatic chain. Interferon was administered for 6 months. The patient remains disease-free at 35 months' follow-up. CONCLUSIONS: Although surgery is the treatment of choice, adjuvant therapy (chemotherapy and immunotherapy) should be considered in those patients without localized disease.