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.

Hospital Civil de Santiago de Cuba: una historia de cambios, dificultades y realizaciones / Civil Hospital of Santiago de Cuba: a history of changes, difficulties and realizations i: en

El Hospital Civil de Santiago de Cuba fue fundado en 1863 y, desde entonces, se ha mantenido prestando asistencia a pacientes de esta provincia y de toda la región oriental. En 1960 fue trasladado a su sede actual y se convirtió en pilar fundamental del inicio de la docencia médica superior para todo el oriente de Cuba. Es mencionado en varios textos desde el siglo XIX, mas se desconoce su creación y trayectoria. En ese sentido, luego de una revisión exhaustiva de documentos y periódicos de la época, se realizó el presente artículo con el objetivo de describir la evolución de este centro y los contextos históricos fundamentales.

The Civil Hospital of Santiago de Cuba was founded in 1863 and, since that time, it has given assistance to patients of this province and of all east region. In 1960 it was transferred to the current head office and became fundamental column in the beginning of higher medical teaching for the whole east of Cuba. It is mentioned in several texts from the XIX century, but its creation and trajectory is not known. In that sense, after an exhaustive review of documents and newspapers of that time, the present work was carried out aimed at describing the evolution of this center and the fundamental historical contexts.

¿Qué intervenciones se han realizado en el sistema de salud con impacto en las atenciones de morbilidad y urgencia en APS?: síntesis rápida de evidencia / What interventions have been carried out in the health system with an impact on morbidity and emergency care in PHC?: rapid evidence synthesis

ANTECEDENTES Y OBJETIVO En Chile la atención primaria de salud (APS) cuenta con un servicio de urgencia (SAPU) y los Servicios de Atención Primaria de Urgencia de Alta Resolutividad (SAR) que ofrecen atenciones de emergencia de baja complejidad durante el horario no hábil. Estos servicios se suelen utilizar como sustituto de la atención de morbilidad, significando que el beneficiario recibe solo una atención por el episodio agudo, sin considerar la continuidad de los servicios de APS. En este contexto, la División de Atención Primaria (DIVAP) solicita esta síntesis de evidencia, con el objetivo de conocer las intervenciones realizadas en el sistema de salud que tienen impacto en el número de atenciones de urgencia y morbilidad de la atención primaria. METODOLOGÍA Se formuló una estrategia de búsqueda para ser utilizada en las bases de datos MEDLINE, EMBASE y en Epistemonikos, con fecha 06 de marzo. Se incluyen documentos que contemplen intervenciones realizadas en APS, en el sistema de salud, que reporten efecto en la atención de urgencia y ambulatoria. Se excluyen intervenciones que reportan impacto en contextos hospitalarios, estudios enfocados en la percepción y razones sobre el uso de urgencias en APS. RESULTADOS Se recuperaron 13 revisiones sistemáticas -Se han propuesto diferentes modelos de organización de la atención para enfrentar la problemática de consultas fuera del horario en atención primaria. Solo 2 de estos modelos reportan resultados en el número de atención de morbilidad y fuera de horario en APS. -No se encontraron RS enfocadas en el impacto de la calidad de la atención de morbilidad ni fuera de horario en APS. -Las intervenciones identificadas que miden el impacto en atención fuera de horario en APS corresponden a educación, programas clínicos e intervenciones a nivel de sistema. -Las intervenciones que miden el impacto en la atención de morbilidad corresponden a triage en el horario de extensión de APS e intervenciones a nivel de sistema. -La mayoría de las intervenciones encontradas se centran en intervenciones o cambios en el sistema de salud realizadas durante la década de 1990 y 2000 en países europeos como Países Bajos y el Reino Unido.

¿Qué intervenciones se han realizado en el sistema de salud con impacto en las atenciones de morbilidad y urgencia en APS?: síntesis rápida de evidencia / What interventions have been implemented in the health health system with an impact on morbidity and emergency care in PHC?: rapid evidence synthesis

A nivel de atención primaria, Chile cuenta con un servicio de urgencia (SAPU) y Servicios de Atención Primaria de Urgencia de Alta Resolutividad (SAR) que ofrecen atenciones de emergencia de baja complejidad durante el horario no hábil. En muchas ocasiones, estos servicios se utilizan como sustituto de la atención de morbilidad, lo que significa que el beneficiario recibe solo una atención por el episodio agudo, sin considerar la continuidad e integralidad de los servicios de APS.

¿Cuál es el efecto de la actividad docente asistencial en establecimientos formadores en comparación con establecimientos no formadores sobre la productividad asistencial y la satisfacción usuaria?: síntesis rápida de evidencia / What is the effect of the teaching assistance activity in training establishments compared to non-training establishments on assistance productivity and non-user satisfaction?: rapid evidence synthesis

ANTECEDENTES Y OBJETIVO En Chile la relación asistencial-docente (RAD) está regulada por la norma técnica N°254. La RAD se define como un vínculo estratégico y de largo plazo, que une al Sector Público de salud con instituciones de educación superior. Ésta tiene como objetivo formar y disponer de profesionales y técnicos competentes para satisfacer las necesidades de salud de la población, beneficiando la calidad de atención que reciben los usuarios del Sistema Nacional de Salud (SNSS). En esta norma, se considera a la RAD como un eje estratégico para el sistema de salud. En este contexto el departamento de Formación, Capacitación y Educación Continua ha solicitado el desarrollo de una síntesis de evidencia, con el objetivo de conocer el efecto que tiene la formación académica sobre la productividad asistencial, y de esta manera entregar información actualizada y relevante para el proyecto de ley que regula la RAD. METODOLOGÍA Se buscaron revisiones sistemáticas que respondieron la pregunta en las bases de datos MEDLINE y EMBASE a través de OVID y en Epistemonikos, con fecha 01 de marzo. Se utiliza la metodología de la certeza de evidencia GRADE. Se incluyen estudios que evalúen la relación docente-asistencial sobre parámetros de productividad o satisfacción usuaria. Se excluyen estudios que evaluaron el efecto sobre educación al usuario, producción en investigación o percepciones de profesionales de salud, sobre el efecto de la educación virtual o de simulación y estudios de RAD exclusivo en pasantías internacionales. RESULTADOS La cantidad de revisiones sistemáticas recuperadas fueron 2, de las que se obtuvieron los siguientes resultados: - Existe alta incertidumbre de la evidencia sobre el efecto de la RAD en desenlaces de productividad o satisfacción usuaria. - De manera general, los datos sugieren que no habría diferencias importantes en la atención o satisfacción usuaria, cuando hay o no presencia de estudiantes. - La docencia asistencial es considerada fundamental para la capacitación y formación de recursos humanos en salud, tanto a nivel nacional como internacional.

Development of a Professional Practice Nursing Model for a University Nursing School and Teaching Hospital: A nursing methodology research.

AIM: The aim of the study was to describe the process of developing a Professional Practice Model by a Nursing School and Nursing Department of University Hospital. DESIGN AND METHOD (S): This is a descriptive nursing methodology research, developed along three stages: preliminary, empirical and validation. The empirical phase used qualitative and quantitative methodology. 28 teachers from the nursing school and nurses from the hospital participated. We defined the elements of the nursing meta-paradigm from narratives and focus group. Then, we extracted propositions regarding the nature of nursing from the relationship between the meta-paradigm elements, which concluded in the core elements. RESULTS: The core elements of this nursing professional practice model are nursing seeks the well-being of the person, family or group; nursing is total and global, person-centred; nursing is compassionate; nursing entails up-to-date, quality scientific, technical and human competencies; nursing is delivered in a teaching hospital environment, with a Christian ethical perspective.

Risk Factors for Malfunction of Ventriculoperitoneal Shunts Performed by Medical Residents in Children: An Exploratory Study / Fatores de risco para disfunção de derivações ventrículo-peritoneais realizadas por médicos residentes em crianças: Estudo exploratório

Introduction Ventriculoperitoneal shunts (VPSs) are common neurosurgical procedures, and in educational centers, they are often performed by residents. However, shunts have high rates of malfunction due to obstruction and infection, especially in pediatric patients. Monitoring the outcomes of shunts performed by trainee neurosurgeons is important to incorporate optimal practices and avoid complications. Methods In the present study, we analyzed the malfunction rates of VPSs performed in children by residents as well as the risk factors for shunt malfunction. Results The study included 37 patients aged between 0 and 1.93 years old at the time of surgery. Congenital hydrocephalus was observed in 70.3% of the patients, while 29.7% showed acquired hydrocephalus. The malfunction rate was 54.1%, and the median time to dysfunction was 28 days. Infections occurred in 16.2% of the cases. Cerebrospinal fluid leukocyte number and glucose content sampled at the time of shunt insertion were significantly different between the groups (p » 0.013 and p » 0.007, respectively), but did not have a predictive value for shunt malfunction. In a multivariate analysis, the etiology of hydrocephalus (acquired) and the academic semester (1st) in which the surgery was performed were independently associated with lower shunt survival (p » 0.009 and p » 0.026, respectively). Conclusion Ventriculoperitoneal shunts performed in children by medical residents were at a higher risk of malfunction depending on the etiology of hydrocephalus and the academic semester in which the surgery was performed.

Introdução As derivações ventrículo-peritoneais (DVPs) são procedimentos neurocirúrgicos comuns e, em centros educacionais, muitas vezes são realizados por residentes. No entanto, os shunts apresentam altas taxas de mau funcionamento devido a obstrução e infecção, especialmente em pacientes pediátricos. O monitoramento dos resultados das válvulas realizadas por neurocirurgiões em treinamento é importante para incorporar as práticas ideais e evitar complicações. Métodos No presente estudo, analisamos as taxas de mau funcionamento de DVPs realizados em crianças por residentes, assim como os fatores de risco para mau funcionamento da válvula. Resultados O estudo incluiu 37 pacientes com idades entre 0 e 1,93 anos na época da cirurgia. Hidrocefalia congênita foi observada em 70,3% dos pacientes, enquanto 29,7% apresentaram hidrocefalia adquirida. A taxa de disfunção foi de 54,1% e o tempo médio para disfunção foi de 28 dias. Infecções ocorreram em 16,2% dos casos. O número de leucócitos do líquido cefalorraquidiano e o conteúdo de glicose coletados no momento da inserção da válvula foram significativamente diferentes entre os grupos (p » 0,013 e p » 0,007, respectivamente), mas não tiveram um valor preditivo para o mau funcionamento da válvula. Em uma análise multivariada, a etiologia da hidrocefalia (adquirida) e o semestre letivo (1°) em que a cirurgia foi realizada foram independentemente associados a menor sobrevida do shunt (p » 0,009 e p » 0,026, respectivamente). Conclusão: Derivações ventrículo-peritoneais realizadas em crianças por médicos residentes apresentaram maior risco de mau funcionamento dependendo da etiologia da hidrocefalia e do semestre letivo no qual a cirurgia foi realizada.

The importance of the therapeutic care plan in colorectal surgery in a teaching hospital

Introduction: A therapeutic plan is elaborated based on the health needs of each user, allowing a multidisciplinary team to assess diagnoses, treatment options, bonds, and optimal hospitalization time. Objectives: To identify risk management tools already used and implemented in a reference teaching hospital in the city of São Paulo and to analyze their application and risk factors in medium and large colorectal surgery. Method: Observational, longitudinal, and prospective study, with 30 patients with colorectal disease hospitalized in the surgical ward of the coloproctology service and in need of surgical treatment. In the first group, the protocol was applied with the knowledge of the researcher only, and, in the second group, with the knowledge of both the researcher and the attending physicians. Results: Sixty percent of the patients were female with a mean age of 60.93 years and body mass index (BMI) of 26.07 Kg/m2. After surgery, patients in the first group who did not receive venous thromboembolism (VTE) prophylaxis in the first 24 hours had an increased risk of having the event compared with those who returned to prophylaxis (p<0.005), thus suggesting this prophylaxis was a protective factor against thromboembolic event (p=0.006). This group also had a higher risk of hypoglycemia when no strict control was performed (p=0.041). Conclusion: The compliance to hospital protocols with applicationmonitoring, notedly in teaching places with annual admission of resident physicians, is a fundamental part of the adequate care of the patient combined with the implementation of therapeutic plans. (AU)

Risk score for failed trial of vaginal birth after a previous cesarean section including data of labor course.

AIM: There is much discussion about the advantages and disadvantages of a trial of labor after cesarean (TOLAC). Some data suggest the greater the likelihood of success, the lower the risks of TOLAC. Our goal was to identify clinical and demographic variables associated with a failed TOLAC, available at admission for spontaneous labor and until 3 h later, with the aim of building two scores for risk of failed TOLAC. METHODS: This is a nested case-control study with live births to women with one previous cesarean, in a public Brazilian teaching hospital. Preterm, induction, noncephalic presentations, twins, fetal malformations were excluded. Cases were failed TOLAC, and controls, the successful TOLAC. It was accessed the association of the cases with 20 variables (P < 0.05). Associated variables were tested in multivariate analysis to build the scores, which were internally validated. RESULTS: We included 260 TOLAC, 42 cases and 218 controls. We found 11 variables associated with failed TOLAC. In the score to be applied at admission, we included hypertension, fundal height, previous vaginal birth and dilatation at admission. In the second score hypertension, fundal height at admission, membrane status and difference in dilatation 3 h after admission. Both scores presented good performance in the receiver-operator curve (areas under curve: 0.73 and 0.84, respectively). Both scores were translated into nomograms for clinical use. CONCLUSION: Two scores were built for risk of failed TOLAC, to be applied at admission and 3 h later. We believe that choosing the more favorable cases makes risks of TOLAC lower.

Performance of nurses in the bed management service of a teaching hospital / Actuación de enfermeros en la gestión de camas de un hospital - escuela / Atuação de enfermeiros na gestão de leitos de um hospital de ensino

ABSTRACT Objectives: to analyze the performance of nurses in the Bed Management service of a public teaching hospital. Methods: descriptive, qualitative research inspired by Dubois theoretical model. 32 participants from the bed management unit and care units of a public hospital were interviewed from February to May 2018. Observations and data records from the Bed Management service complemented data collection. Theme/Category-Based Content Analysis was used. Results: the performance of nurses was described in three analysis matrices, represented by the categories: acquisition, implementation and maintenance of nursing resources; transformation of nursing resources into nursing service and results of the work of the nurse in Bed Management. Final Considerations: understanding the performance of nurses in bed management contributes to the scenario of new practices and different roles that favor visibility and strengthening of the nurse's identity.

RESUMEN Objetivos: analizar la actuación de los enfermeros en la gestión de camas de un hospital-escuela público. Métodos: se trata de una investigación descriptiva, cualitativa, inspirada en el modelo teórico de Dubois. Se entrevistaron 32 participantes de la unidad de Gestión de Camas y de las unidades asistenciales de un hospital público, durante el período comprendido entre febrero y mayo de 2018. La observación y el registro de los datos del servicio de gestión de camas complementaron la recolección y para su clasificación, se utilizó el Análisis de Contenido Temático Categorial. Resultados: el desempeño del enfermero se reveló en tres matrices de análisis, representadas por las categorías: adquisición, implementación y mantenimiento de los recursos de enfermería; transformación de los recursos de enfermería en servicios de enfermería; y resultados del trabajo del enfermero en la Gestión de Camas. Consideraciones Finales: es evidente que el desempeño de los enfermeros en la gestión de camas contribuye con el escenario de nuevas prácticas y diferentes roles a favor de la visibilidad y el fortalecimiento de la identidad del enfermero.

RESUMO Objetivos: analisar a atuação de enfermeiros na gestão de leitos de um hospital público de ensino. Métodos: trata-se de uma pesquisa descritiva, qualitativa, inspirada no modelo teórico de Dubois. Foram entrevistados 32 participantes da unidade de gestão de leitos e unidades assistenciais de um hospital público no período de fevereiro a maio de 2018. A observação e os registros de dados do serviço de Gestão de Leitos complementaram a coleta. Utilizou-se a Análise de Conteúdo Temático Categorial. Resultados: a atuação do enfermeiro foi desvelada em três matrizes de análise, representadas pelas categorias: aquisição, implementação e manutenção de recursos de enfermagem; transformação de recursos de enfermagem em serviços de enfermagem; e resultados do trabalho do enfermeiro da Gestão de Leitos. Considerações Finais: entender como a atuação de enfermeiros na Gestão de Leitos contribui no cenário de novas práticas e diferentes papéis em prol da visibilidade e fortalecimento da identidade do enfermeiro.

Atuação do enfermeiro na gestão de leitos / Nurse's role in bed management

A Gestão de Leitos está respalda pela Política Nacional de Atenção Hospitalar por meio da Portaria n° 3.390 de 30 de dezembro de 2013 com vistas à uma otimização de leitos hospitalares, em resposta a um cenário de exigência orçamentária restritiva e necessidade de melhor integração da rede de atenção. A gestão interna de leitos é ainda uma atividade em construção, mas é considerado um campo inovador de atuação para enfermeiros. O serviço de gestão de leitos do Hospital de clínicas da Universidade Federal do Paraná iniciou em Outubro de 2015. O objetivo deste estudo consistiu em analisar a atuação do enfermeiro de uma unidade de gestão de leitos de um hospital público na perspectiva do modelo teórico de Dubois e autores. Trata-se de uma pesquisa descritiva qualitativa. Os dados foram obtidos por meio de entrevistas com cinco enfermeiros da Gestão de Leitos, 21 enfermeiros das unidades assistenciais e seis médicos residentes do Complexo Hospital de Clínicas (CHC). Os dados foram coletados por meio de entrevistas semiestruturadas, após a explicação dos objetivos do estudo aos participantes, e tiveram os áudios gravados e posteriormente transcritos. Contemplou ainda, observação com um total de 23 horas e complemento com dados do serviço, ambos relacionados aos enfermeiros da Gestão de Leitos. A coleta ocorreu nos meses de fevereiro a maio de 2018. A análise aconteceu por meio da Análise de Conteúdo Temático Categorial, com o uso do software MAXQDA® como recurso de operacionalização dos dados. Uma matriz de análise inspirada no modelo teórico de Dubois e autores (2013) foi previamente construída e utilizada para direcionar a análise dos dados. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa do Complexo Hospital de Clínicas/PR da Universidade Federal do Paraná, CAEE N° 73923417.1.0000.0096 em fevereiro de 2018. Os participantes foram selecionados por amostragem não probabilística, e após a aplicação dos critérios de inclusão e exclusão, totalizaram 32 participantes. A partir das categorias analíticas, emergiram subcategorias que possibilitaram dimensões que compreenderam o trabalho do enfermeiro na Gestão de leitos. O estudo foi submetido a teste piloto para adequação dos instrumentos do trabalho. Os resultados foram organizados na matriz de análise, compreendendo três categorias: Aquisição, implantação e manutenção de recursos de enfermagem; Transformação de recursos de enfermagem em serviços de enfermagem relevantes e; Resultados do trabalho do enfermeiro na Gestão de leitos. Entender como é atuação de enfermeiros no serviço de Gestão de Leitos é elemento crucial no cenário de novas práticas que circundam novos espaços e diferentes papéis em prol da visibilidade e fortalecimento de identidade para este profissional.

Bed Management is supported by the National Policy on Hospital Care, Order No. 3390 of December 30, 2013, which aims to optimize the hospital beds, in response to a restrictive budget scenario requirements and the need for better attention network integration. The internal bed management is still a business in progress, and it is considered an innovative work for nurses. The bed management service of the Complexo Hospital das Clínicas (Complex of Clinic Hospital) (CHC, Brazilian acronym), belonging to Federal University of Paraná, began in October 2015. This study aimed to analyze the nurse's performance in a Bed Management Unit in a public hospital under the perspective of the theoretical model of Dubois et al. (2013). This is a descriptive-qualitative research. Data were obtained by interviews with five nurses from the Bed Management Unit, twenty-one nurses from the care unit, and six physicians/residents of the CHC. Data were collected through semi-structured interviews after explaining the study objectives to the participants, and the respective audios were recorded and later they were transcribed. This study also included observation of twenty-three hours and was complemented with data from the service, both related to the Nurses of the Bed Management Unit. The data were collected from February to May 2018. The analysis was made by means of the Categorical Thematic Content Analysis, using MAXQDA® software as data operation resource. An analysis matrix inspired by the theoretical model of Dubois et al. (2013) was previously constructed and used to guide the data analysis. This study was approved by the Research Ethics Committee of the Complexo Hospital das Clínicas, belonging to Federal University of Paraná, Centro de Atendimento Educacional Especializado (Specialized Educational Assistance Center) (CAEE, Brazilian acronym) No. 73923417.1.0000.0096, in February 2018. Participants were selected by nonprobabilistic sampling and, after applying inclusion and exclusion criteria, amounted to thirty-two participants. Using analytical categories as base, subcategories emerged, which enabled dimensions that comprised the nurse's performance in Bed Management. This study was submitted to a pilot test for work tools adjustments. Results were organized in the analysis matrix, comprising three categories: (a) Acquisition, implantation, and maintenance of nursing resources; (b) Transformation of nursing resources in relevant nursing services; and (c) Nursing Work Results in Bed Management. Understanding how nurses work in Bed Management service is a crucial element in the new practice scenario that surround the new spaces and different roles in favor of the visibility and strengthening the identity of this professional.

Análise da taxa de geração de resíduos de serviços de saúde em um hospital universitário / Analisis de la tasa de produccion de residuos hospitalares en un hospital universitario / Analysis of the medical waste generation rate in a university hospital

Objective: to identify the medical waste generation rates (kg.bed-1.day-1) for the waste groups A, B, D (including recyclables) and E, and to verify seasonal influence in the generation of waste. Methods: Data were collected by weighing the waste, during seven consecutive days for four weeks, with each week correspondingto a season. Results: The waste generation rate presented the following values in kg.bed-1.day-1 for each group: A: 0.831, B: 0.088, D: 2,607, D-Recyclable: 0.525 and E: 0.102. Based on the analysis of variance (ANOVA) test, it was not found evidence that seasonality influences with the generation of the waste. Conclusion: Hospitals with similar numbers of beds have divergent values for the waste generation rates, therefore it was not possible to use a reference rate for comparison with other hospitals. Finally, the ANOVA test did not found evidence that seasonality influences the generation of the waste.

Objetivo: identificar as taxas de geração de resíduos do serviço de saúde (kg.leito-1.dia-1) para os grupos de resíduos A, B, D (incluindo os recicláveis) e E verificar a influência da sazonalidade na geração de resíduos. Métodos: Os dados foram coletados através de pesagens desses resíduos, durante sete dias consecutivos, em quatro semanas, sendo que cada semana contemplou uma estação do ano. Resultados: A taxa de geração de resíduos apresentou os seguintes valores em kg.leito-1.dia-1 para cada grupo: A: 0,831, B: 0,088, D:2,607, D-Recicláveis: 0,525 e E: 0,102. Através do teste ANOVA não foram encontradas evidências de que haja influência da sazonalidade na geração dos resíduos. Conclusão: Hospitais com número de leitos semelhantes apresentam taxas de geração de resíduos diferentes, portanto não foi possível utilizar uma taxa de geração de referência para comparação com outros hospitais. Ainda, o teste ANOVA não indicou que a sazonalidade influencia a geração de resíduos.

Objetivo: identificar las tasas de generación de desechos en los Servicios de Salud (kg.lecho-1.día-1) para los grupos A, B, D (incluyendo materiales reciclables) y E, y comprobar la influencia de la estacionalidad en la generación de desechos. Método: Los datos fueron colectados mediante el pesaje de los desechos, durante siete días consecutivos durante cuatro semanas, con cada semana a corresponder a una temporada. Resultados: La tasa de generación de desechos presentan los siguientes valores en kg.lecho-1.día-1 para cada grupo: A: 0,831, B: 0,088, D: 2607, D-Reciclable: 0.525 y E: 0.102. Con base en el análisis de varianza (ANOVA), no fueron encontradas evidencias de influencia de la estacionalidad en la generación de los desechos. Conclusión: Los hospitales con un número similar de lechos tienen tasas de generación de desechos divergentes, por lo queno fue posible utilizar un valor de referencia para la comparación con otros hospitales. Finalmente, el ANOVA no encontró evidencia de que la estacionalidad influye en la generación de los residuos.

A estrutura organizacional de serviços de enfermagem em hospitais de ensino / The organizational structure of nursing services in teaching hospitals

Resumo: Para atender aos objetivos de descrever a configuração da estrutura dos serviços de enfermagem; explorar as dimensões estruturais, formalização e descentralização destes serviços; e identificar as estratégias utilizadas pelos enfermeiros gerentes para organizar o cuidado em hospitais de ensino do Paraná-Brasil e Groningen-Holanda, foi realizada uma pesquisa de abordagem qualitativa, que se caracteriza como estudo de casos múltiplos. A pesquisa consistiu de 15 casos - 12 realizados no Paraná e 03 em Groningen. Foram realizadas entrevistas com 15 enfermeiros gerentes que ocupavam posição de destaque na estrutura organizacional destes hospitais, conduzidas por uma matriz elaborada com questões relacionadas à dimensão da divisão e coordenação do trabalho e outras para identificação de serviços de alta complexidade, trianguladas com a análise documental. Os dados foram coletados no Paraná de março a maio de 2014 e em Groningen, de abril a setembro de 2015. A teoria organizacional elaborada por Mintzberg foi utilizada para examinar as características e as relações entre os elementos da organização da estrutura de Enfermagem. O processo de análise e o cruzamento dos casos forneceu base para generalizações, e as estruturas dos serviços de enfermagem foram separadas em grupos. Posteriormente, foram exploradas as dimensões estruturais formalização e descentralização e suas variações. Para a identificação das estratégias utilizadas pelos enfermeiros gerentes para organizar o trabalho nos hospitais de ensino dos dois cenários, foi utilizada a análise temática de conteúdo e os seguintes temas emergiram: Definição da estrutura organizacional; Características dos trabalhadores; e As forças que influenciam o ambiente de trabalho. Baseando-se na abordagem metodológica e no modelo teórico, os resultados apontaram que os serviços de enfermagem apresentaram formas estruturais híbridas, com prevalência de estruturas profissionais e mecanicistas. Na estrutura dos serviços de Enfermagem pesquisados, foi encontrada a coexistência de alto grau de formalização e alto grau de descentralização; e alto grau de formalização e baixo grau de descentralização. Embora existam diferenças entre os dois países relacionadas à economia, população, sistema de saúde, entre outras, não houve diferença significativa entre o tipo de estratégia adotada pelos gerentes de enfermagem para organizar o seu trabalho. Concluiu-se que a melhor estrutura é a que melhor se adapta à situação do serviço, aos objetivos da organização, ao tipo de atividades desenvolvidas e ao ambiente externo. Outro aspecto é que as diferentes partes da estrutura podem exigir a diferenciação das funções e responsabilidades e diferentes níveis de descentralização e formalização do processo do trabalho para serem eficaz. Entende-se que os gerentes de enfermagem exercem papel fundamental na escolha e definição de elementos estruturais que irão determinar o tipo de estrutura organizacional do serviço e, consequentemente, a sua eficiência. Neste sentido, a principal contribuição desta pesquisa está relacionada à importância do gerente de enfermagem em encontrar um ponto de equilíbrio e coerência entre a estrutura adotada e as constantes mudanças nas demandas institucionais e dos sistemas de saúde para garantir um processo de trabalho alinhado aos objetivos organizacionais e às necessidades de saúde dos pacientes.

Abstract: The aim of the research was to describe the structure configuration of nursing services; explore the structural dimensions of formalization and decentralization of these services; and identify the strategies used by managers to organize nursing care in teaching hospitals of Paraná-Brazil and Groningen-Holland. It was held a qualitative approach research, which is characterized as a multiple case study. The survey consisted of 15 cases - 12 performed in Paraná and 03 in Groningen. 15 nurse-managers, who assumed a prominent position in the organizational structure of these hospitals, were interviewed. The survey was conducted by a matrix composed of questions about the dimension of division and coordination of work, and others, for identification of high complexity services, triangulated with document analysis. Data was collected in Paraná from March to May 2014, and in Groningen, from April to September 2015. The organizational theory developed by Mintzberg was used to examine the characteristics and relations among the elements of the organization of nursing structure. The process of analysis and cross cases provided the basis for generalizations, and the structures of nursing services were separated into groups. It was later explored the structural dimensions of formalization and decentralization and its variations. To identify the strategies used by managers to organize the nurses' work in teaching hospitals of the two scenarios, it was used the thematic analysis of content and the following themes emerged: Definition of the organizational structure; Characteristics of workers; and forces that influence the work environment. Based on the methodological approach and the theoretical model, the results showed that the nursing services presented hybrid structural forms, with prevalence of professional and mechanistic structures. In the structure of the surveyed nursing services, it has been found that there are high coexistence degree of formalization and high degree of decentralization; and high degree of formalization and low degree of decentralization. Although there are differences between the two countries, such as economy, population, health care, among others, there was no significant difference between the type of strategy adopted by nursing managers to organize their work. It was concluded that the best structure is the one that best fits the service situation, the organization's objectives, the type of activities developed, and the external environment. Another aspect is that different parts of the structure may require the differentiation of roles and responsibilities of the nurses, and different levels of decentralization and formalization of the labor process to be effective. It is understood that nursing managers play a fundamental role in the selection and definition of structural elements that will determine the type of organizational structure of the service and, therefore, its efficiency. In this sense, the main contribution of this research is related to the importance of nursing manager to find a balance point and between of the adopted structure and the constant changes in the institutional demands and health systems to ensure a working process aligned with organizational goals, and, consequently, the health needs of patients. Keywords: Organisational structure, Decentralization, Formalization, Nursing service, Management, Teaching hospital, Nursing; Strategies; Personnel Administration; Teaching hospitals. The aim of the research was to describe the structure configuration of nursing services; explore the structural dimensions of formalization and decentralization of these services; and identify the strategies used by managers to organize nursing care in teaching hospitals of Paraná-Brazil and Groningen-Holland. It was held a qualitative approach research, which is characterized as a multiple case study. The survey consisted of 15 cases - 12 performed in Paraná and 03 in Groningen. 15 nurse-managers, who assumed a prominent position in the organizational structure of these hospitals, were interviewed. The survey was conducted by a matrix composed of questions about the dimension of division and coordination of work, and others, for identification of high complexity services, triangulated with document analysis. Data was collected in Paraná from March to May 2014, and in Groningen, from April to September 2015. The organizational theory developed by Mintzberg was used to examine the characteristics and relations among the elements of the organization of nursing structure. The process of analysis and cross cases provided the basis for generalizations, and the structures of nursing services were separated into groups. It was later explored the structural dimensions of formalization and decentralization and its variations. To identify the strategies used by managers to organize the nurses' work in teaching hospitals of the two scenarios, it was used the thematic analysis of content and the following themes emerged: Definition of the organizational structure; Characteristics of workers; and forces that influence the work environment. Based on the methodological approach and the theoretical model, the results showed that the nursing services presented hybrid structural forms, with prevalence of professional and mechanistic structures. In the structure of the surveyed nursing services, it has been found that there are high coexistence degree of formalization and high degree of decentralization; and high degree of formalization and low degree of decentralization. Although there are differences between the two countries, such as economy, population, health care, among others, there was no significant difference between the type of strategy adopted by nursing managers to organize their work. It was concluded that the best structure is the one that best fits the service situation, the organization's objectives, the type of activities developed, and the external environment. Another aspect is that different parts of the structure may require the differentiation of roles and responsibilities of the nurses, and different levels of decentralization and formalization of the labor process to be effective. It is understood that nursing managers play a fundamental role in the selection and definition of structural elements that will determine the type of organizational structure of the service and, therefore, its efficiency. In this sense, the main contribution of this research is related to the importance of nursing manager to find a balance point and between of the adopted structure and the constant changes in the institutional demands and health systems to ensure a working process aligned with organizational goals, and, consequently, the health needs of patients.

[Costs of serious adverse events in a community teaching hospital, in Mexico]. / Costos de eventos adversos graves en un Hospital Comunitario de Enseñanza en México.

BACKGROUND: Serious adverse events during hospital care are a worldwide reality and threaten the safety of the hospitalised patient. OBJECTIVE: To identify serious adverse events related to healthcare and direct hospital costs in a Teaching Hospital in México. MATERIAL AND METHODS: A study was conducted in a 250-bed Teaching Hospital in San Luis Potosi, Mexico. Data were obtained from the Quality and Patient Safety Department based on 2012 incidents report. Every event was reviewed and analysed by an expert team using the "fish bone" tool. The costs were calculated since the event took place until discharge or death of the patient. RESULTS: A total of 34 serious adverse events were identified. The average cost was $117,440.89 Mexican pesos (approx. €7,000). The great majority (82.35%) were largely preventable and related to the process of care. Undergraduate medical staff were involved in 58.82%, and 14.7% of patients had suffered adverse events in other hospitals. CONCLUSIONS: Serious adverse events in a Teaching Hospital setting need to be analysed to learn and deploy interventions to prevent and improve patient safety. The direct costs of these events are similar to those reported in developed countries.

A case study of the implementation of a competency-based curriculum in a Caribbean Teaching Hospital / Un estudio de caso de la implementación de un currículo basado en competencias en un Hospital Docente del Caribe

OBJECTIVE: Several teaching hospitals are currently modifying their curriculum to comply with the changing demands in medical education. As a result, we decided to evaluate whether a competency-based curriculum implemented in a Caribbean teaching hospital fulfilled the requirements as defined by the CanMEDS framework. METHODS: We made use of a triangulation method in the survey to obtain information on the educational process. Two separate methods were used consisting of site visits by visiting professors and a medical educator. The focus was on the structure, content and assessments of the educational activities. RESULTS: Major recommendations included increased involvement of medical specialists in the educational activities in the clinical workplace. There was need for improvement of communication between medical specialists, patients, nurses, trainees and residents. Overall, improvements were observed in the structure of clinical rotations and content of the training programme. CONCLUSION: The implemented assessment programme provided necessary information for effective evaluation of the competency-based curriculum. We were able to identify new and feasible methods for improving the curriculum in our educational setting.

OBJETIVO: Varios hospitales docentes están actualmente modificando sus currículos a fin de satisfacer las demandas cambiantes de la educación médica. Por tal motivo, se tomó la decisión de evaluar si un currículo basado en competencias puesto en marcha en un hospital docente del Caribe cumplía con los requerimientos definidos por el programa de formación médica conocido como CanMEDS Framework. MÉTODOS: Se hizo uso de un método de triangulación en el estudio, a fin de obtener información sobre el proceso educativo. Se usaron dos métodos separados consistentes en visitas de inspección realizadas por profesores visitantes y un educador médico. La atención se centró en la estructura, el contenido, y la evaluación de las actividades educativas. RESULTADOS: Las recomendaciones principales incluyeron la necesidad de aumentar la participación de médicos especialistas en el lugar donde los estudiantes realizan su trabajo clínico. Se vio la necesidad de mejorar la comunicación entre especialistas médicos, pacientes, enfermeras, entrenados, y residentes. En general, se observaron mejoras en la estructura de las rotaciones clínicas y el contenido de los programas de entrenamiento. CONCLUSIÓN: El estudio realizado proveyó la información necesaria para la evaluación efectiva del currículo basado en competencias, e hizo posible identificar métodos nuevos y factibles para mejorar los planes de estudio en nuestro contexto educacional.

Asociación entre la presencia de estudiantes de medicina y los indicadores de calidad en pacientes obstétricas en un hospital universitario de Bogotá, Colombia: estudio de corte transversal / A cross-sectional study of the association between the presence of medical students attending obstetric patients and indicators of their healthcare quality in a teaching hospital in Bogotá, Colombia

Objetivo: determinar si la presencia de estudiantes de medicina se asocia a diferencias en los indicadores de calidad de la atención y en la satisfacción de las pacientes obstétricas. Materiales y métodos: estudio de corte transversal. Se incluyeron pacientes hospitalizadas para atención de parto durante dos periodos: uno con la presencia estudiantes y otro sin estudiantes de medicina en el servicio de Obstetricia del Hospital Universitario Clínica San Rafael de Bogotá (HUCSR), institución general de alta complejidad, durante el periodo comprendido entre el primero de diciembre de 2005 y el 15 marzo de 2006. Tamaño muestral estimado: 278 pacientes. Se midieron las variables sociodemográficas, los antecedentes obstétricos, los resultados maternos y perinatales, los indicadores de satisfacción desde el punto de vista de la paciente, y la duración de la estancia hospitalaria. Resultados: los dos grupos comparados fueron similares en sus características basales. No se encontraron mayores diferencias en la estancia, incidencia de infecciones, porcentaje de cesáreas y satisfacción de la paciente. Conclusiones: la presencia de estudiantes de medicina no se encuentra asociada a malos resultados maternos o perinatales o a la satisfacción con la atención recibida. Se requieren estudios controlados adicionales para determinar con mayor validez el verdadero impacto de la rotación de estudiantes de medicina en la calidad de la atención y la satisfacción de las usuarias.

Objective: Determining whether the presence of medical students is associated with differences in indicators of obstetric patients’ healthcare quality and their satisfaction with such service. Materials and methods: A cross-sectional study was carried on obstetric patients hospitalized for labor and delivery from 1st December 2005 to 15th March 2006 at the San Rafael teaching hospital. This is a high complexity general institution located in Bogota, Colombia. There were two study periods; the first did not involve medical students whereas they were present during the second study period Estimated sample size was 278 patients. Sociodemographic variables, obstetric background, maternal and perinatal results and indicators of patient satisfaction and hospital stay duration (in hours) were measured. Results: Comparing both groups revealed similar base characteristics; no major differences were presented regarding hospital stay, incidence of infection, percentage of caesareans or patient satisfaction. Conclusions: The presence of medical students around obstetric patients was not associated with poor maternal or perinatal results or patient satisfaction with the attention being received. Further controlled studies (implying greater validity) are required for determining the true impact of rotating medical students regarding the quality of healthcare attention and user satisfaction.

Satisfacción con la atención médica de pacientes hospitalizados en un servicio clínico docente y en uno no docente / Satisfaction of health care in hospitalized patients in a teaching hospital and a non teaching hospital

Introducción: En Chile, una proporción importante de hospitales públicos son docente-asistenciales. El objetivo del presente estudio fue determinar y comparar los niveles de satisfacción con la atención médica entre un centro asistencial docente y uno no docente. Material y método: Estudio de corte transversal. Se aplicó un cuestionario para evaluar satisfacción con la atención médica y grado de aceptación hacia estudiantes de Medicina, a pacientes hospitalizados en servicios de urología del Hospital Dr. Gustavo Fricke (no docente) y Hospital Carlos Van Buren (docente), entre septiembre y noviembre de 2009. Se utilizó razón de validez de contenido (CVR) como criterio de inclusión para los diferentes ítems del cuestionario final, que consideró 14 ítems, además de evaluarse su consistencia interna. Resultados: Fueron encuestados 140 pacientes en total, 70 de cada servicio. No hubo diferencia en la satisfacción por servicio (90 por ciento y 88,6 por ciento). Respecto a las variables demográficas, hubo diferencia en edad, proporción de pensionados, y nivel educacional, por servicios La única variable que mostró asociación con satisfacción fue el sexo, apreciándose en un 95 por ciento de hombres contra un 81,4 por ciento de mujeres (p=0,01). Un 94,3 por ciento de los pacientes aceptó la presencia de los estudiantes en el servicio docente. Discusión: En la muestra estudiada, estar internado en uno u otro centro no afectó la satisfacción de los pacientes. La única variable que se asoció a la satisfacción fue el ser hombre, y la presencia del estudiante fue aceptada por la gran mayoría de pacientes.

Material and method: Cross-sectional study. A survey was carried out to evaluate satisfaction with health care and the level of acceptance of medical students by hospitalized patients in urology services in Gustavo Frike Hospital (non teaching) and Carlos Van Buren (teaching), between September and November of 2009. Content validity ratios (CVR) was used as inclusion criteria for the 14 different items on the questionnaire, and it was evaluated for internal consistency. Results: 140 patients completed the questionnaire, 70 at each hospital. There was no difference in the level of satisfaction between hospitals (90 percent and 88.6 percent). With respect to the demographic variables, between the two hospitals there were differences according to age of patients, proportion of retirees, and level of education. The only variable that was associated with satisfaction was sex, found in 95 percent of men and 81.4 percent of women (p=0.01). 94.3 percent of patients accepted the presence of students at the teaching hospital. Discussion: In this sample, hospitalization in the teaching or the non teaching hospital did not affect patient satisfaction. The only variable that was associated with satisfaction was sex, and the presence of students was accepted by the majority of patients.

Caracterização, motivação e nível de satisfação dos técnicos de enfermagem de um hospital universitário / Characterization, motivation and satisfaction level of nursing technicians of a university hospital / Caracterización, Motivación y Nivel de Satisfacción de los técnicos de enfermería de un hospital universitario

A qualidade do trabalho organizacional é influenciada pelas características dos profissionais. A enfermagem envolve múltiplas categorias e atividades. A seleção de pessoal é responsável pela entrada na empresa de profissionais com competências adequadas ao serviço. Buscou-se identificar o perfil dos técnicos de enfermagem (TE) de um hospital universitário do Centro-Oeste brasileiro. Os dados foram coletados através de questionário estruturado, aplicado pela pesquisadora na unidade, de fevereiro a julho de 2008. A amostra reuniu 185 TE, dos quais 57,8% citaram a estabilidade no emprego como fator influenciador na escolha da instituição de trabalho. Como fator de insatisfação, a estrutura da unidade alcançou 60%. Os TE que visam integrar um hospital universitário necessitam desenvolver competências para trabalharem em uma perspectiva de integralidade para atender as diretrizes do Sistema Único de Saúde, do ensino, da assistência e da pesquisa em saúde. Conclui-se que esses resultados podem auxiliar os gestores no replanejamento do processo seletivo.

Quality of organizational work is dependent on the professionals hired. Nursing involves multiple categories and activities. Selection of staff accounts for admission of professionals with appropriate job expertise. The study aims at identifying the profile of nursing technicians (NT) at a university hospital in the Brazilian Midwest. Data were collected through a structured questionnaire applied between February and July, 2008 by the researcher in the hospital unit. The sample consisted of 185 NT. Out of the total sample, 57.80% cited job security as an influential factor in the choice of the institution as a workplace. As a factor of dissatisfaction, the structure of the unit came up with 60%. The NT interested in joining a university hospital must develop skills to acquire a comprehensive view of the whole and to meet the needs of the Single Health System, education, care and health research. The results presented can help managers redefine the recruiting process.

La calidad de los trabajos de organización es influenciada por las características de los profesionales. La enfermería implica múltiples categorías y múltiples actividades. La selección de personal es responsable por la entrada en la institución de profesionales con competencias adecuadas al servicio. Se buscó identificar el perfil de técnicos de enfermería (TE) de un hospital universitario en el Centro-Oeste de Brasil. Los datos fueron recolectados a través de cuestionario estructurado, aplicado por la investigadora en la unidad, entre febrero y julio de 2008. La muestra consistió de 185 TE, de los cuales 57,80% citaran la estabilidad en el empleo como un factor que influyó en la elección de la institución de trabajo. Como factor de insatisfacción, la estructura de la unidad alcanzó 60%. Los TE que buscan integrar un hospital universitário necesitan desarrollar habilidades para trabajar en una visión integral para satisfacer las necesidades del Sistema Único de Salud, de la educación, de la atención y de la investigación en salud. Se concluye que esos resultados pueden ayudar los administradores en el rediseño del proceso de selección.

Fundamentos iniciais para o planejamento funcional do Instituto do Coração / First principles for the functional planning of Heart Institute

No dia 26 de maio de 1968, o cirurgião Euryclides Zerbini e sua equipe realizaram o primeiro transplante cardíaco da América Latina, alcançando prestígio mundial pouco tempo depois de o doutor Christian Barnard ter realizado, na África do Sul, a primeira experiência desse tipo em todo o mundo. Como resultado e com o incondicional apoio do então governador de São Paulo, Senhor Laudo Natel, e do chefe da sua Casa Civil, doutor Henri Aidar, a quemo Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (USP) estava subordinado, se deu início a preparação de projetos do futuro Instituto do Coração, o InCor. Foi constituído um grupo de trabalho multi profissional, com representantes das principais futuras áreas ou departamentos do hospital que, juntos,preparariam o InCor para ser um dos mais importantes centros médicos do país. Todas as futuras unidades foram planejadas para operar em conjunto e harmoniosamente: internação, laboratórios, métodos gráficos, serviço social, psicologia, farmácia, terapia intensiva, anestesia, nutrição, bioengenharia etc. Toda documentação para a parte funcional seria organizada sob a forma de manuais... Durante anos, os hospitais evoluíram para serem instituições confiáveis por meio dos notáveis avanços da Medicina moderna. Essas instituições não somente oferecem assistência médica, mas extensivos programas de desenvolvimento e investigações, educação e ensino. Sua enorme importância no setor Saúde, além de enfocar a atenção à Saúde e pesquisas científicas, tem peso razoável nos investimento nacionais, já que absorve aproximadamente 50 por cento dos gastos com saúde. A racionalização das atividades nosocomiais por meio de um planejamento funcional, mesmo antes de o hospital iniciar suas operações, contribui para o controle racional dos custos hospitalares, já que é observado o lema “a função precede a forma” pois o tamanho e distribuição de insumos são determinados pelos serviços que pretende oferecer...