Markov chains in the improvement of hospital patient flows: a bibliometric analysis

Introduction: The management of patient flows influences hospital performance, and Markov chains are used to model them, helping to plan capacity, allocate resources and schedule admissions. Objective: To evaluate the scientific activity related to the application of Markov chains in the improvement of patient flows in hospital institutions. Methods: An observational, descriptive and retrospective bibliometric study was applied; the ScienceDirect database was used. The strategy was divided into three: evolution of the application of Markov chains in hospitals; specifically for management; and for the improvement of patient flows; 520, 331 and 9 documents were located, respectively. Results: Research articles predominated, which accounted for 87.91 % of the scientific production. A total of 58.24 % of the articles were in the area of decision science. An analysis of the journals shows that 85.71 % were located in quartile 1, of which the one with the highest production was the European Journal of Operational Research. Four main lines of research were identified: resource optimization; capacity planning; policy development for activity sequencing; and modeling for improvement and decision making. Conclusions: Future research should focus on collaborative analysis, country-specific productivity and generalization to other international impact databases.

Introducción: La gestión de flujos de pacientes influye en el rendimiento hospitalario. Para su modelación, se implementan las cadenas de Markov que contribuyen a planificar la capacidad, asignar recursos y programar ingresos. Objetivo: Evaluar la actividad científica relacionada con la aplicación de las cadenas de Markov en la mejora de los flujos de pacientes en instituciones hospitalarias. Métodos: Se aplicó un estudio bibliométrico de tipo observacional, descriptivo y retrospectivo. Se utilizó la base de datos ScienceDirect. La estrategia se dividió en tres: evolución de la aplicación de las cadenas de Markov en hospitales, específicamente para la gestión, y para la mejora de los flujos de pacientes. Se localizaron 520, 331 y 9 documentos respectivamente. Resultados: Predominaron los artículos de investigación, los cuales representaron el 87,91 % de la producción científica. El 58,24 % de los artículos se encontraron en el área de la ciencia de la decisión. Un análisis de las revistas evidencia que el 85,71 % se encontró ubicado en el cuartil 1; de ellas, la de mayor producción fue European Journal of Operational Research. Se identificaron cuatro líneas de investigación principales: optimización de recursos, planificación de la capacidad, desarrollo de políticas para la secuenciación de las actividades, y modelación en función de la mejora y toma de decisiones. Conclusiones: Las investigaciones futuras deben centrarse en el análisis de la colaboración, la productividad en función del país y la generalización en otras bases de datos de impacto internacional.

Implementation of the Lean Healthcare System in the Emergency Room of the Clinical Hospital of the Federal University of Uberlândia: A Case Study.

The objective of this study was to analyze the effectiveness of the implementation of the lean healthcare system at the emergency room of the Clinical Hospital of the Federal University of Uberlândia, based on a comparison of hospital indicators obtained over the three phases corresponding to the period of one year before the implementation (T1), the year during the implementation (T2) and one year after implementation (T3). The methodology applied through this study can be classified as a case study that is exploratory and descriptive and developed in stages. Based herein on the search for hospital indicators, as occurred in the implementation of a lean process at the Clinical Hospital Emergency Department, along with a description of the implemented lean system. During the collection period of data relevant to the National Emergency Department Overcrowding Score and Length of Stay Indicator, the motivation of the teams grew, but with a notable tension between municipal management and hospital management. It was found that, despite the fluctuations, the patient length of stay in the Emergency Room remained high. With the exception of the variable of female deaths before 24 h of hospitalization, all other variables showed percentage increases before and after the intervention. This study reported the difficulties encountered by HC-UFU in implementing the lean project in an emergency room, thus ensuring that other institutions that intend to implement this project do not make the same types of mistakes.

Estrategias de dirección para el enfrentamiento a la pandemia de la COVID-19 / Management strategies to cope with COVID-19 pandemic

Las enfermedades infecciosas pueden convertirse en pandemias y constituir emergencias sanitarias. Desestabilizan los sistemas de salud, la vida económica, política, social y medioambiental de un país. En una situación de pandemia, se produce un aumento progresivo de las demandas asistenciales, que responden con la curva epidémica, y exige de los sistemas sanitarios la reorganización de sus recursos en función de la atención a los pacientes. En este trabajo se exponen las principales estrategias de dirección asumidas en el Hospital Militar Central Dr. Luis Díaz Soto en la preparación de la institución para el enfrentamiento a la COVID-19. Una vez esclarecida la tarea, se definió en la institución, la misión, visión, objetivos generales y política de calidad para la asistencia médica en esta situación sanitaria. Se realizaron 3 actividades fundamentales, la creación de un puesto de mando central, la definición de las áreas clasificadas como zona roja y la reorganización de las actividades asistenciales, que incluyó los elementos de garantía de la bioseguridad. Como indicadores hospitalarios para analizar mensualmente el resultado de la actividad asistencial se determinaron el índice de ocupación, el promedio de estadía, la letalidad y la mortalidad bruta y neta. La estrategia de dirección permitió la organización de la institución para el enfrentamiento a la pandemia(AU)

Infectious diseases can become pandemics and constitute health emergencies. They destabilize health systems and the economic, political, social and environmental life of a country. In a pandemic situation, there is a progressive increase in the demand for care, which responds to the epidemic curve and requires health systems to reorganize their resources in terms of patient care. This paper presents the main management strategies adopted at the Central Military Hospital Dr. Luis Díaz Soto in the preparation of the institution to face COVID-19. Once the task was clarified, the institution defined its mission, vision, general objectives and quality policy for medical assistance in this health situation. Three fundamental activities were carried out: the creation of a central command post, the definition of the areas classified as red zones and the reorganization of healthcare activities, which included the elements of biosafety assurance. The hospital indicators used to analyze the results of care activities on a monthly basis included the occupancy rate, average length of stay, case fatality, and gross and net mortality. The management strategy allowed the organization of the institution to face the pandemic(AU)

Restruturação de um hospital geral para o enfrentamento à pandemia Covid-19: o caso do CHC/UFPR / Restructuring of a general hospital to combat the Covid-19 pandemic: the case of CHC/UFPR

Resumo: O enfrentamento a uma pandemia requer que hospitais, estrategicamente, gerenciem o seu espaço, equipe e suprimentos com vistas à oferta segura de ações ao público que atende. O objetivo consistiu em analisar a reestruturação do CHC/UFPR frente à pandemia Covid-19 nos componentes "estrutura", "processo" e "resultado" e suas relações com o ensino, a pesquisa e a assistência. A metodologia empregada foi a pesquisa do tipo Estudo de caso único, realizado no período de junho de 2022 a fevereiro de 2023. O total de 42 profissionais vinculados ao hospital (com ou sem cargo nas funções administrativas e assistenciais multiprofissionais) foram entrevistados por videoaudiogravação (Microsoft Teams), considerados fonte primária dos dados. Dados secundários foram adicionados por meio de coleta documental, oriundos de pastas Computadorizadas do hospital, disponibilizadas por compartilhamento de nuvem digital e impressões da pesquisadora, registradas em Diário de Bordo, oriundo de aspectos que emergissem no decurso das entrevistas. Os dados foram operacionalizados pelo Software MaxQda®, o qual apresentou os segmentos codificados. Para a análise dos dados, utilizou-se a Análise de Conteúdo Temático Categoria (ACTC). A matriz de análise comportou os dados construída à luz da tríade de Avedis Donabedian: Estrutura, Processo e Resultado como referencial teórico e também corresponderam a colunas e linhas horizontais para os elementos Assistência, Ensino e Pesquisa. Obteve-se o total de 1108 Unidades de registro (URs). As três categorias foram expressas por componentes da tríade e estas, desdobradas em subcategorias, a saber: categoria 1: Estrutura (Recursos Humanos, Recursos Físicos; Recursos Tecnológicos, Materiais e insumos; Recursos financeiros e apoio externo); categoria 2: Processo (Protocolos, Fluxos e Dinâmica de atendimento; Atuação profissional) e categoria 3: Resultado (Resultado imediato da reestruturação do CHC; Mudanças no estado de saúde dos indivíduos; Lições aprendidas; Satisfação de expectativas dos trabalhadores; e, Planejamento para o pós-Covid-19). Ante ao exposto, foi possível a proposição de um modelo gráfico de contingenciamento a pandemias. O hospital dentro das suas condições reestruturadas atendeu a demanda conforme o objetivo priorizado pelos gestores. Percebeu-se a tríade "estrutura, processo e resultado" operacionalizada numa engrenagem prática, sem a qual torna ineficiente a missão de uma organização. Embora a atribuição de pesos não tenha sido foco da pesquisa, foi possível perceber que a missão de assistência esteve em evidência ao passo em que o ensino e a pesquisa permearam mais em determinadas subcategorias face a outras. Esta pesquisa pode contribuir ao planejamento de ações que possam vir a ser necessários em situações semelhantes e futuras no cenário de saúde conjecturados na sustentabilidade hospitalar, objetivo comum por muitas organizações. O uso de modelos e planos de contingência a pandemias pode instrumentalizar condutas e tomada de decisões por gestores em crises instauradas em contexto hospitalar.

Abstract: When facing a pandemic, hospitals must strategically manage their space, staff and supplies aiming at the safe offering of actions to the public it attends. The objective was to analyze the restructuring of the CHC/UFPR in the face of the Covid-19 pandemic as to the "structure", "process" and "result" components, and their relationship with teaching, research, and assistance. The methodology used was the single case study research, carried out from June 2022 to February 2023. A total of 42 professionals linked to the hospital (with or without positions in administrative and multidisciplinary care functions) were interviewed via video audio recording (Microsoft Teams), considered the primary source of data. Secondary data were added through documentary collection, from the computerized folders of the hospital, made available through digital cloud sharing and the researcher's impressions, recorded in the Logbook, arising from aspects that emerged during the interviews. The data were operationalized by the Software MaxQda®, which presented the coded segments. For data analysis, it was used the Category Thematic Content Analysis (ACTC). The analysis matrix comprised the data constructed considering the Avedis Donabedian's triad: Structure, Process and Result, as a theoretical reference and it corresponded to columns and horizontal lines for the elements Assistance, Teaching and Research. A total of 1108 Registration Units (URs) were obtained. The three categories were expressed by components of the triad and these were broken down into subcategories, namely: category 1: Structure (Human Resources, Physical Resources; Technological Resources, Materials and inputs; Financial resources and external support); category 2: Process (Protocols, Flows and Dynamics of care; Professional performance) and category 3: Result (Immediate result of the restructuring of the CHC; Changes in the health status of individuals; Lessons learned; Satisfaction of workers' expectations; and, Planning for post-Covid-19). In view of the above, it was possible to propose a graphic model for pandemic contingency. The hospital, within its restructured conditions, met the demand according to the objective prioritized by the managers. The triad "structure, process and result" was operationalized in a practical manner, without which the mission of an organization would become inefficient. Although the attribution of weights was not the focus of the research, it was possible to notice that the assistance was in evidence while teaching and research permeated more in certain subcategories compared to others. This research can contribute to the planning of actions that may be necessary in similar and future situations in the health scenario conjectured in hospital sustainability, a common objective for many organizations. The use of models and contingency plans for pandemics can instrumentalize conducts and decision-making by managers in crises arising in a hospital context.

Los determinantes de la estancia hospitalaria en un hospital universitario de alta complejidad

Objetivo: Establecer y cuantificar los determinantes de la estancia hospitalaria en un hospital universitario de Medellín de alta complejidad de Medellín, entre 2013 y 2018, valorar su importancia y modelar la estancia esperada. Metodología: Estudio observacional analítico retrospectivo de datos agregados. Siguiendo el método paso a paso, se corrieron siete modelos con estancia hospitalaria media como variable dependiente y las respectivas variables independientes: complejidad, oportunidad de apoyos diagnósticos, disponibilidad de insumos, casos de estancia prolongada y capacidad financiera. Se seleccionó el mejor modelo usando los criterios de ajuste Akaike e información Bayesiana, junto con las medidas de significancia global y significancia individual de los coeficientes. Se realizaron pruebas estadísticas de validez del modelo y se calcularon los coeficientes estandarizados. Resultados: Los valores medios de las variables más relevantes y su desviación estándar (de) fueron: estancia hospitalaria media, 8,09 días (de = 0,40); complejidad por consumo de recursos, 1,28 unidades (de = 0,07); apoyos diagnósticos, 90,74 mil estudios (de = 10,05); casos de estancia extrema, 4,36 % (de = 0,70), y complejidad por casuística, 1 (de = 0,03). Significancia global F = 55,2, p< 0,001. Significancia de los coeficientes: complejidad por consumo de recursos, p< 0,01; apoyos diagnósticos y casos de estancia extrema, p< 0,001; complejidad por casuística, p< 0,05. Coeficientes estandarizados: complejidad por consumo de recursos, 0,35; apoyos diagnósticos, 0,35; casos de estancia extrema, 0,26, y complejidad por casuística, 0,24. R2 ajustado 0,82. Conclusión: Los determinantes de la estancia hospitalaria en orden de importancia son: complejidad por consumo de recursos, apoyos diagnósticos, casos de estancia extrema, complejidad por casuística, inventario disponible y ganancias brutas.

Objective: To establish and quantify the determinants of hospital stay in a high complexity university hospital in Medellin between 2013 and 2018, assess their importance, and model the expected length of stay. Methodology: Retrospective analytical observational study of aggregate data. While following the method step by step, seven models were used, where mean hospital stay was the dependent variable and the respective independent variables were complexity, timeliness of diagnostic procedures, availability of supplies, cases of prolonged stay and financial capacity. The best model was selected using the Akaike and Bayesian information criterion, along with measures of both overall significance and individual significance of the coefficients. Statistical tests of model validity were performed and standardized coefficients were calculated. Results: The mean values of the most relevant variables and their standard deviation (SD) were: mean hospital stay, 8.09 days (SD = 0.40); complexity by resource consumption, 1.28 units (SD = 0.07); diagnostic procedures, 90.74 thousand studies (SD = 10.05); cases of extremely prolonged stay, 4.36% (SD = 0.70), and complexity by casuistry, 1 (SD = 0.03). Overall significance: F = 55.2, p < 0.001. Significance of coefficients: complexity by resource consumption, p < 0.01; diagnostic procedures and cases of extremely prolonged stay, p < 0.001; complexity by casuistry, p < 0.05. Standardized coefficients: complexity by resource consumption, 0.35; diagnostic procedures, 0.35; cases of extremely prolonged stay, 0.26; and complexity by casuistry, 0.24. Adjusted R2 0.82. Conclusion: In order of importance, the determinants of hospital stay are complexity by resource consumption, diagnostic procedures, extremely prolonged stay, complexity by casuistry, available inventory and gross profit.

Objetivo: Estabelecer e quantificar os determinantes da permanência hospitalar em um hospital universitário de alta complexidade de Medellín, entre 2013 e 2018, valorar sua importância e fazer a modelação da permanência esperada. Metodologia: Estudo observacional analítico retrospectivo de dados agregados. Seguindo o método passo a passo, foram aplicados sete modelos com permanência hospitalar média como variável dependente e as respectivas variáveis independentes: complexidade, oportunidade de apoios diagnósticos, disponibilidade de insumos, casos de permanência prolongada e capacidade financeira. Selecionou-se o melhor modelo usando os critérios de ajuste Akaike e informação Bayesiana, junto com as medidas de significância individual dos coeficientes. Realizaram-se provas estatísticas de validade do modelo e calcularam-se os coeficientes padronizados. Resultados: Os valores médios das variáveis mais relevantes e seu desvio-padrão (DP) foram: permanência hospitalar média, 8.09 dias (DP = 0,40); complexidade por consumo de recursos, 1,28 unidades (DP = 0,07); apoios diagnósticos, 90,74 mil estudos (DP = 10,05); casos de permanência extrema, 4,36 % (DP = 0,70), e complexidade por casuística, 1 (DP = 0,03). Significância global F = 55,2, p < 0,001. Significância dos coeficientes: complexidade por consumo de recursos, p < 0,01; apoios diagnósticos e casos de permanência extrema p < 0,001; complexidade por casuística, p < 0,05. Coeficientes padronizados: complexidade por consumo de recursos, 0,35; apoios diagnósticos, 0,35; casos de permanência extrema, 0,26 e complexidade por casuística, 0,24. R2 ajustado 0,82. Conclusão: Os determinantes da permanência hospitalar em ordem de importância são: complexidade por consumo de recursos, apoios diagnósticos, casos de permanência extrema, complexidade por casuística, inventário disponível e lucros brutos.

Sistema de Gestión Hospitalaria para la atención de la pareja infértil. Centro Territorial de Holguín, 2021

Introducción: La infertilidad es una enfermedad del sistema reproductivo que altera el equilibrio biológico, psicológico y social de las parejas. En Cuba existe un programa para el tratamiento de la pareja infértil y el Ministerio de Salud Pública incluye en sus directrices implementar las bases organizativas, sistema de trabajo, indicadores, funciones y control que garanticen el perfeccionamiento del Programa para la óptima atención de parejas infértiles, y dentro de esto se incluye confeccionar bases de datos donde se registren las parejas tratadas por este motivo. Objetivos: Implementar un Sistema de Gestión Hospitalaria para la atención de la pareja infértil, en el Centro Territorial de Holguín. Métodos: Se realizó un estudio de desarrollo tecnológico, se confeccionó sobre el sistema de base de datos relacional postgreSQL, se empleó la herramienta Odoo con el objetivo de englobar en un único software todas las prestaciones que necesita la consulta. Se utilizó el lenguaje de programación Python. Resultados: SCAPI, permite gestionar la información de los pacientes y sus historias clínicas, está compuesto por módulos relacionados: configuración general, permite crear los perfiles de usuarios y los permisos para interactuar con el sistema; SCAPI muestra y gestiona toda la información relacionada con la historia clínica digital, la agenda de turnos, medios diagnósticos (estudios de reserva ovárica, espermogramas, ecografías ováricas, estudios hormonales, técnicas de baja y alta tecnología entre otros). Conclusiones: El Sistema de Gestión Hospitalaria para la atención de la pareja infértil, contribuye al objetivo de una mayor calidad de la atención al paciente pues gestiona la información de estos y sus historias clínicas de manera rápida, oportuna y fiable.

Introduction: Biological infertility is a disease of the reproductive system that alters the psychological and social balance of couples. In Cuba there is a program for the treatment of infertile women and the Ministry of Public Health includes in its guidelines to implement the organizational bases, work system, indicators, functions and control that guarantee the improvement of the Program, including databases where couples treated for this reason are registered. Objective: To implement a Hospital Management System for the infertile couple care in the Holguín Territorial Center. Methods: A study of technological development was carried out using postgre SQL relational database system, Odoo tool, and Python programming language. Results: SCAPI allows to manage the information of patients and their medical records; it is made up of modules that are related to each other: the general configuration module which allows you to create user profiles and permissions to interact with the system; the SCAPI module which shows and manages all the information related to the digital medical history, appointment schedules, and diagnostic means (ovarian reserve studies, spermograms, ovarian ultrasound, hormonal studies, low and high technology techniques, among others). Conclusions: Hospital Management System for the care of infertile couples allows managing fast, timely and reliable information on patients and their medical records during care consultations for infertile couples with the aim of achieving a higher quality of patient care.

The Large-Scale Implementation of a Health Information System in Brazilian University Hospitals: Process and Outcomes.

Governments around the globe are paving the way for healthcare services that can have a profound impact on the overall well-being and development of their nations. However, government programs to implement health information technologies on a large-scale are challenging, especially in developing countries. In this article, the process and outcomes of the large-scale implementation of a hospital information system for the management of Brazilian university hospitals are analyzed. Based on a qualitative approach, this research involved 21 hospitals and comprised a documentary search, interviews with 24 hospital managers and two system user focus groups, and a questionnaire of 736 respondents. Generally, we observed that aspects relating to the wider context of system implementation (macro level), the managerial structure, cultural nuances, and political dynamics within each hospital (meso level), as well as the technology, work activities, and individuals themselves (micro level) acted as facilitators and/or obstacles to the implementation process. The dynamics and complex interactions established between these aspects had repercussions on the process, including the extended time necessary to implement the national program and the somewhat mixed outcomes obtained by hospitals in the national network. Mostly positive, these outcomes were linked to the eight emerging dimensions of practices and work processes; planning, control, and decision making; transparency and accountability; optimization in the use of resources; productivity of professionals; patient information security; safety and quality of care; and improvement in teaching and research. We argued here that to maximize the potential of information technology in healthcare on a large-scale, an integrative and cooperative vision is required, along with a high capacity for change management, considering the different regional, local, and institutional contexts.

Aplicativos móveis desenvolvidos para a gestão intra-hospitalar de pacientes com acidente vascular cerebral: uma revisão sistemática / Mobile applications developed for the in-hospital management of patients with stroke: a systematic review

O uso de tecnologias móveis e sem fio para apoiar a realização dos objetivos de saúde é uma tendência dentro da e-saúde. Existem lacunas de conhecimento adicionais no uso emergente de smartphones para a gestão e monitoramento de doenças crônicas como o acidente vascular cerebral, principalmente dentro do ambiente hospitalar. O objetivo deste estudo foi o de revisar os estudos que utilizaram aplicativos móveis para a gestão de pacientes hospitalizados com acidente vascular cerebral. Esta revisão sistemática seguiu as recomendações preconizadas pelo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), sendo realizada nas bases de dados eletrônicas Medline/PubMed e Embase, além de busca manual às referências de estudos já publicados sobre o assunto. Foram encontrados 207 estudos e após análise dos critérios de inclusão e exclusão, 6 foram incluídos para análise completa. O uso de aplicativos móveis pode acelerar o tempo de atendimento de pacientes internados com acidente vascular cerebral, diminuindo a morte neuronal, melhorando a mortalidade hospitalar, diminuindo a hemorragia intracraniana e contribuindo para um retorno precoce para a casa dos pacientes.

The use of mobile and wireless technologies to support the achievement of health goals is a trend within e-health. There are additional knowledge gaps in the emerging use of smartphones for the management and monitoring of chronic diseases such as stroke, particularly within the hospital setting. The objective this study was review studies developed with the interaction of mobile applications for the management of hospitalized patients with stroke. This systematic review followed the recommendations recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and was carried out in the Medline/PubMed and Embase electronic databases, in addition to a manual search of references to studies already published on the subject, and 207 studies were found and after analyzing the inclusion and exclusion criteria, 6 were included for complete analysis. The use of mobile applications can accelerate the care times of hospitalized patients with stroke, decreasing neuronal death, improvement in hospital mortality, less intracranial hemorrhage, and contributing to an early return home of patients.

Classification of medicines and materials in hospital inventory management: a multi-criteria analysis.

BACKGROUND: In the hospital environment, to achieve an optimum level of operations and service, it is necessary to develop adequate inventory management system. Stocks can be managed, amongst other ways, through inputs classification, which is generally carried out based on a single criterion, such as monetary value, demand or criticality, which does not fully address the complexity of a hospital's inventory management system. Thus, the present study proposes a multi-criteria decision support model to help classify the stock of medicines and materials, enabling a more effective inventory management system for hospitals. METHODS: Methodologically, the study followed 3 stages: (1) preliminary phase; (2) modelling and choice phase; and (3) finalization phase. Each stage had a set of specific steps that were followed. The first stage identified the actors of the process, objectives, criteria and alternatives, establishing 5 criteria and 48 alternatives; the second stage was the choice and execution of the multi-criteria decision method to solve the problem. It was decided to use the Flexible and Interactive Tradeoff method for the sorting problematic. Finally, in the third stage, the sensitivity analysis for the developed model and the validation of the results with decision makers were carried out. In the study, 48 medicines and materials were included to validate the proposed model; however, the model could be used for more items. RESULTS: From the total of 48 medicines and hospital medical materials selected for the study, the classification of 34 of these alternatives to a single class was obtained through modelling and the other 14 alternatives were destined to two possible classes; moreover, the sensitivity analysis performed showed robust results. The items classified in class W should receive special attention by the stock manager; therefore, they should be monitored weekly. Items classified in class B should be monitored biweekly and finally, items classified in class M, should be monitored monthly. CONCLUSIONS: The classification of medicines and materials developed according to the inventory demands allowed more efficient purchasing decisions, optimizing the stock of materials and medicines at the hospital while optimizing the inventory manager's activities, saving time. Consequently, the proposed model can support the development of other multicriteria models in different hospital scenarios.

Glucose variability is a marker for COVID-19 severity and mortality

ABSTRACT Objective: We aimed to investigate the association between glucose coefficient of variation (CV) and mortality and disease severity in hospitalized patients with coronavirus disease-19 (COVID-19). Subjects and methods: Retrospective cohort study in a tertiary center of patients with COVID-19 admitted to designated departments between March 11th, 2020, and November 2nd, 2020. We divided patients based on quartiles of glucose CV after stratification to those with and without diabetes mellitus (DM). Main outcomes were length of stay and in-hospital mortality. Results: The cohort included 565 patients with a mean age of 67.71 ± 15.45 years, and 62.3% were male. Of the entire cohort, 44.4% had DM. The median glucose CV was 32.8% and 20.5% in patients with and without DM, respectively. In patients with DM, higher glucose CV was associated with a longer hospitalization in the unadjusted model (OR = 2.7, 95% CI [1.3,5.6] for Q4), and when adjusted for age, sex, comorbidities, and laboratory markers, this association was no longer statistically significant (OR = 1.3, 95% CI [0.4,4.5] for Q4). In patients with and without DM, higher glucose CV was associated with higher rates of in-hospital mortality in the unadjusted model, but adjustment for comorbidities and laboratory markers eliminated the association (OR = 0.5, 95% CI [0.1,3.4] for Q4 in patients with DM). Conclusion: Higher glucose CV was associated with increased in-hospital mortality and length of stay, but this association disappeared when the adjustment included laboratory result data. Glucose CV can serve as a simple and cheap marker for mortality and severity of disease in patients with COVID-19.

Centro especializado ambulatorio de Cienfuegos: una mirada desde la gestión hospitalaria en su primera década / Specialized ambulatory center of Cienfuegos province: a view to hospital management in its first decade

La celebración en el 2019 de una década de trabajo ininterrumpido del primer hospital ligero diseñado en Cuba fue motivo para la realización de este trabajo, que tuvo como objetivo describir los principales resultados en los aspectos de meso y microgestión hospitalaria del Centro Especializado Ambulatorio Héroes de Playa Girón de Cienfuegos, desde el 2009 hasta el 2019. Múltiples investigaciones mostraron la utilidad de la gestión por procesos para garantizar la calidad de la atención médica y la integración de los programas de seguridad institucional y del paciente en las funciones gerenciales y asistenciales. La primera gestión hospitalaria del Centro Especializado Ambulatorio, sobre la base de las mejores experiencias nacionales e internacionales, cumplió con los objetivos del diseño para el cual fue creado al integrar calidad, racionalidad y eficiencia. Esta experiencia puede ser ejemplo para otras instituciones que precisen de un centro de atención ambulatoria y muy corta estadía en la concepción de un hospital universitario(AU)

The celebration in 2019 of a decade of continuous work of the first ambulatory hospital designed in Cuba motivated the production of this work, that had as an objective to describe the main results in the aspects of hospital meso and micro-management of Héroes de Playa Girón Specialized Ambulatory Center of Cienfuegos province, from 2009 to 2019. Several research works showed the usefulness of management by processes to guarantee the quality of medical care and the integration of institutional and patients safety programs in management and care functions. The first hospital management of the Specialized Ambulatory Center, based on the best national and international experiences, accomplished the objectives for what it was design to by integrating quality, rationality and efficiency. This experience would be an example for other institutions that need an ambulatory care center and a short time in the creation of a university hospital(AU)

Glucose variability is a marker for COVID-19 severity and mortality.

Objective: We aimed to investigate the association between glucose coefficient of variation (CV) and mortality and disease severity in hospitalized patients with coronavirus disease-19 (COVID-19). Subjects and Methods: Retrospective cohort study in a tertiary center of patients with COVID-19 admitted to designated departments between March 11th, 2020, and November 2nd, 2020. We divided patients based on quartiles of glucose CV after stratification to those with and without diabetes mellitus (DM). Main outcomes were length of stay and in-hospital mortality. Results: The cohort included 565 patients with a mean age of 67.71 ± 15.45 years, and 62.3% were male. Of the entire cohort, 44.4% had DM. The median glucose CV was 32.8% and 20.5% in patients with and without DM, respectively. In patients with DM, higher glucose CV was associated with a longer hospitalization in the unadjusted model (OR = 2.7, 95% CI [1.3,5.6] for Q4), and when adjusted for age, sex, comorbidities, and laboratory markers, this association was no longer statistically significant (OR = 1.3, 95% CI [0.4,4.5] for Q4). In patients with and without DM, higher glucose CV was associated with higher rates of in-hospital mortality in the unadjusted model, but adjustment for comorbidities and laboratory markers eliminated the association (OR = 0.5, 95% CI [0.1,3.4] for Q4 in patients with DM). Conclusion: Higher glucose CV was associated with increased in-hospital mortality and length of stay, but this association disappeared when the adjustment included laboratory result data. Glucose CV can serve as a simple and cheap marker for mortality and severity of disease in patients with COVID-19.

Custeio Baseado em Atividade e Tempo (TDABC) em um Departamento de Endoscopia de um hospital privado / Time-driven Activity-based Costing (TDABC) in an Endoscopy Department of a private hospital

Contexto: A gestão da saúde baseada em valor (VBHC) vem sendo a estratégia de diversas instituições de saúde no mundo todo, como forma de melhorar a qualidade dos serviços entregues de forma sustentável. Medir os resultados em saúde e custos é fundamental para a manutenção do VBHC e é um passo essencial para a sua implementação. Objetivo: O objetivo deste estudo de caso é retratar a aplicação do método TDABC em um procedimento de endoscopia ambulatorial com colonoscopia de um hospital privado do Sul do Brasil. Métodos: Este estudo aplicou o método Time-driven Activity-based Costing (TDABC) como técnica de microcusteio em um centro da saúde suplementar brasileira para avaliar o custo de procedimentos realizados na endoscopia. Foram analisados descritivamente os custos e tempos dos procedimentos e identificados os recursos e atividades de maior representatividade financeira. Por fim, foi feita uma comparação entre o custo aferido e a taxa de reembolso dos procedimentos. Resultados: O custo por procedimento apurado por meio do método é de R$ 684,77, e seu valor de reembolso médio é de R$ 993,91, mostrando-se lucrativo para a instituição. Conclusões: A aplicação do TDABC gerou melhor entendimento sobre todos os custos envolvidos no procedimento e representa o primeiro passo para a difusão do método aos demais processos e departamentos do hospital.

Context: Value-based health management (VBHC) has been the strategy of several health institutions around the world, as a way to improve the quality of services delivered in a sustainable way. Measuring health outcomes and costs is critical to maintaining the VBHC and is an essential step in its implementation. Objective: The objective of this case study is to portray the application of the TDABC method in an outpatient endoscopy procedure with colonoscopy in a private hospital in southern Brazil. Methods: This study applied the Time-driven Activity-based Costing (TDABC) method as a microcosting technique in a Brazilian supplementary health center to assess the cost of procedures performed in endoscopy. The costs and times of the procedures were descriptively analyzed and the resources and activities of greater financial representation were identified. Finally, a comparison was made between the measured cost and the reimbursement rate of the procedures. Results: The cost per procedure calculated using the method is R$ 684.77, and its average reimbursement value is R$ 993.91, proving to be profitable for the institution. Conclusions: The application of TDABC generated a better understanding of all the costs involved in the procedure and represents the first step towards disseminating the method to other hospital processes and departments.

Reduction of the Cycle Time in the Biopsies Diagnosis Through a Simulation Based on the Box Müller Algorithm.

Anatomic pathology services study disease in hospitals on the basis of macroscopic and microscopic examination of organs and tissues. The focus of this research investigation was on improving clinical biopsy diagnosis times through simulation based on the Box-Muller algorithm to reduce the waiting time in the diagnosis of clinical biopsies. The data were provided by a hospital in San José (Costa Rica). They covered 5 years and showed waiting times for a pathological diagnosis that for some biopsies were close to 120 days. The correlation between the main causes identified and the cycle time in the biopsy diagnostic process was defined. A statistical analysis of the variables most representative of the process and of the waiting times was carried out. It followed the DMAIC structure (Define, Measure, Analyse, Improve, Control) for the continuous improvement of processes. Two of the activities of the process were identified as being the main bottlenecks. Their processing times had a normal distribution, for which reason a Box-Muller algorithm was used to generate the simulation model. The results showed that waiting times for a diagnosis can be reduced to 3 days, for a productive capacity of 8 000 biopsies per annum, optimizing the logistics performance of health care.

Cómo la gestión del conocimiento en un área de gestión hospitalaria se convierte en una propuesta de generación, transmisión y transferencia como objetivo universitario / How knowledge management in a hospital management area becomes a generation, transmission and transfer proposal as a university objective

Las organizaciones de salud deben generar los espacios necesarios para el avance del conocimiento científico, es así como la propuesta que viene desarrollando la Clínica Universitaria Bolivariana ­hoy Hospital Universitario­ se ha materializado no solo en aportes a las líneas clínicas de la institución como maternidad, neonatos, crónicas y enfermedades de la mujer y del piso pélvico, sino también en un enfoque de las ciencias relacionadas con la salud pública, la administración, la economía y la ingeniería, con lo que hoy se configura como el Área de Gestión Hospitalaria.

Health organizations must generate the necessary spaces for the advancement of scientific knowledge, this is how the proposal that the Bolivarian University Clinic has been developing ­ today University Hospital ­ has materialized not only in contributions to the clinical lines of the institution such as maternity, neonates, chronic diseases and diseases of women and the pelvic floor, but also in a focus on sciences related to public health, administration, economics and engineering, with what is now configured as the Hospital Management Area.

As organizações de saúde devem gerar os espaços necessários para o avanço do conhecimento científico, é assim que a proposta que a Clínica Universitária Bolivariana vem desenvolvendo ­ hoje Hospital Universitário ­ se materializou não apenas em contribuições para as linhas clínicas da instituição como maternidade, neonatos , doenças crônicas e doenças da mulher e do assoalho pélvico, mas também com foco nas ciências relacionadas à saúde pública, administração, economia e engenharia, com o que agora se configura como Área de Gestão Hospitalar.

Time-driven activity-based costing as a strategy to increase efficiency: An analyses of interventional coronary procedures.

Monitoring the costs is one of the key components underlying value-based health care. This study aimed to evaluate the cost-saving opportunities of interventional coronary procedures (ICPs). Data from 90 patients submitted to elective ICP were evaluated in five Brazilian hospitals. Time-driven activity-based costing, that guides the cost estimates using the time consumed and the capacity cost rates per resource as the data input, was used to assess costs and the time spent over the care pathway. Descriptive cost analyses were followed by a labour cost-saving estimate potentially achieved by the redesign of the ICP pathway. The mean cost per patient varied from $807 to $2639. The length of the procedure phase per patient was similar among the hospitals, while the post-procedure phase presented the highest variation in length. The highest direct cost saving opportunities are concentrated in the procedure phase. By comparing the benchmark service with the most expensive one, it was estimated that redesigning physician practices could decrease 51% of the procedure cost. This application is pioneered in Brazil and demonstrates how detailed cost information can contribute to driving health care management to value by identifying cost-saving opportunities.

Obsolescência programada em serviços de saúde: o caso da Máfia das Próteses / Planned obsolescence in public health services: the Prosthetic Mafia case

Resumo Obsolescência programada é um conjunto de ações empreendidas por parte do produtor com o objetivo de estabelecer o decaimento gradativo de algum atributo de uma mercadoria para, assim, estimular artificialmente a demanda pelo consumo. A literatura sobre o fenômeno tem apontado como vítimas somente indivíduos e, como forma de manifestação do fenômeno, objetos. Este trabalho aponta a ocorrência do fenômeno de obsolescência programada em serviços públicos de saúde. Para isso, é empreendido um estudo exploratório-interpretativo de abordagem qualitativa e utilizado como estratégia de pesquisa o estudo de caso. A unidade de análise foi a nomeada Máfia das Próteses e, para coleta de dados, foram empregadas as técnicas de pesquisa bibliográfica e documental. Como resultado, foram selecionados e expostos três casos da ocorrência do fenômeno em cirurgias. Foi também realizado um esforço interpretativo dos condicionantes, da dinâmica e dos efeitos da prática de sabote cirúrgico com objetivo de estimular a demanda por serviços médicos e equipamentos médico-hospitalares. Como contribuição, este estudo realiza o delineamento dos elementos que caracterizam a ocorrência deste fenômeno em serviços médicos. Além disso, inaugura uma agenda de futuros estudos que abordam tanto o Estado sendo vitimado pela prática, quanto a ocorrência do fenômeno no setor de serviços.

Abstract Planned obsolescence is a set of actions undertaken by the producer to establish the gradual decay of some attribute of a commodity, artificially stimulating the demand for consumption. The literature on the phenomenon has identified only individuals as victims and objects as forms of expression. This study reports the occurrence of planned obsolescence in public health services. To this end, it consists of an exploratory-interpretative study with a qualitative approach, using the case study of the so-called Prosthetic Mafia. Data were collected by means of bibliographic and documentary research, resulting in three cases that expose the phenomenon occurrence in surgeries. The results were analyzed through an attempt to interpret the conditions, dynamics, and effects of the practice of surgical sabotage to stimulate the demand for medical services and medical-hospital equipment. This study outlines the elements that characterize planned obsolescence occurrence in medical services, inaugurating an agenda of future studies that address both the State being victimized by the practice and the phenomenon in the service sector.

A política de contratualização dos hospitais de ensino: o que mudou na prática? / The contracting policy of teaching hospitals: what did actually change?

Resumo O Programa de Reestruturação dos Hospitais de Ensino (HE) foi implantado como uma das estratégias para enfrentar a crise do setor. Pretendia introduzir novos modos de financiamento, de gestão e articulação destes hospitais com a rede de saúde. O artigo apresenta resultados de estudo qualitativo, de caso múltiplo, envolvendo quatro HE contratualizados em 2004. Foram entrevistados, em 2010, 32 dirigentes hospitalares, gestores do Sistema Único de Saúde (SUS) e dos ministérios envolvidos. Utilizando como referencial teórico elementos da micropolítica das organizações de saúde, revisitou-se o banco de dados como objetivo analisar as mudanças decorrentes dessa política governamental no cotidiano dos HE, procurando caracterizar o posicionamento e protagonismo dos diferentes atores institucionais e as dificuldades na sua implementação. A despeito da melhoria das condições financeiras, as mudanças observadas nos HE foram restritas. Analisar a política de contratualização permite compreender como um projeto consistente e idealizado pode reproduzir o comportamento conservador que caracteriza a gestão pública.

Abstract The Teaching Hospital Restructuring Program was introduced as a strategy to fight the crisis in this sector. It brings to new funding, management and relationship standards between teaching hospitals and health system. This study presents the results obtained from a multiple case study involving four teaching hospitals whose contracts were executed in 2004. In 2010, a number of 32 interviews were conducted with both hospital and SUS managers, in addition to managers connected with the Federal Government Departments involved in the contracting system. By using elements from the micropolicy of health organizations as theoretical reference, the database was revisited with the goal of analyzing possible changes derived from such governmental policy applied in the daily life of teaching hospitals, in an attempt to explain the position taken by the diverse institutional actors as well as the main role played by the managers and the difficulties encountered in its introduction. Despite the improvements in the financial situation, the changes observed in teaching hospitals were not significant. An analysis of the contracting policy leads to an understanding of how a consistent and idealized project can reproduce the usual conservative behavior found in public management.

Hospital Investment Decisions in Healthcare 4.0 Technologies: Scoping Review and Framework for Exploring Challenges, Trends, and Research Directions.

BACKGROUND: Alternative approaches to analyzing and evaluating health care investments in state-of-the-art technologies are being increasingly discussed in the literature, especially with the advent of Healthcare 4.0 (H4.0) technologies or eHealth. Such investments generally involve computer hardware and software that deal with the storage, retrieval, sharing, and use of health care information, data, and knowledge for communication and decision-making. Besides, the use of these technologies significantly increases when addressed in bundles. However, a structured and holistic approach to analyzing investments in H4.0 technologies is not available in the literature. OBJECTIVE: This study aims to analyze previous research related to the evaluation of H4.0 technologies in hospitals and characterize the most common investment approaches used. We propose a framework that organizes the research associated with hospitals' H4.0 technology investment decisions and suggest five main research directions on the topic. METHODS: To achieve our goal, we followed the standard procedure for scoping reviews. We performed a search in the Crossref, PubMed, Scopus, and Web of Science databases with the keywords investment, health, industry 4.0, investment, health technology assessment, healthcare 4.0, and smart in the title, abstract, and keywords of research papers. We retrieved 5701 publications from all the databases. After removing papers published before 2011 as well as duplicates and performing further screening, we were left with 244 articles, from which 33 were selected after in-depth analysis to compose the final publication portfolio. RESULTS: Our findings show the multidisciplinary nature of the research related to evaluating hospital investments in H4.0 technologies. We found that the most common investment approaches focused on cost analysis, single technology, and single decision-maker involvement, which dominate bundle analysis, H4.0 technology value considerations, and multiple decision-maker involvement. CONCLUSIONS: Some of our findings were unexpected, given the interrelated nature of H4.0 technologies and their multidimensional impact. Owing to the absence of a more holistic approach to H4.0 technology investment decisions, we identified five promising research directions for the topic: development of economic valuation methodologies tailored for H4.0 technologies; accounting for technology interrelations in the form of bundles; accounting for uncertainties in the process of evaluating such technologies; integration of administrative, medical, and patient perspectives into the evaluation process; and balancing and handling complexity in the decision-making process.

Predicting special care during the COVID-19 pandemic: a machine learning approach.

More than ever, COVID-19 is putting pressure on health systems worldwide, especially in Brazil. In this study, we propose a method based on statistics and machine learning that uses blood lab exam data from patients to predict whether patients will require special care (hospitalization in regular or special-care units). We also predict the number of days the patients will stay under such care. The two-step procedure developed uses Bayesian Optimisation to select the best model among several candidates. This leads us to final models that achieve 0.94 area under ROC curve performance for the first target and 1.87 root mean squared error for the second target (which is a 77% improvement over the mean baseline)-making our model ready to be deployed as a decision system that could be available for everyone interested. The analytical approach can be used in other diseases and can help to plan hospital resources in other contexts.