Characterization of cardiac arrest in the emergency department of a Brazilian University Reference Hospital: A prospective study.

BACKGROUND & OBJECTIVES: Sudden cardiac arrest (CA) represents one of the greatest challenges for medicine due to the vast number of cases and its social and economic impact. Despite advances in cardiopulmonary resuscitation (CPR) techniques, mortality rates have not significantly decreased over decades. This study was undertaken to characterize patients that have suffered CA and to identify factors related to mortality. METHODS: This prospective study was conducted at Emergency Department of São Paulo Hospital, Brazil. Two hundred and eighty five patients were followed for one year after treatment for CA. The mean age was 66.3±17.2 yr, and they were predominantly male (55.8%) and Caucasian (71.9%). Mortality rate and factors associated with mortality were the primary and secondary outcome measures. Data were collected using an in-hospital Utstein-style report. A logistic regression analysis was used to determine which variables were related to mortality. RESULTS: Regarding the characteristics of CPR, 76.5 per cent occurred in hospital, respiratory failure was the most common presumed immediate cause of CA (30.8%) and pulseless electrical activity was the most frequent initial rhythm (58.7%). All attempts at CPR utilized chest compressions and ventilation and the most utilized interventions were epinephrine (97.2%) and intubation (68.5%). Of all patients treated, 95.4 per cent died. Patients with pulseless electrical activity had a higher risk of death than those patients with ventricular fibrillation. INTERPRETATION & CONCLUSIONS: The findings of the study highlighted that the mortality rate among CA patients was high. The variable that best explained mortality was the initial CA rhythm.

Nursing workload and severity of COVID-19 patients in the Intensive Care Unit.

OBJECTIVE: To evaluate the workload and severity of patients in the Intensive Care Unit (ICU) with COVID-19. METHOD: Cross-sectional, analytical study carried out in the ICU of a private hospital. All patients over the age of 18 with a diagnosis of COVID-19 admitted from September 2020 to June 2021 were included. Workload assessed by the Nursing Activities Score (NAS), and severity by the Sequential Organ Failure Assessment. Descriptive and inferential analyses were performed. RESULTS: 217 patients were included, mostly men, mean age 62.41 years, white, obese, non-smokers and sedentary. The average NAS was 84.79. Staffing was in line with legislation and NAS. NAS was not associated with severity. Severity was associated with higher age, gender, comorbidities, sedentary lifestyle, time on mechanical ventilation, hospitalization and death. CONCLUSION: Workload was high and not associated with severity or outcomes. Severity was associated with demographic and clinical conditions. This study shows the importance of staff sizing, with a view to promoting safety and quality of care.

Construction and validation of an in-hospital transport simulation scenario.

OBJECTIVE: To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. METHODS: A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. RESULTS: Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. CONCLUSION: In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

Prevention of Sudden Death Related to Sport: The Science of Basic Life Support-from Theory to Practice.

The sudden cardiac arrest (CA) and death of athletes are dramatic and emotionally impacting events for health professionals, family, and society. Although the practice of sport participation improves general health, physical fitness, and quality of life, intense physical exercise can be a trigger for CA and sudden death occasionally in the presence of known or unknown cardiac disorders (mainly hypertrophic cardiomyopathy) and risk factors (environment, health style, family, and genetic). The present review found that sudden death associated with CA was not such a common event in competitive athletes, but it might be an underestimated event in recreational athletes. Thus, considering the exponential increase in sport participation, both in a recreational or competitive way, and the rate of sudden CA, knowledge of implementing prevention and treatment strategies is crucial. This includes preparation of health professionals and lay people in basic life support (BLS); screening and pre-participation assessment in sport programs and health education; and promotion for the recognition of CA and early completion of BLS and rapid access to automatic external defibrillator to improve the victim survival/prognosis. Thus, the purpose of this review is to provide for health professionals and lay people the most updated information, based on current guidelines, of how to proceed in an emergency situation associated with sudden CA of young adult athletes.

Nursing workload and severity of COVID-19 patients in the Intensive Care Unit / Carga de trabajo de enfermería y gravedad de los pacientes con COVID-19 en la Unidad de Cuidados Intensivos / Carga de trabalho de Enfermagem e gravidade de pacientes com COVID-19 na Unidade de Terapia Intensiva

ABSTRACT Objective: To evaluate the workload and severity of patients in the Intensive Care Unit (ICU) with COVID-19. Method: Cross-sectional, analytical study carried out in the ICU of a private hospital. All patients over the age of 18 with a diagnosis of COVID-19 admitted from September 2020 to June 2021 were included. Workload assessed by the Nursing Activities Score (NAS), and severity by the Sequential Organ Failure Assessment. Descriptive and inferential analyses were performed. Results: 217 patients were included, mostly men, mean age 62.41 years, white, obese, non-smokers and sedentary. The average NAS was 84.79. Staffing was in line with legislation and NAS. NAS was not associated with severity. Severity was associated with higher age, gender, comorbidities, sedentary lifestyle, time on mechanical ventilation, hospitalization and death. Conclusion: Workload was high and not associated with severity or outcomes. Severity was associated with demographic and clinical conditions. This study shows the importance of staff sizing, with a view to promoting safety and quality of care.

RESUMEN Objetivo: Evaluar la carga de trabajo y la gravedad de los pacientes de la Unidad de Cuidados Intensivos (UCI) con COVID-19. Método: Estudio transversal y analítico realizado en la UCI de un hospital privado. Se incluyeron todos los pacientes mayores de 18 años con diagnóstico de COVID-19 ingresados entre septiembre de 2020 y junio de 2021. Carga de trabajo evaluada mediante la Nursing Activities Score (NAS), y gravedad mediante la valoración secuencial de fallo orgánico. Se realizaron análisis descriptivos e inferenciales. Resultados: Se incluyeron 217 pacientes, en su mayoría hombres, edad media 62,41 años, raza blanca, obesos, no fumadores y sedentarios. El NAS medio era de 84,79. Los niveles de personal se ajustaban a la legislación y al NAS. El NAS no se asoció con la gravedad. La gravedad se asoció a mayor edad, sexo, comorbilidades, sedentarismo, tiempo de ventilación mecánica, hospitalización y muerte. Conclusión: La carga de trabajo fue elevada y no se asoció a la gravedad ni a los resultados. La gravedad se asoció a las condiciones demográficas y clínicas. Este estudio muestra la importancia del dimensionamiento del personal, con vistas a promover la seguridad y la calidad de los cuidados.

RESUMO Objetivos: Avaliar carga de trabalho e gravidade dos pacientes na Unidade de Terapia Intensiva (UTI) com COVID-19. Método: Estudo transversal, analítico realizado na UTI em hospital privado. Incluídos todos os pacientes maiores de 18 anos, com diagnóstico de COVID-19 admitidos de setembro de 2020 a junho de 2021. Carga de trabalho avaliado pelo Nursing Activities Score (NAS), e gravidade pelo Sequential Organ Failure Assessment. Realizado análises descritiva e inferencial. Resultados: Incluídos 217 pacientes, maioria homens, média de idade 62,41 anos, brancos, obesos, não tabagistas e sedentários. A média do NAS foi 84,79. O dimensionamento de pessoal estava em concordância com legislação e NAS. O NAS não foi associado a gravidade. Houve associação da gravidade com maior idade, sexo, comorbidades, sedentarismo, tempo de ventilação mecânica, internação e óbito. Conclusão: A carga de trabalho foi alta e não associada a gravidade e desfechos. A gravidade foi associada às condições demográficas e clínicas. Este estudo mostra a importância do dimensionamento de pessoal, com vistas à promoção da segurança e qualidade assistencial.

Types and frequency of errors in the preparation and administration of drugs.

OBJECTIVE: To identify compatibility, types and frequency of errors in preparation and administration of intravenous drugs. METHODS: A cross-sectional and descriptive study performed at the emergency department of a university hospital in the city of São Paulo (SP). The sample consisted of 303 observations of the preparation and administration of intravenous drugs by nursing aides, nursing technicians and registered nurses, using a systematized script, similar to a checklist. The following variables were collected: errors related to dispensing, omission, schedule, unauthorized administration, dosage, formulation, incompatibility, preparation and administration. RESULTS: In the preparation stage, the following errors were identified: no hand hygiene (70.29%), and no use of aseptic technique (80.85%). Upon administration, no hand hygiene (81.18%), and no use of aseptic technique (84.81%). In 31.35% of observations, there was more than one medication at the same time for the same patient, of which 17.89% were compatible, 56.84% were incompatible and 25.26% were not tested, according to the Micromedex database. CONCLUSION: In both preparation and administration stages, the most frequent errors were no hand hygiene and no use of aseptic technique, indicating the need to develop and implement education programs focused on patient safety.

Do not attempt resuscitation orders at the emergency department of a teaching hospital.

OBJECTIVE: To identify factors associated with not attempting resuscitation. METHODS: A cross-sectional study conducted at the emergency department of a teaching hospital. The sample consisted of 285 patients; in that, 216 were submitted to cardiopulmonary resuscitation and 69 were not. The data were collected by means of the in-hospital Utstein Style. To compare resuscitation attempts with variables of interest we used the χ2 test, likelihood ratio, Fisher exact test, and analysis of variance (p<0.05). RESULTS: No cardiopulmonary resuscitation was considered unjustifiable in 56.5% of cases; in that, 37.7% did not want resuscitation and 5.8% were found dead. Of all patients, 22.4% had suffered a previous cardiac arrest, 49.1% were independent for Activities of Daily Living, 89.8% had positive past medical/surgical history; 63.8% were conscious, 69.8% were breathing and 74.4% had a pulse upon admission. Most events (76.4%) happened at the hospital, the presumed cause was respiratory failure in 28.7% and, in 48.4%, electric activity without pulse was the initial rhythm. The most frequent cause of death was infection. The factors that influenced non-resuscitation were advanced age, history of neoplasm and the initial arrest rhythm was asystole. CONCLUSION: Advanced age, past history of neoplasia and asystole as initial rhythm were factors that significantly influenced the non-performance of resuscitation. Greater clarity when making the decision to resuscitate patients can positively affect the quality of life of survivors.

Assessment of nurse's knowledge about Glasgow coma scale at a university hospital.

OBJECTIVE: To assess knowledge of nurses of emergency services and intensive care units about Glasgow Coma Scale. METHODS: This cross-sectional analytical study included 127 nurses of critical units of an university hospital. We used structured interview with 12 questions to evaluate their knowledge about the scale. Association of Knowledge with professionals' sociodemographic variables were verified by the Fisher-test, χ2 and likelihood ratio. RESULTS: Most of participants were women mean aged 31.1 years, they had graduated more than 5 years previously, and had 1 to 3 years of work experience. In the assessment of best score possible for Glasgow scale (question 3) nurses who had graduate more than 5 years ago presented a lower percentage success rate (p=0.0476). However, in the question 7, which evaluated what interval of the scale indicated moderate severity of brain trauma injury, those with more years of experience had higher percentage of correct answers (p=0.0251). In addition, nurses from emergency service had more correct answers than nurses from intensive care unit (p=0.0143) in the same question. Nurses graduated for more than 5 years ago had a lower percentage of correct answers in question 7 (p=0.0161). Nurses with more work experience had a better score (p=0.0119) to identify how assessment of motor response should be started. CONCLUSION: Number of year since graduation, experience, and work at critical care units interfered in nurses' knowledge about the scale, which indicates the need of training. OBJETIVO: Avaliar o conhecimento de enfermeiros de unidades críticas, serviços de emergência e unidades de terapia intensiva em relação à escala de coma de Glasgow. MÉTODOS: Estudo transversal e analítico com 127 enfermeiros de unidades críticas de um hospital universitário. Utilizou-se entrevista estruturada com 12 questões que avaliaram conhecimento sobre a escala. Associação do conhecimento com variáveis sociodemográficas dos profissionais foi verificada pelo teste de Fisher, teste χ2 e razão de verossimilhança. RESULTADOS: Houve predominância de mulheres, média de idade de 31,1 anos, especialistas, mais de 5 anos de formado e experiência profissional de 1 a 3 anos. Na avaliação do melhor escore possível para pontuação na escala (questão 3), enfermeiros com tempo de formação maior que 5 anos apresentaram menor porcentual de acertos (p=0,0476). Em relação à questão 7, que avaliou qual intervalo da escala indicava gravidade moderada do trauma craniencefálico, observou-se que quanto maior o tempo de experiência, maior o porcentual de acertos (p=0,0251), sendo que enfermeiros do serviço de emergência tiveram mais acertos nessa questão em relação aos das unidades de terapia intensiva (p=0,0143). Além disso, enfermeiros formados há mais de 5 anos apresentaram menor porcentual de acertos nessa questão (p=0,0161). Quando se identificou como deve ser iniciada a avaliação da resposta motora, enfermeiros com maior tempo de trabalho na unidade apresentaram mais acertos (p=0,0119). CONCLUSÃO: Tempo de formação, experiência e trabalho na unidade interferiu no conhecimento de enfermeiros sobre a escala, evidenciando necessidade de capacitação.

The Spiritism as therapy in the health care in the epilepsy.

OBJECTIVE: to present a brief history of Spiritism, the vision of epilepsy by Spiritism, and the potential of spirituality and religiosity care as complementary and coadjutants treatments in epilepsy. METHOD: this is a brief review about the impact of faith, spirituality, and religiosity, particularly the Spiritism philosophy as complementary treatment to neurological disorders (particularly focusing on epilepsy) and mental health. We conduct a review of published articles (about religion/spirituality and epilepsy) in the Pubmed and SciELO databases. CONCLUSION: the exercise of spirituality and religiosity can be a positive coping strategy to support the traditional therapy of patients with epilepsy and other neurological disorders. However, it is necessary to demystify myths and beliefs about the epilepsy and improve knowledge about this important health dimension among professionals, patients, and caregivers to explore their full treatment and supportive potential.

Correlation between classification in risk categories and clinical aspects and outcomes.

Objective: to correlate classification in risk categories with the clinical profiles, outcomes and origins of patients. Method: analytical cross-sectional study conducted with 697 medical forms of adult patients. The variables included: age, sex, origin, signs and symptoms, exams, personal antecedents, classification in risk categories, medical specialties, and outcome. The Chi-square and likelihood ratio tests were used to associate classifications in risk categories with origin, signs and symptoms, exams, personal antecedents, medical specialty, and outcome. Results: most patients were women with an average age of 44.5 years. Pain and dyspnea were the symptoms most frequently reported while hypertension and diabetes mellitus were the most common comorbidities. Classifications in the green and yellow categories were the most frequent and hospital discharge the most common outcome. Patients classified in the red category presented the highest percentage of ambulance origin due to surgical reasons. Those classified in the orange and red categories also presented the highest percentage of hospitalization and death. Conclusion: correlation between clinical aspects and outcomes indicate there is a relationship between the complexity of components in the categories with greater severity, evidenced by the highest percentage of hospitalization and death.

Construction and validation of an in-hospital transport simulation scenario / Construção e validação de cenário de simulação de transporte intra-hospitalar

ABSTRACT Objective To build and validate the content of a clinical simulation scenario for teaching in-hospital transport of critically ill patients. Methods A descriptive study of construction and validation of a clinical simulation scenario for teaching in-hospital transport. A scenario based on the literature was built, followed by validation, using the Delphi technique, by five specialists, with an agreement of 80%. The experts were selected through snowball sampling. An instrument was developed containing 26 topics to be assessed for relevance, clarity, objectivity, feasibility, current content, vocabulary, and a field for observations. Results Two rounds were carried out by the specialists to reach a consensus of 80%. According to the experts´ recommendation, the initial scenario was written more clearly and objectively, and divided into two parts: patient preparation and patient transport. Conclusion In this study, the construction and validation of the scenario for teaching in-hospital transport were successfully performed. It may be applied in several services to evaluate the training of nursing undergraduate students, as well as for the professional improvement of those who work in the in-hospital transport service.

RESUMO Objetivo Construir e validar o conteúdo de um cenário de simulação clínica para ensino do transporte intra-hospitalar de pacientes críticos. Métodos Estudo descritivo de construção e validação de um cenário de simulação clínica para o ensino de transporte intra-hospitalar. Foi construído um cenário fundamentado na literatura seguido da validação, por meio da técnica Delphi, por cinco especialistas, com nível de concordância de 80%. Os especialistas foram selecionados por meio da amostragem do tipo bola de neve. Foi desenvolvido um instrumento contendo 26 tópicos, para serem avaliados quanto a pertinência, clareza, objetividade, exequibilidade, conteúdo atual e vocabulário. Havia ainda um campo para observações. Resultados Foram realizadas duas rodadas pelos especialistas para a obtenção de consenso de 80%. De acordo com a recomendação dos especialistas, o cenário inicial foi escrito de forma mais clara e objetiva, e divido em duas partes: preparo do paciente e transporte do paciente. Conclusão Neste estudo, foram realizadas, com êxito, a construção e a validação do cenário para ensino do transporte intra-hospitalar. Ele poderá ser aplicado em diversos serviços para avaliação da formação dos graduandos de enfermagem, assim como para aprimoramento profissional daqueles que atuam no serviço de transporte intra-hospitalar.

Systemic Arterial Hypertension in the Emergency Service: medication adherence and understanding of this disease.

OBJECTIVE: To identify the epidemiological profile of hypertension patients, how much they understand about the disease and the rate of adherence to treatment by these patients who had been hospitalized in the Brazilian emergency service. METHODS: This cross-sectional study was performed with 116 patients, both male and female and aged over 18 years, who had been hospitalized in the Emergency Service of a University Hospital between March and June, 2013. The studied variables were data referring to socio-demographics, comorbidities, physical activity and knowledge regarding the disease. Patient adherence to treatment and the identification of the barriers were respectively evaluated using the Morisky test and the Brief Medication Questionnaire. RESULTS: Most of the patients involved in this study were women (55%), with white skin color (55%), married (51%), retirees or pensioners (64%) and with a low educational level (58%). Adherence to treatment, in most cases (55%), was moderate and the most prevalent adherence barrier was recall (67%). When medication was acquired at no cost to the patient, there was greater adherence to treatment. CONCLUSION: This study's patients had a moderate understanding about the disease. The high correlation between the number of drugs used and the recall barrier suggests that monotherapy is an option that can facilitate treatment adherence and reduce how often the patients forget to take their medication.

Factors associated with functional impairment of elderly patients in the emergency departments.

OBJECTIVE: To assess the functional capacity of elderly patients in the emergency department as to Basic and Instrumental Activities of Daily Living. METHODS: A cross-sectional study of 200 elderly patients admitted to the emergency department of a teaching hospital in São Paulo (SP), Brazil. The functional capacity of the elderly was assessed by the Katz index and Lawton & Brody scale. Statistical analyses were performed using analysis of variance, Bonferroni correction, χ2 test, or the likelihood ratio test. RESULTS: Most seniors were independent (65%), and the degree of dependence was related to age, female gender, being single and widowed, and presence of cerebrovascular disease and dementia. The more dependent elderly for Instrumental Activities of Daily Living had increased dependence for Basic Activities. CONCLUSION: We emphasize the importance of assessing the functional capacity of the elderly in the emergency department as it provides data for the nursing care in order to minimize or to avoid their functional impairment.

Knowledge of healthcare professionals about rights of patient's images.

Objective To assess knowledge of healthcare professionals about capture and reproduction of images of patients in a hospital setting. Methods A cross-sectional and observational study among 360 healthcare professionals (nursing staff, physical therapists, and physicians), working at a teaching hospital in the city of São Paulo (SP). A questionnaire with sociodemographic information was distributed and data were correlated to capture and reproduction of images at hospitals. Results Of the 360 respondents, 142 had captured images of patients in the last year, and 312 reported seeing other professionals taking photographs of patients. Of the participants who captured images, 61 said they used them for studies and presentation of clinical cases, and 168 professionals reported not knowing of any legislation in the Brazilian Penal Code regarding collection and use of images. Conclusion There is a gap in the training of healthcare professionals regarding the use of patient´s images. It is necessary to include subjects that address this theme in the syllabus of undergraduate courses, and the healthcare organizations should regulate this issue.

Cohort study on the factors associated with survival post-cardiac arrest.

CONTEXT AND OBJECTIVE: Cardiac arrest is a common occurrence, and even with efficient emergency treatment, it is associated with a poor prognosis. Identification of predictors of survival after cardiopulmonary resuscitation may provide important information for the healthcare team and family. The aim of this study was to identify factors associated with the survival of patients treated for cardiac arrest, after a one-year follow-up period. DESIGN AND SETTING: Prospective cohort study conducted in the emergency department of a Brazilian university hospital. METHODS: The inclusion criterion was that the patients presented cardiac arrest that was treated in the emergency department (n = 285). Data were collected using the In-hospital Utstein Style template. Cox regression was used to determine which variables were associated with the survival rate (with 95% significance level). RESULTS: After one year, the survival rate was low. Among the patients treated, 39.6% experienced a return of spontaneous circulation; 18.6% survived for 24 hours and of these, 5.6% were discharged and 4.5% were alive after one year of follow-up. Patients with pulseless electrical activity were half as likely to survive as patients with ventricular fibrillation. For patients with asystole, the survival rate was 3.5 times lower than that of patients with pulseless electrical activity. CONCLUSIONS: The initial cardiac rhythm was the best predictor of patient survival. Compared with ventricular fibrillation, pulseless electrical activity was associated with shorter survival times. In turn, compared with pulseless electrical activity, asystole was associated with an even lower survival rate.

One-year follow-up of neurological status of patients after cardiac arrest seen at the emergency room of a teaching hospital.

OBJECTIVE: To describe neurological status and associated factors of survivors after cardiac arrest, upon discharge, and at 6 and 12 month follow-up. METHODS: A cohort, prospective, descriptive study conducted in an emergency room. Patients who suffered cardiac arrest and survived were included. A one-year consecutive sample, comprising 285 patients and survivors (n=16) followed up for one year after discharge. Neurological status was assessed by the Cerebral Performance Category before the cardiac arrest, upon discharge, and at 6 and 12 months after discharge. The following factors were investigated: comorbidities, presence of consciousness upon admission, previous cardiac arrest, witnessed cardiac arrest, location, cause and initial rhythm of cardiac arrest, number of cardiac arrests, interval between collapse and start of cardiopulmonary resuscitation, and between collapse and end of cardiopulmonary resuscitation, and duration of cardiopulmonary resuscitation. RESULTS: Of the patients treated, 4.5% (n=13) survived after 6 and 12 months follow-up. Upon discharge, 50% of patients remained with previous Cerebral Performance Category of the cardiac arrest and 50% had worsening of Cerebral Performance Category. After 6 months, 53.8% remained in the same Cerebral Performance Category and 46.2% improved as compared to discharge. After 12 months, all patients remained in the same Cerebral Performance Category of the previous 6 months. There was no statistically significant association between neurological outcome during follow-up and the variables assessed. CONCLUSION: There was neurological worsening at discharge but improvement or stabilization in the course of a year. There was no association between Cerebral Performance Category and the variables assessed.

Knowledge, perceptions and use of generic drugs: a cross sectional study.

OBJECTIVE: To assess the level of knowledge, perceptions and usage profile for generic drugs among laypersons. METHODS: A cross-sectional study was conducted with 278 volunteers (180 women and 98 men, aged 37.1±15.8 years). A questionnaire was drawn up with questions on their use, perceptions and knowledge of generic drugs. RESULTS: Most respondents (99.6%) knew that generic drugs exist, but only 48.6% were able to define them correctly, while 78.8% of the respondents had some information about generics. This information was obtained mainly through television (49.3%). In terms of generic drug characteristics, 79.1% stated that they were confident about their efficacy, 74.8% believed that generic drugs have the same effect as branded medications, 88.8% said that generics were priced lower than branded medications, and 80.2% stated that they bought generic drugs because of price. With regard to drugs prescribed by medical practitioners, 17.6% of the participants said that their doctors never prescribed generics and only 7.5% confirmed that their doctors always prescribed generics. CONCLUSION: For the lay public, the sample in this study has sufficient knowledge of generic drugs in terms of definition, efficacy and cost. Consequently, the volunteers interviewed are very likely to use generics. Furthermore, the results of this study indicate that programs should be implemented in order to boost generic drug prescriptions by medical practitioners.