[Impact of Lean methodology to improve care processes and levels of satisfaction in patient care in a clinical laboratory]. / Impacto de la metodología Lean en la mejora de procesos asistenciales y niveles de satisfacción en la atención de pacientes en un laboratorio clínico.

INTRODUCTION: The application of the Lean methodology in health institutions is an effective tool to improve the capacity and workflow, as well as to increase the level of satisfaction of patients and employees. OBJECTIVE: To optimise the time of outpatient care in a clinical laboratory, by implementing a methodology based on the organisation of operational procedures to improve user satisfaction and reduce the number of complaints for delays in care. MATERIAL AND METHODS: A quasi-experimental before and after study was conducted between October 2011 to September 2012. XBar and S charts were used to observe the mean service times and standard deviation. The user satisfaction was assessed using service questionnaires. RESULTS: A reduction of 17 minutes was observed in the time of patient care from arrival to leaving the laboratory, and a decrease of 60% in complaints of delay in care. Despite the high staff turnover and 38% increase in the number of patients seen, a culture of empowerment and continuous improvement was acquired, as well as greater efficiency and productivity in the care process, which was reflected by maintaining standards 12 months after implementation. CONCLUSION: Lean is a viable methodology for clinical laboratory procedures, improving their efficiency and effectiveness.

Health-related quality of life after pediatric liver transplant: single-center experience in Chile.

INTRODUCTION: Orthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. Currently, the improved survival of these patients is well documented, but their quality of life post-transplant is not described. In Chile, Hospital Luis Calvo Mackenna (HLCM) has performed pediatric liver transplantation in children from around the country since 1994. The aim of this study is to evaluate our patients' and parents' current quality of life. METHODS: A cross-sectional study was conducted between July 2010 and June 2011. All liver transplant patients currently in control at HLCM were invited to complete the PedsQL 4.0 report (Pediatric Quality of Life Inventory). For each group, average score was calculated and comparisons were done using Student t and χ(2) tests. RESULTS: Forty-nine patients were enrolled. One-third of the patients were between 2 and 4 years, one-third between 5 and 12, and the rest were 13 to 18 years old. Half of the patients had their transplants for more than 3 years, 53% were female, 53% lived in cities far from the transplant center, 72.5% had chronic liver disease, 53% had received a liver from cadaveric donor, and 21% had received more than 1 liver transplant. Patients under 4 years referred good health-related quality of life (HRQOL) in all categories. All school-age patients had poor or very poor psychosocial HRQOL. DISCUSSION: Our good results obtained in transplant patients under 4 years may be because the questionnaire was completed by caregivers. The school-age patients were affected in terms of school functioning, as they were not able to participate in all the activities. These findings need to be compared with HRQOL perception in other groups, such as children with other chronic conditions, and evaluated with other broader factors, as reported in international HRQOL publications.

Pediatric liver transplantation experience and outcome in Chile.

INTRODUCTION: In 1994 our group began its experience with pediatric liver transplantation. The experience gained during this period is the largest in the country, positioning the Hospital Luis Calvo Mackenna and Clinica Las Condes as major referral centers in the public and private sectors. The aim of this study was to report our experience of our pediatric liver transplantation program during this period. METHODS: The liver transplantation database of Hospital Luis Calvo Mackenna and Clinica Las Condes between January 1994 and July 2011 was reviewed recording age, gender, indications for transplantation, surgical technique, complications, and survival. Survival rates were calculated using Kaplan-Meier analysis. RESULTS: During the period described 230 transplantations were performed in 189 pediatric patients. Fifty-five percent were male patients. The average age was 5 years. The main causes of transplantation were biliary atresia (50%), fulminant hepatic failure (25%), and other cholestatic diseases by 10%. Vascular and biliary complications were the leading cause of graft loss and retransplantation. The overall rate of retransplantation at 5 years was 20%. The technique of living donor was used in 28% of the cases. The 1-year patient actuarial survival rate was 80%, 73% at 5 years, and 68% at 10 years. In the last 3 years the survival rate at 1 year exceeds 90%. DISCUSSION: Our program includes more than 90% of the national liver experience. The incorporation of living donor is a milestone that has enabled us to save many patients who previously died while waiting for an organ. Its use in cases of full acute liver failure has allowed us to dramatically reduce mortality on the waiting list. Our results in the last 3 years reflect the experience that results in a significant decrease in mortality, comparing favorably to other series published in the international literature.

Pediatric liver transplant outcome using severe hypernatremic donors.

INTRODUCTION: Pediatric liver transplantation is limited by donation. In the last 5 years, urgent conditions have forced transplant teams to accept donors with minor suboptimal conditions, termed "extended donor criteria." Among those, the risk of using severe hypernatremic donors (SHD) for liver transplant is not yet well established. The aim of this study is to report the outcome of pediatric patients receiving grafts from SHD. METHODS: Clinical records of patients transplanted in the last 3 years at Hospital Luis Calvo Mackenna, Santiago, Chile, were reviewed. Outcome was evaluated in terms of patient and graft survival and complications potentially associated to the donor condition. RESULTS: Five of 33 deceased donor transplants presented with SHD. All recipients were waiting transplant in an acute condition, one of them in acute liver failure (ALF). No living related donor was available. Donors' serum sodium was 169 to 193 mEq/L before medical management and between 157 and 172 mEq/L at procurement. One patient died from sepsis related to biliary complications, and the patient suffering ALF developed primary graft nonfunction, received a second transplant 2 weeks later, and recovered to stable medical condition. No other complication was registered in these patients. DISCUSSION: Our findings allow us to postulate that hypernatremic deceased donors may be used for pediatric liver transplant under special circumstances.

Liver transplantation in children weighing less than 10 kg: Chilean experience.

BACKGROUND: Orthotopic liver transplantation is the treatment of choice for most terminal liver diseases in children. In small children (≤ 10 kg), this procedure is challenging and has special considerations. The aim of this study is to describe the experience of a Chilean liver transplantation program in this subgroup of patients. METHODS: The liver transplant database of Hospital Luis Calvo Mackenna and Clinica Las Condes was reviewed. All children less than 10 kg undergoing liver transplantation between January 1994 and July 2011 were included. Patient and graft outcomes and main complications were analyzed. RESULTS: We have performed 230 pediatric liver transplantations, 49 of them in 41 patients weighing less than 10 kg. The first indication for transplantation was biliary atresia in 25 patients (61%). A living related donor was used in 23 cases (51%). Actuarial survival was 75.7% at 1 year and 67.1% at 5 years. The main cause of death was infection, and the leading cause of graft loss was vascular complication. DISCUSSION: Our transplant program includes 2 centers that perform more than 90% of pediatric liver transplantations in Chile, including public health pediatric patients from all around the country. Patients weighing less than 10 kg represent the most challenging group in pediatric liver transplantation due to higher rates of vascular and biliary complications and postoperative infections.

Large deletions and splicing-site mutations in the STK11 gene in Peutz-Jeghers Chilean families.

Peutz-Jeghers syndrome (PJS) is an autosomal dominant disorder characterized by mucocutaneous melanocytic macules, gastrointestinal hamartomatous polyposis and an increased risk of various neoplasms. Germline mutations in the serine/threonine kinase 11 (STK11) gene have been identified as a cause for PJS. The aim of this study was to characterize the genotype of Chilean PJS patients. Mutation screening of 13 patients from eight PJS families was performed using a single strand conformation polymorphism analysis, DNA sequencing and multiplex ligation-dependent probe amplification assay. The breakpoints of the genomic rearrangements were assessed by a long-range polymerase chain reaction and sequencing. The results revealed the existence of seven different pathogenic mutations in STK11 gene in seven unrelated families, including three point mutations and four large genomic deletions. Three of these point mutations (43%, 3/7) may be considered as novel. Our results showed that a germline mutation is present in STK11 in 88% of probands fulfilling the diagnostic criteria of PJS. In this study, the combination of two different experimental approaches in the screening of the STK11 in PJS, led to a higher percentage of mutation detection.