Legislation in Hospital Dentistry: Gaps, Perspectives and Desires

Abstract Objective: To analyze the existing state legislation, including not only the ordinary laws, but also their infralegal regulation and the state legislation on Hospital Dentistry. Material and Methods: A survey was carried out in the databases of the Legislative Assemblies of the Brazilian States and the Federal District, as well as the Regional and Federal Councils of Dentistry in Brazil. Subsequently, a survey was carried out in the databases of the Ministry of Health, State Dental Councils and Federal Dental Council in Brazil. Results: Only 8 Brazilian states have legislation in force regarding hospital dentistry, which represents 29.63% of the federative units. Among the Brazilian regions, the Midwest presented the highest prevalence of the laws found (37.50%), followed by the North (25%) and the other regions with the same coverage (12.50%). Also, an orientation and an ordinance from the Ministry of Health, six resolutions from the Federal Council of Dentistry, and a technical note from the National Health Surveillance Agency were found. Conclusion: Several States do not have rules on the subject, making it imperative to create a federal rule that not only imposes the presence of the dentist, but also regulates the proportion of the team, workload, and availability.

Fatores associados as solicitações judiciais para acesso a leitos de UTI no estado de São Paulo / Factors associated with judicial requests for access to ICU beds in the State of São Paulo / Factores asociados a lassolicitudes judiciales de acceso a camas de UCI en el Estado de São Paulo

Introdução: A busca pela judicialização da saúde vem crescendo exponencialmente no país e por isso uma análise de seus efeitos e resultados no sistema de saúde é de extrema importânciapara o correto planejamento em saúde pública. Objetivos: analisar o perfil dos processos de judicialização em saúde referentes às necessidades por leitos de Unidade de Tratamento Intensivo no estado de São Paulo.Métodos: Estudo transversal constituído por todos os acórdãos no Tribunal de Justiça do Estado de São Paulo, no período compreendido entre 2009 e 2019. Os dados foram analisados de forma descritiva e expressos em frequências absolutas. Resultados: Foram selecionadas 299 ações para a análise, sendo a maior demanda tendo como autor principal no âmbito privado (n=292). Houve aumento de 0,66% no número de processos de demanda de leitos de 2009 a 2019 (n=66).Conclusões: Apesar da maioria dos pedidos de processo de judicialização advirem de pacientes com origem na esfera pública de saúde, a maioria dos processos são iniciados pela iniciativa privada. Nesse contexto, o estado necessita elaborar uma maior padronização nos acórdãos de modo a viabilizar com precisão a caracterização do perfil de autoria (AU).

Introduction: The search for healthcare judicialization has been increasing exponentially nationwide. Accordingly, an analysis of its effects and results in the health system is of utmost importance for correct planning in public health.Objectives: To analyze the profile of health lawsuits related to the need for Intensive Care Unit beds in the state of São Paulo.Methods: Crosssectional study consisting of all the judgments in the Court of Justice of the State of São Paulo from 2009 to 2019. The data were analyzed descriptively and expressed as absolute frequencies.Results: Two hundred ninety-nine (299) actions were selected for analysis, with the largest lawsuit having the private sector as the main plaintiff (n=292). There was a 0.66% increase in the number of bed cases from 2009 to 2019 (n=66).Conclusions: Although most lawsuit claims come from patients arising from the public health sphere, most lawsuits are initiated by the private sector. In this context, the state needs to elaborate a greater standardization in the judgments in order to make it possible to characterize plaintiffs' profiles accurately (AU).

Introducción: La búsqueda por la judicialización de la salud viene creciendoexponencialmente en el país y, por lo tanto, un análisis de sus efectos y resultados en el sistema de salud es de suma importancia para una correcta planificación en salud pública.Objetivos: Analizar el perfil de los procesos de judicialización de la salud con relación a las necesidades de camas de la Unidad de Terapia Intensiva en el Estado de São Paulo.Métodos: Estudio transversal compuesto por todas las sentencias del Tribunal de Justicia del Estado de São Paulo, en el período comprendido entre 2009 y2019. Los datos se analizaron descriptivamente y se expresaron en frecuencias absolutas.Resultados: Se seleccionaron para el análisis un total de 299 acciones, de las cuales la mayor demanda tenía como principal demandante el ámbito privado (n=292). Huboun aumento del 0,66% en el número de demandas de camas de 2009 a 2019 (n=66).Conclusiones: Aunque la mayoría de las solicitudes de procesos de judicialización provienen de pacientes procedentes del ámbito sanitario público, la mayoría de los procedimientos son iniciados por la iniciativa privada. En este contexto, el Estado necesita desarrollar juicios más normalizados para caracterizar con precisión el perfil de autoría (AU).

Inapropriate use of antibiotics effective against gram positive microorganisms despite restrictive antibiotic policies in ICUs: a prospective observational study.

BACKGROUND: Gram-positive spectrum antibiotics such as vancomycin, teicoplanin, daptomycin, and linezolid are frequently used in empirical treatment combinations in critically ill patients. Such inappropriate and unnecessary widespread use, leads to sub-optimal utilisation. However they are covered by the antibiotics restriction programme. This prospective observational study, evaluates gram-positive anti-bacterial utilisations in intensive care units (ICUs) with various evaluation criteria, to determine the frequency of inappropriate usage and the intervention targets required to ensure optimum use. METHODS: This clinical study was conducted prospectively between 01.10.2018 and 01.10.2019 in the medical and surgical ICUs of Gazi University Faculty of Medicine Hospital, Turkey. The total bed capacity was 55. Patients older than 18 years and who were prescribed gram-positive spectrum antibiotics (vancomycin, teicoplanin, linezolid, and daptomycin) were included. Patients under this age or immunosuppressed patients (neutropenic,- HIV-infected patients with hematologic or solid organ malignancies) were not included in the study. During the study period, 200 treatments were evaluated in 169 patients. The demographic and clinical features of the patients were recorded. Besides observations by the clinical staff, the treatments were recorded and evaluated by two infectious diseases specialists and two clinical pharmacists at 24-h intervals from the first day to the last day of treatment. SPSS software for Windows, (version 17, IBM, Armonk, NY) was used to analyse the data. Categorical variables were presented as number and percentage, and non-categorical variables were presented as mean ± standard deviation. RESULTS: It was found that inappropriate gram-positive antibiotic use in ICUs was as high as 83% in terms of non-compliance with the selected quality parameters. Multivariate analysis was performed to evaluate the factors associated with inappropriate antibiotic use, increased creatinine levels were found to increase the risk of such use. CONCLUSIONS: In spite of the restricted antibiotics programme, inappropriate antibiotic use in ICUs is quite common. Thus, it is necessary to establish local guidelines in collaboration with different disciplines for the determination and follow-up of de-escalation of such use and optimal treatment doses.

Legal Perspectives on Telemedicine Part 2: Telemedicine in the Intensive Care Unit and Medicolegal Risk.

Tele-intensive care unit (tele-ICU) implementation has been shown to improve clinical and financial outcomes. The expansion of this new care delivery model has outpaced the development of its accompanying regulatory framework. In the first part of this commentary we discussed legal and regulatory issues of telemedicine in general and expanded on tele-ICU implementation in particular. Major legal and regulatory barriers to expansion remain, including uncertainty regarding license portability and reimbursement. In this second part we discuss the effects of telemedicine implementation on the various aspects of medicolegal risk and risk mitigation, with a particular focus on tele-ICU. There is a paucity of legal data regarding the effect of tele-ICU implementation on medicolegal risk. We will therefore systematically discuss the effects of tele-ICU on the various root causes of medical error. Given the substantial capital and operational investment that must be undertaken to build and run a tele-ICU, any reduction in risk adds to the financial return on investment and further decreases barriers to implementation.

Palliative Care, Ethics, and the Law in the Intensive Care Unit.

Over the course of the last half-century, intensive care units have been the setting for many ethical and legal debates in medicine. This article outlines 3 important domains that lie at the intersection of critical care, palliative care, ethics, and the law: withholding and withdrawal of potentially life-sustaining therapies, making decisions for critically ill patients who lack decision-making capacity, and approaching cases of perceived futility when patients and families still request everything that is medically possible. Important principles and precedents that underlie our understanding of how nurses should approach critically ill patients are reviewed.

Litigation associated with intensive care unit treatment in England: an analysis of NHSLA data 1995-2012.

BACKGROUND: The intensive care unit (ICU) is a high-cost high-risk area in which analysis of previous litigation cases may help to improve future practice. METHODS: Claims received by the National Health Service Litigation Authority (NHSLA) relating to ICU, from 1995 to 2012, were analysed according to clinical categories. The severity of outcome was classified as none, low, moderate, severe and death. The cost of the claims were corrected to 2013 values using the retail prices index. RESULTS: Of the 523 claims in the NHSLA dataset, 210 were excluded (as the claims did not relate to ICU care) and 313 were included in the analysis. The commonest claim categories were [number (% of all claims)]: positioning/nursing standards/skin care (mostly relating to pressure sores)- 86 (28%), infection- 79 (26%), respiratory/airway- 63 (20%). The commonest claims relating to patient death were: respiratory/airway (30%), missed/delayed diagnosis (20%) and paediatrics (17%). The claims categories with the highest proportion of severe outcomes were: positioning/nursing standards/skin care (52%) and infection (33%). The total cost of closed claims was £19,973,339. The categories incurring the highest costs were: infection (£6.6 million), positioning/skin care/nursing standards (£4.5 million), delayed/inadequate treatment (£4.3 million). CONCLUSIONS: Litigation arising from care in the ICU is common, costly, and is likely to follow a poor outcome. Whilst the importance of airway/respiratory care and infection control measures are highlighted, the clear prominence of pressure sores in ICU-related litigation is worrisome and represents one particular area for practice improvement.

[End-of life decisions in intensive care units. Influence of patient wishes on therapeutic decision making]. / Therapiezieländerungen auf einer internistischen Intensivstation. Einfluss von Willensäußerungen der Patienten auf Therapieentscheidungen.

BACKGROUND: Among the ethical principles in medicine, respect for patient autonomy has gained the highest revaluation in recent decades. In Germany this was fostered by new legal regulations which came into effect in 2009 and clarified issues regarding end-of-life (EOL) decisions. In this study the influence of direct or mediated wishes of patient wills on EOL decisions in a medical intensive care unit (ICU) were investigated. METHODS: A retrospective analysis of all patients who died in the years 2009-2010 while being treated in the medical ICU of a large German university hospital was carried out. RESULTS: During the observation period 3,401 patients were treated in the ICU of whom 19 % (n=658) died in hospital. Of the 658 patients who died 126 (19 %) had received unlimited therapy, life support was withheld in 241 patients (37 %) and life support was withdrawn in 245 patients (37 %). In 46 patients (7 %) palliative care was instituted from the beginning of the ICU stay. In 104 cases (16 %) the patients themselves made the EOL decision and in 78 cases (12 %) an advance directive was given. A legal healthcare proxy was designated in 8 %. In 541 cases (82 %) the relatives were involved in the EOL decisions. No serious or unsolvable conflicts with relatives were experienced. Involvement of a court of law was not necessary in any of the cases. CONCLUSIONS: In a high percentage of the patients (81 %) who died during the course of intensive care treatment EOL policies were in place. The patients or their relatives were almost always involved in the decision making process. The current German law is in concordance with the established EOL practice in this intensive care unit.

[End of life care in intensive care units]. / Accompagnement de fin de vie aux soins intensifs.

In intensive care units, death occurs after a medical decision of treatment limitation in a great majority of patients. In this context, taking care of the patient and his relatives is ethically, practically and emotionally complex. End of life is a well known factor of conflict, burnout and stress among medical and nursing teams in the ICU. The recommendations described in the following article are expected to clarify the roles and practices of the professionals involved in end of life procedures in the ICU.

Legal issues in the practice of critical care medicine: a practical approach.

The intensive care unit is characterized by severely ill patients who frequently succumb to their disease, despite complex modern therapies and the best efforts of dedicated care teams. Although critical care is not historically characterized as a high-risk medical specialty with respect to litigation, the urgency, complexity, and invasive nature of intensive care unit care clearly increases legal risk exposure. Physicians do not practice in a vacuum. Instead, the practice of medicine is increasingly affected by government regulation, societal pressures, and pubic expectations. Law governs the interactions among the government, institutions, and individuals. Therefore, at a time when the practice of medicine itself is becoming increasingly more complex, physicians and other healthcare providers also face increasing administrative and legal challenges. Therefore, it is imperative that physicians develop an understanding of basic substantive and procedural law; first, so that their practices can be more focused and rewarding and less a fear of the unknown; second, that we can work proactively to minimize our legal risk; third, so that we can better communicate with risk managers, attorneys, and insurers; and finally, so that we can better understand and participate in future legal, legislative, regulatory, and public policy development. Accordingly, this general overview briefly addresses the substantive law of medical malpractice, informed consent, the law relating to research in critical care, Emergency Medical Treatment and Active Labor Act, the False Claims Act, peer review, state board disciplinary issues, and the Health Insurance Portability and Accountability Act; in addition, relevant procedural considerations will be briefly summarized.

Confidentiality. 9: The law relating to whistle blowing.

Alex Black, a staff nurse on an intensive care unit, was extremely concerned about the lack of adequate staffing levels on the unit. He had put his concerns in writing to his manager, but no action appeared to have been taken. On one weekend there was such a lack of staff that it was impossible to ensure that one nurse was attending every patient on a ventilator at all times. A young girl, injured in a road accident, was brought into the unit following surgery, and was placed on a ventilator. Alex was asked to monitor her care as well as that of another patient being ventilated. The girl died and Alex considered that this might not have happened if there had been adequate staff levels. He knows that the family are ignorant of how low the standards of care were and is anxious that they should be notified. Would it be lawful for him to tell them?

[Maternal protection law and exposure of personnel in the recovery room and surgical intensive care unit by inhalation anesthetics]. / Mutterschutzgesetz und Kontamination des Personals im Aufwachraum und auf der chirurgischen Intensivstation durch Inhalationsanästhetika.

UNLABELLED: According to Section 4 of the German maternity law (MuSchG), pregnant and nursing women are not allowed to work in places where they may be exposed to hazardous gases. Due to MuSchG these women are often effered work in the recovery room (RR) and the surgical intensive-care unit (ICU). The present study examined the occupational exposure in the RR and the ICU to nitrous oxide, isoflurane and the new volatile agents desflurane and sevoflurane in accordance with the German work place safety and maternity laws. METHODS: Trace concentrations of inhalational agents which 10 (ICU) and 207 (RR) patients exhaled after anaesthesia were measured in the RR air and the rooms of the ICU. Measurements were effected with a real-time infrared spectrometer continuously every 90 seconds for period of 6 (ICU) and 14.5 (RR) hours. RESULTS: The mean concentrations exceeded both in RR and ICU the legal limits of workplace concentrations prescribed by the German maternity law. Concentrations for both desflurane and seroflurane were up to more than twice as high as those of isoflurane. Exposition levels at the ICU and in the RR exceeded those measured in the operating theatre. The ICU personnel had a higher exposure to anaesthetic gases than those working in the RR. CONCLUSION: To reduce the working-place concentrations below the legal threshold it is necessary to use local scavenging devices in addition to appropriate ventilation systems. According to our data, pregnant and nursing women should not be allowed to work in the RR or to nurse mechanically ventilated patients after surgery in the ICU.