¿Qué experiencias internacionales se han desarrollado en la implementación de servicios/hospitales de alta complejidad en neurología/neurocirugía y cuáles son sus características? / What international experiences have been developed in the implementation of highly complex services / hospitals in neurology / neurosurgery and what are their characteristics?

INTRODUCCIÓN: El Instituto de Neurocirugía Alfonso Asenjo (INCA) de Chile es un hospital de referencia a nivel nacional de alta complejidad para pacientes adultos y pediátricos, creado en el año 1942(1). Es un Establecimientos Autogestionado en Red, es decir, que está integrado a la red asistencial, entrega atención de alta complejidad técnica, desarrollo de especialidades, tiene atribuciones para organizarse internamente, administrar sus recursos y cuenta con un alto número de prestaciones(2). El actual Instituto se encuentra en un edificio de construcción del año 1953 por lo que a lo largo de estos años ha tenido cierto deterioro en su materialidad, en relaciones funcionales y necesidades clínicas. En la cuenta pública del 2019, el INCA menciona que es imprescindible su reposición ya que no es posible mejorar las actuales condiciones y pensar en un proyecto a futuro en el actual edificio. Para ello se está trabajando en un proyecto de pre-inversión hospitalario para el nuevo INCA y se espera para principios del año 2021 tener la aprobación para pasar a la etapa de anteproyecto(3). En este contexto la División de Gestión de Redes Asistencial (DIGERA) del Ministerio de Salud ha solicitado información en torno a las experiencias de implementación de servicios u hospitales de alta complejidad en neurocirugía reportadas a nivel internacional con el fin de tener información actualizada de los modelos de atención y gestión de centros de este tipo. RESUMEN DE HALLAZGOS: Siguiendo con la metodología de síntesis rápidas de evidencia se hizo una búsqueda de Revisiones Sistemáticas (RS), al no encontrarse ninguna que respondiera a la pregunta de investigación se realizó una búsqueda de estudios primarios (EP). Se incluyeron todo tipo de publicaciones: artículos de investigación, experiencias, cartas al editor u otro medio de comunicación que describiera la forma de organización, experiencias de trabajo o implementación de servicios u hospitales de alta complejidad, en neurocirugía u otra especialidad neurológica. Se incluyeron todo tipo de experiencias, independiente de la población de atención del centro o del tipo de financiamiento. No se utilizaron filtros por idioma, país o fecha de publicación. De acuerdo a las necesidades del solicitante, se excluyeron publicaciones que tuvieran como objetivo describir las características de pacientes hospitalizados o ambulatorios; publicaciones que describieran o propusieran una intervención sin haberla implementado; publicaciones que tuvieran como objetivo describir o justificar la incorporación de nuevas tecnologías a sus centros; y publicaciones que se desarrollaran en un contexto de atención primaria en salud. Al realizar la búsqueda, los títulos y resúmenes fueron seleccionados por dos revisoras independientes, discutiendo cada uno de los disensos encontrados. Se encontraron inicialmente 173 EP. De éstos, se excluyeron 133 por disenso o duplicados. Luego de la revisión a texto completo de 40 EP, se excluyeron 20 por no cumplir con los criterios de inclusión descritos anteriormente. De esta forma, se utilizaron 20 estudios primarios(4,5,14­23,6­13) publicados entre 2012 y 2020. Los estudios incluidos corresponden a siete de diseño de cohorte(7,10­12,15,22,23), un estudio ecológico(8), una descripción sobre la historia de un centro(21), dos estudiostransversales(4,20), cuatro estudios cuasi experimentales antes-después (13,14,17,19), dos cartas al editor(16,18), una serie de casos(5), un ensayo controlado no aleatorizado(6) y un estudio cualicuantitativo: análisis de contenido inductivo y comparación antes-después de la intervención(9). CONSIDERACIONES DE IMPLEMENTACIÓN: Consideraciones de Aplicabilidad: La evidencia aquí contemplada proviene de documentos publicados en distintos países en 4 continentes, con los que se pudieran identificar similitudes con Chile. Por ejemplo, el tema de respuesta ante la pandemia de COVID-19 al cual tuvieron que adaptarse los hospitales a nivel mundial o el tipo de ingreso per cápita al que pertenece cada país, ya que algunos países como Canadá, EEUU, Alemania y España que, al igual que Chile, pertenecen a la OCDE y son catalogados de ingresos altos, sin embargo, esto no es un indicativo de una asignación de recursos adecuada para un buen funcionamiento hospitalario. Por otro lado, los estudios no informan respecto del tipo de financiamiento que posee cada institución mencionada. Tampoco se menciona el tipo de población cubierta, el porcentaje, ni el tipo de sistemas de salud en los que están insertos los servicios/hospitales mencionados. Dicho lo anterior, se recomienda un análisis profundo y cauteloso de los datos o características de interés para evaluar su posible aplicabilidad al contexto chileno. Por otro lado,cabe destacar que en este resumen incluyó documentos de distintos tipos de publicaciones (cartas al editor, artículos científicos, documentos narrativos), sin asignar un valor ni la graduación de la calidad a estos resultados. Consideraciones Económicas: Solamente un documento hizo referencia a los costos de los procedimientos neuroquirúrgicos de un hospital de alto volumen vs uno de bajo volumen, concluyendo que los hospitales de alto volumen son más rentables(8). No se mencionan costos directos o indirectos del resto de los procesos o intervenciones mencionados. Consideraciones de Equidad: Si bien no se pueden realizar comparaciones entre los hospitales, se puede mencionar que la los estudios muestran una diversidad en las estructuras hospitalarias y recursos tanto económicos, estructurales y de RRHH, por ejemplo, ante la misma pandemia COVID-19 el Departamento de Neurocirugía de la Universidad del Sur de Florida, pudo implementar un protocolo específico, que incluye entre otras cosas, dividir el personal en 3 equipos para que cada equipo trabaje 1 semana y cumpla 2 semanas de cuarentena, y otorgar equipamiento de protección personal adecuado, mientras que el Hospital Mayo en Lahoreno (Pakistán) no contaba con un protocolo, las medidas de protección eran básicas (mascarilla, toma de temperatura) y reasignó el personal de neurología a la atención de urgencias(18). Otro ejemplo sería el Centro Médico Hadassah (Israel), que cuenta con un grupo de enfermeras que dan atención personalizada y de acompañamiento a los pacientes(20) mientras el Centro Médico Bugando (Tanzania)(5) se encuentra en estado de precariedad y no cuenta con RRHH suficientes para dar atención de pacientes, estos cuatro ejemplos son todos hospitales de tercer nivel y de referencia en sus países. Consideraciones de Monitoreo y Evaluación: No se encontraron revisiones sistemáticas que respondan esta pregunta de investigación y los estudios primarios encontrados presentan información poco especifica. Sin embargo, estos resultados pueden ayudar a identificar un hospital, país o sistema de referencia sobre la cual se desee seguir profundizando. Además, es necesario monitorear la publicación de nueva evidencia que evalúe de manera más específica intervenciones o características requeridas para la implementación del nuevo INCA y la población hará uso de este hospital.

Telemonitoring for Patients With COVID-19: Recommendations for Design and Implementation.

Despite significant efforts, the COVID-19 pandemic has put enormous pressure on health care systems around the world, threatening the quality of patient care. Telemonitoring offers the opportunity to carefully monitor patients with a confirmed or suspected case of COVID-19 from home and allows for the timely identification of worsening symptoms. Additionally, it may decrease the number of hospital visits and admissions, thereby reducing the use of scarce resources, optimizing health care capacity, and minimizing the risk of viral transmission. In this paper, we present a COVID-19 telemonitoring care pathway developed at a tertiary care hospital in the Netherlands, which combined the monitoring of vital parameters with video consultations for adequate clinical assessment. Additionally, we report a series of medical, scientific, organizational, and ethical recommendations that may be used as a guide for the design and implementation of telemonitoring pathways for COVID-19 and other diseases worldwide.

Close to Home: Perinatal Palliative Care in a Community Hospital.

BACKGROUND: Advances in prenatal testing and diagnosis have resulted in more parents learning during pregnancy that their child may die before or shortly after birth. These advances in testing and diagnosis have also resulted in more parents choosing, despite the diagnosis, to continue their pregnancies and pursue a palliative approach to their infant's short life. Perinatal hospice and palliative care is a growing model of care developed in response to these parents' previously unmet needs. A seldom-discussed opportunity to provide this care exists in outlying community hospitals, which are ideally placed to provide care close to home for families who have chosen comfort measures and time with their child. PURPOSE: This article reviews the definition and utility of perinatal palliative care, the population it serves, attempts to support a rational for development of community-based programs, and describes one community hospital's experience with perinatal palliative care in their community. METHODS/SEARCH STRATEGY: This article describes the development and processes of a perinatal palliative care program at a community hospital in Fredericksburg, Virginia. IMPLICATIONS FOR PRACTICE: Perinatal palliative care can be developed with the assistance of already existing training materials, resources, and staff. While the cohort of patients may be small, implementing perinatal palliative care in a community setting may result in wider availability of this care and more accessible options for these families. IMPLICATIONS FOR RESEARCH: Research possibilities include developing a template for creating a perinatal palliative care program at community hospitals that could be replicated elsewhere; assessing parental satisfaction and quality indicators of perinatal palliative care at community hospitals and at referral hospitals; and assessing outcomes in various settings.

Cognitive impairment, quality of life and healthcare utilization in patients with chronic kidney disease stages 3 to 5.

AIM: This study aimed to examine associations between cognitive impairment and quality of life and healthcare utilization in patients with chronic kidney disease (CKD) stages 3 to 5. METHODS: A cross-sectional study was conducted in 379 outpatients with a mean age of 65.7 years at tertiary care hospitals in Thailand. Cognitive function was measured using the Mini-Mental State Examination, and quality of life was measured using the five-dimension European quality of life (EQ-5D-5L) multi-attribute utility instrument. The effects of cognitive impairment on the likelihood of reporting 'no problems' for each EQ-5D dimension, the quality of life scores and healthcare utilization were determined using an appropriate multivariate analysis. RESULTS: The prevalence of cognitive impairment in patients with CKD stages 3 to 5 was 15.8% (95% confidence interval [CI], 12.3, 19.9). Patients with cognitive impairment had a significantly lower likelihood of achieving good outcomes in the mobility, self-care, usual activities and anxiety/depression dimensions of the EQ-5D-5L than those with normal cognition. Patients with cognitive impairment had a significantly lower quality of life score than those with normal cognition by 0.06 points (95% CI, 0.01, 0.10). Cognitive impairment increased the number of emergency visits (rate ratio, RR, 3.47; 95% CI, 1.45, 8.29). Compared to CKD stage 3, CKD stage 5 decreased the quality of life score by 0.06 points (95% CI, 0.01, 0.10) and increased the rate of hospitalization (RR, 2.29; 95% CI, 1.27, 4.12). CONCLUSION: Cognitive impairment in patients with CKD was associated with lower quality of life scores and increased healthcare utilization.

Cardiac disease in pregnancy and the multidisciplinary team: the Wellington experience.

AIM: To define the range and severity of cardiac disease in pregnant women in New Zealand, as well as the maternal and neonatal morbidity and mortality compared with the background obstetric population. METHODS: We retrospectively audited pregnant women with cardiac comorbidity seen by a multidisciplinary team at a tertiary referral centre consisting of midwives, cardiologists, obstetricians and anaesthetists in 2016-2017. RESULTS: Seventy-two women were referred to the multidisciplinary team. The most common referral reasons were arrhythmia (n=20, 27.8%), congenital anomalies (n=19, 26.4%) and palpitations (n=10, 13.9%). Fifty-two of these women were found to be at increased risk of morbidity or mortality. A specific delivery plan was devised for 37 of these women (69.8%). There was no serious maternal morbidity or mortality. Instrumental delivery rates were higher for women with cardiac comorbidity than the background obstetric population (19.2% vs 10.8%, p=0.049), however, neonatal admissions were not increased (11.5% compared with 16.5%). CONCLUSION: Multidisciplinary review of obstetric patients with cardiac disease provides an important service to ensure risk modification prior to conception and throughout pregnancy and the puerperium.

Safety monitoring of treatment in bipolar disorder in a tertiary care setting in Sri Lanka and recommendations for improved monitoring in resource limited settings.

BACKGROUND: Safety monitoring of medicines is essential during therapy for bipolar disorder (BD). We determined the extent of safety monitoring performed according to the International Society for Bipolar Disorders (ISBD) guidelines in patients with BD attending the main tertiary care psychiatry clinics in Sri Lanka to give realistic recommendations for safety monitoring in resource limited settings. METHODS: Patients diagnosed with BD on mood stabilizer medications for more than 1 year were recruited. Data were collected retrospectively from clinic and patient held records and compared with the standards of care recommended by ISBD guidelines for safety monitoring of medicines. RESULTS: Out of 256 patients diagnosed with BD, 164 (64.1%) were on lithium. Only 75 (45.7%) had serum lithium measurements done in the past 6 months and 96 (58.5%) had concentrations recorded at least once in the past year. Blood urea or creatinine was measured in the last 6 months only in 30 (18.3%). Serum electrolytes and thyroid-stimulating hormone (TSH) concentrations were measured in the last year only in 34 (20.7%) and 30 (18.3%) respectively. Calcium concentrations were not recorded in any patient. None of the patients on sodium valproate (n = 119) or carbamazepine (n = 6) had blood levels recorded to establish therapeutic concentrations. Atypical antipsychotics were prescribed for 151 (59%), but only 13 (8.6%) had lipid profiles and only 31 (20.5%) had blood glucose concentration measured annually. Comorbidities experienced by patients influenced monitoring more than the medicines used. Patients with diabetes, hypothyroidism and hypercholesterolemia were more likely to get monitored for fasting blood glucose and (p < 0.001), TSH (p < 0.001) and lipid profiles (p < 0.001). Lithium therapy was associated with TSH monitoring (p < 0.05). Therapy with atypical antipsychotics was not associated with fasting blood glucose or lipid profile monitoring (p > 0.05). A limitation of the study is that although some tests were performed, the results may not have been recorded. CONCLUSIONS: Safety monitoring in BD was suboptimal compared to the ISBD guidelines. ISBD standards are difficult to achieve in resource limited settings due to a multitude of reasons. Realistic monitoring benchmarks and recommendations are proposed for methods to improve monitoring in resource limited settings based on our experience.

Cough management in primary, secondary and tertiary settings.

This review reflects upon the management of cough in primary, secondary and tertiary care settings. It reviews the burden of cough, the diagnostic tools employed to investigate the cause of cough and pragmatic treatment strategies. A clinical case vignette presenting in primary care highlights the challenges of managing cough by family practitioners. An approach to establishing a persistent cough clinic service in secondary care is described. Finally, the entity of idiopathic cough in tertiary care and the specialist approaches to treating recalcitrant cough are addressed.

Qualitative Slow Blood Flow in Lower Extremity Deep Veins on Doppler Sonography: Quantitative Assessment and Preliminary Evaluation of Correlation With Subsequent Deep Venous Thrombosis Development in a Tertiary Care Oncology Center.

OBJECTIVES: To determine whether the qualitative sonographic appearance of slow deep venous flow in the lower extremities correlates with quantitative slow flow and an increased risk of deep venous thrombosis (DVT) in oncology patients. METHODS: In this Institutional Review Board-approved retrospective study, we reviewed lower extremity venous Doppler sonographic examinations of 975 consecutive patients: 482 with slow flow and 493 with normal flow. The subjective slow venous flow and absence of initial DVT were confirmed by 2 radiologists. Peak velocities were recorded at 3 levels. Each patient was followed for DVT development. The associations between DVT and the presence of slow venous flow were examined by the Fisher exact test; a 2-sample t test was used for peak velocity and DVT group comparisons. The optimal cutoff peak velocity for correlation with the radiologists' perceived slow flow was determined by the Youden index. RESULTS: Deep venous thrombosis development in the slow-flow group (21 of 482 [4.36%]) was almost doubled compared with patients who had normal flow (11 of 493 [2.23%]; P = .0456). Measured peak venous velocities were lower in the slow-venous flow group (P < .001). Patients with subsequent DVT did not have a significant difference in venous velocities compared with their respective patient groups. The sum of 3 venous level velocities resulted in the best cutoff for dichotomizing groups into normal versus slow venous flow. CONCLUSIONS: Qualitative slow venous flow in the lower extremities on Doppler sonography accurately correlates with quantitatively slower flow, and this preliminary evaluation suggests an associated mildly increased rate of subsequent DVT development in oncology patients.

Trajectory of cause of death among brought dead neonates in tertiary care public facilities of Pakistan: A multicenter study.

BACKGROUND: Considering the fact that Pakistan is amongst the countries with very high neonatal mortality rates, we conducted a research study to determine the possible causes and characteristics of neonates presenting dead to the emergency department of tertiary public health care facilities of Pakistan using verbal autopsies. METHODS: A descriptive case series study was conducted in emergency department/pediatrics ward/neonatal ward/nursery unit of ten tertiary care public health facilities, situated in seven major cities of Pakistan from November, 2011 to June, 2013. Precoded verbal autopsy proforma was used to collect information regarding cause of death, family narratives and other associated risks accountable for pathway to mortality. RESULTS: We identified 431 neonates presenting dead to the emergency department (238 males and 193 females). Sepsis (26.7%), birth asphyxia (18.8%) and persistent pulmonary arrest (17.2%) were main primary causes of brought death. Around 72% brought dead neonates were referred from doctors/health care facilities and more than 28% caregivers mentioned that they were not informed about the diagnosis/ailment of their deceased newborn. CONCLUSIONS: Findings of our study suggest that infectious disease remains the main primary cause of neonatal mortality. Underweight in newborns (64%) was estimated as a leading associated risk. Delays in referrals to respective health care facility enlightened the concern of sub-standard prerequisites of neonatal care that could be one of the major contributing risk factor of high mortality rates.

Há relação entre custos hospitalares e tempo porta-balão? / Is there an association between hospital costs and door-to-balloon time?

O tempo porta-balão (TPB) tornou-se uma medida de desempenho e é foco de iniciativas de melhoria da qualidade assistencial. Este estudo teve como objetivo avaliar a relação entre o TPB e seu impacto nos custos de internação hospitalar. Métodos: Pacientes tratados com intervenção coronária percutânea primária, entre 2008 e 2013, foram divididos de acordo com o TPB < ou ≥ 90 minutos. Todos os custos registrados na alta hospitalar foram ajustados por meio do Índice de Variação de Custos Médico-Hospitalares.Resultados: Foram incluídos 141 pacientes, agrupados em TPB < 90 minutos (n = 77) e TPB ≥ 90 minutos(n = 64). Os TPB foram 64,0 ± 14,1 minutos e 133,8 ± 35,2 minutos, respectivamente. Não foram observadasdiferenças nos desfechos clínicos entre os grupos. Os custos foram de R$ 34.883,24 ± 27.749,46, sendo ocusto médio para TPB < 90 minutos de R$ 33.194,24 ± 27.387,61, e para TPB ≥ 90 minutos, de R$ 36.947,58± 28.267,80 (p = 0,43). Os custos, segundo a artéria culpada, foram de R$ 29.588,53 ± 16.358,85 para acoronária direita; R$ 48.494,62 ± 44.015,04 para a circunflexa; e de R$ 34.016,96 ± 26.503,94 paraa descendente anterior. Houve diferença entre os custos dos procedimentos relativos à artéria circunflexacomparados aos da coronária direita ou da descendente anterior (p = 0,01), mas não houve diferença entre os custos relativos à coronária direita, comparados à descendente anterior (p = 0,68). Conclusões: Não houve diferença nos custos hospitalares, no âmbito da saúde suplementar, quando os grupos foram divididos de acordo com o TPB. Os desfechos clínicos foram semelhantes, e foi encontrada uma diferença de custos em pacientes com a artéria circunflexa culpada...

Door-to-balloon time (DBT) has become a measure of performance and is the focus in quality of care improvement initiatives. This study aimed to evaluate the association between DBT and its impacton hospital costs. Methods: Patients treated with primary percutaneous coronary intervention between 2008 and 2013 were divided according to the DBT < or ≥ 90 minutes. All costs recorded at hospital discharge were adjusted bythe Medical-Hospital Cost Variation Index. Results: A total of 141 patients were included, grouped as DBT < 90 minutes (n = 77) and DBT ≥ 90 minutes(n = 64). DBT was 64.0 ± 14.1 minutes and 133.8 ± 35.2 minutes, respectively. There were no diferences in clinical outcomes between the groups. The costs were R$ 34,883.24 ± 27,749.46, with the mean cost for DBT < 90 minutes being R$ 33,194.24 ± 27,387.61 and the cost for DBT ≥ 90 minutes R$ 36,947.58 ±28,267.80 (p = 0.43). The costs, according to the culprit artery, were R$ 29,588.53 ± 16,358.85 for the rightcoronary artery; R$ 48,494.62 ± 44,015.04 for the left circumflex artery; and R$ 34,016.96 ± 26,503.94 forthe left anterior descending artery. There was a difference between the costs of procedures related to theleft circumflex artery when compared to the right coronary or left anterior descending arteries (p = 0.01),but there was no difference between the costs related to the right coronary, when compared to the left anterior descending artery (p = 0.68). Conclusions: There was no difference in hospital costs regarding the private health insurance, when the groups were divided according to the DBT. Clinical outcomes were similar and a difference in costs wasfound for patients with the circumflex artery as the culprit vessel...

What is the effect of a formalised trauma tertiary survey procedure on missed injury rates in multi-trauma patients? Study protocol for a randomised controlled trial.

BACKGROUND: Missed injury is commonly used as a quality indicator in trauma care. The trauma tertiary survey (TTS) has been proposed to reduce missed injuries. However a systematic review assessing the effect of the TTS on missed injury rates in trauma patients found only observational studies, only suggesting a possible increase in early detection and reduction in missed injuries, with significant potential biases. Therefore, more robust methods are necessary to test whether implementation of a formal TTS will increase early in-hospital injury detection, decrease delayed diagnosis and decrease missed injuries after hospital discharge. METHODS/DESIGN: We propose a cluster-randomised, controlled trial to evaluate trauma care enhanced with a formalised TTS procedure. Currently, 20 to 25% of trauma patients routinely have a TTS performed. We expect this to increase to at least 75%. The design is for 6,380 multi-trauma patients in approximately 16 hospitals recruited over 24 months. In the first 12 months, patients will be randomised (by hospital) and allocated 1:1 to receive either the intervention (Group 1) or usual care (Group 2). The recruitment for the second 12 months will entail Group 1 hospitals continuing the TTS, and the Group 2 hospitals beginning it to enable estimates of the persistence of the intervention. The intervention is complex: implementation of formal TTS form, small group education, and executive directive to mandate both. Outcome data will be prospectively collected from (electronic) medical records and patient (telephone follow-up) questionnaires. Missed injuries will be adjudicated by a blinded expert panel. The primary outcome is missed injuries after hospital discharge; secondary outcomes are maintenance of the intervention effect, in-hospital missed injuries, tertiary survey performance rate, hospital and ICU bed days, interventions required for missed injuries, advanced diagnostic imaging requirements, readmissions to hospital, days of work and quality of life (EQ-5D-5 L) and mortality. DISCUSSION: The findings of this study may alter the delivery of international trauma care. If formal TTS is (cost-) effective this intervention should be implemented widely. If not, where already partly implemented, it should be abandoned. Study findings will be disseminated widely to relevant clinicians and health funders. TRIAL REGISTRATION: ANZCTR: ACTRN12613001218785, prospectively registered, 5 November 2013.

Road map to developing a fellowship program in a tertiary care hospital.

BACKGROUND: The American Academy of Pediatrics has identified the need for more subspecialists. Beginning a pediatric pulmonary fellowship program in a tertiary care hospital can be a challenging process. Persistence, perseverance, and working through barriers to education are important strides to take toward achieving this goal. We share our experience with this endeavor. The objective of this study was to describe our experience developing a pediatric pulmonary fellowship program, the challenges we faced, and the methods we used to meet and overcome those challenges. METHODS: Self-reflection by the program director, associate director, and coordinator involved in the development and implementation of a successful fellowship program. This includes the step by step process, effort, and time commitment needed for planning and implementing a fellowship program. Our goals are to share this information with the medical community. RESULTS/OUTCOMES/IMPROVEMENTS: Planning, preparing, and implementing a pediatric pulmonary fellowship program can be challenging in the current economic climate, especially considering budget constraints and increasingly demanding clinical mandates. Department chairs and administrators view work relative value units as a marker for remuneration; educational efforts are more often an unfunded mandate. Major difficulties included imposing new educational expectations on the clinical staff and expanding the budget to include fellows' costs. Developing a program information form (PIF) was a work-in-progress over a two-year period with the dedicated staff meeting regularly during this time.

Avaliação preliminar de prescrições para idosos em Serviço de Cardiologia de um Hospital de Ensino / Preliminary assessment of prescriptions for elderly patients in the cardiology unit of a teaching hospital

Fundamentos: Indicadores são ferramentas úteis para se conhecer o perfil da prescrição. Objetivo: Analisar os indicadores de prescrição medicamentosa recomendados pela Organização Mundial da Saúde em prescrições de pacientes idosos internados em enfermaria de cardiologia do sistema público de saúde. Métodos: Estudo exploratório-descritivo de abordagem qualitativa através da análise de 1382 prescrições, durante o período de internação, de 223 pacientes idosos admitidos na enfermaria da cardiologia clínica de um hospital de ensino. Resultados: A média de medicamentos por prescrição foi 11,66. Foram prescritos 16 117 medicamentos: 72,69% prescritos pelo nome genérico; 99,39% padronizados pela instituição; 2,86% antimicrobianos; 41,87% injetáveis e 4,39% medicamentos psicotrópicos. Os medicamentos mais prescritos foram: dipirona sódica (7,84%), omeprazol (4,80%) e maleato de enalapril (4,78%). No primeiro nível da classificação do Anatomical Therapeutic Chemical, as classes mais utilizadas foram: sistema cardiovascular (35,18%), trato gastrintestinal (23,42%), sangue e órgãos hematopoiéticos (17,81%). No segundo nível, as classes predominantes foram: antitrombóticos (17,61%),analgésicos (9,30%) e antieméticos (8,20%). Conclusões: Nas prescrições analisadas, o consumo médio de medicamentos foi alto, justificado pela complexidade, idade e doenças concomitantes dos pacientes; parte dos medicamentos foi prescrita pelo nome comercial, contrariando a legislação vigente para o serviço público. Para uma utilização de medicamentos mais racional e segura em idosos no serviço de cardiologia, conclui-se que há necessidade de se estabelecerem padrões mínimos para os indicadores de prescrição referentes ao número de medicamentos, injetáveis, antimicrobianos e psicotrópicos, de acordo com a complexidade do âmbito hospitalar na faixa etária estudada.

Background: Indicators are useful tools for examining drug prescription profiles. Objective: To analyze drug prescription indicators recommended by the World Health Organization in prescriptions for elderly patients in a cardiology ward under Brazil’s Unified National Health System (SUS). Methods: This exploratory descriptive study uses a qualitative approach through analyzing 1,382 prescriptions issued during the hospitalization of 223 elderly patients in the clinical cardiology Ward of a teaching hospital. Results: The average number of drugs per prescription was 11.66, with a total of 16,117 medications prescribed: 72.69% prescribed by their generic names; 99.39% listed as approved by the institution; 2.86% antimicrobials; 41.87% injectables; and 4.39% psychotropics. The medications most frequently prescribed were dipyrone (7.84%), omeprazole (4.80%)and enalapril maleate (4.78%). At the first ATC classification level, the classes most used were: cardiovascular system (35.18%), gastrointestinal tract(23.42%); and blood or blood-forming organs (17.81%). At the second level, the predominant classes were: antithrombotics (17.61%), analgesics (9.30%) and antiemetics (8.20%). Conclusions: In the prescriptions analyzed, average drug consumption was high, justified by thecomplexity, age and concomitant diseases of the patients, with some medications prescribed by brandname, breaching Brazilian National Health System law. This leads to the conclusion that, in order to ensure safer and more rational use of medications for elderly patients in cardiology units, minimum indicator standards must be established for the number of injectable, antimicrobial and psychotropic drugs prescribed, tailored to the complexity of the hospital environment for the age bracket addressed by this study.

Homogeneity of antimicrobial policy, yet heterogeneity of antimicrobial resistance: antimicrobial non-susceptibility among 108,717 clinical isolates from primary, secondary and tertiary care patients in London.

OBJECTIVES: We examined the 4 year trend in antimicrobial susceptibilities and prescribing across levels of care at two London teaching hospitals and their multisite renal unit, and for the surrounding community. METHODS: Laboratory and pharmacy information management systems were interrogated, with antimicrobial use and susceptibilities analysed between hospitals, within hospitals and over time. RESULTS: A total of 108,717 isolates from 71,687 patients were identified, with significant differences (at P < 0.05) in antimicrobial susceptibility between and within hospitals. Across the 4 years, rates of ESBL-/AmpC-producing Enterobacteriaceae ranged from 6.4% to 10.7% among community isolates, 17.8% to 26.9% at ward level and 25.2% to 52.5% in critical care. Significant variations were also demonstrated in glycopeptide-resistant enterococci (ward level 6.2%-17.4%; critical care 21.9%-56.3%), MRSA (ward level 18.5%-38.2%; critical care 12.5%-47.9%) and carbapenem-resistant Pseudomonas spp. (ward level 8.3%-16.9%; critical care 19.9%-53.7%). Few instances of persistently higher resistance were seen between the hospitals in equivalent cohorts, despite persistently higher antimicrobial use in Hospital 1 than Hospital 2. We found significant fluctuations in non-susceptibility year on year across the cohorts, but with few persistent trends. CONCLUSIONS: The marked heterogeneity of antimicrobial susceptibilities between hospitals, within hospitals and over time demands detailed, standardized surveillance and appropriate benchmarking to identify possible drivers and effective interventions. Homogeneous antimicrobial policies are unlikely to continue to be suitable as individual hospitals join hospital networks, and policies should be tailored to local resistance rates, at least at the hospital level, and possibly with finer resolution, particularly for critical care.

Tertiary prophylaxis in adults: is there a rationale?

There is lack of evidence-based recommendations or clear-cut consensus regarding the clinical and economic utility of regular prophylaxis started in adulthood, with the aim of keeping the clinical situation from getting worse by prevention of further bleeds contributing to increasing musculo-skeletal or other morbidity in haemophilia. Such a prophylaxis program has been shown in relatively small cohorts to be effective in reducing bleeding occurrence, with a variable effect on the joint status, but with significantly higher factor consumption and consequently higher costs than on-demand therapy. There has been no attempt to identify subsets of patients who may benefit from "tertiary" prophylaxis more than others, for example, due to their bleeding phenotype and/or requirements for product issued on-demand or to identify the dosage that provides the optimal balance of clinical benefit and cost effectiveness. This article reviews the published literature on prophylaxis started beyond the age of 18 years, the barriers to the uptake of prophylaxis programs particularly in adults and highlights areas in need of further research.

A prospective observational study to assess quality of life and prescription pattern in osteoarthritis patients at tertiary health centre in Mumbai.

BACKGROUND: Osteoarthritis (OA) is a major cause of disability and is focused in "Bone and Joint Decade" declared by WHO which substantially affect different dimensions of quality of life. The aim of present study was to find the disease pattern in OA patients, monitoring prescription pattern to assess prognosis of osteoarthritis by WOMAC index. MATERIALS AND METHODS: An observational study on prospective data collected for the evaluation of Quality of Life (QOL) in OA was conducted at tertiary health care centre in Mumbai. Patients with a diagnosis of OA were enrolled. The patient's history and clinical examination was based on classification criteria of the American College of Rheumatology; drugs prescribed were noted on case record form. Same procedure was carried out for the first and second follow-ups at 6 th and 12 th weeks respectively. RESULTS: The patients belong to primary OA (84%) as compared to secondary OA (16%). Females (70.56% and 10%) were affected more commonly than males (13.44% and 6%). Knee Joint was worst affected in 76%, followed by hip joint in 16% and shoulder, ankle, wrist, elbow joint each having 2% (n=1) involvement. NSAIDs continued to dominate prescriptions given to 84% of patients followed by antiarthritic drugs and calcium supplements in 54% cases. The WOMAC score was higher in most of patients. After medication hydroxy chloroquine sulfate has shown maximum reduction in average WOMAC sore followed by paracetamol, indomethacin and diclofenac sodium. CONCLUSION: Osteoarthritis has a significant impact on quality of life, only partly ameliorated by anti-arthritic drugs, as assessed by the WOMAC scale in this study population. Further, a study with larger sample size is needed to further support our findings.