Partnership among hospitals to reduce healthcare associated infections: a quasi-experimental study in Brazilian ICUs.

BACKGROUND: Healthcare-associated infections (HAIs) are relevant in developing countries where frequencies can be at least 3 times higher than in developed countries. The purpose of this research was to describe the intervention implemented in intensive care units (ICUs) to reduce HAIs through collaborative project and analyze the variation over 18 months in the incidence density (ID) of the three main HAIs: ventilator associated pneumonia (VAP), central line-associated bloodstream infections (CLABSIs) and catheter-related urinary tract infections (CAUTIs) and also the length of stay and mortality in these ICUs. METHODS: A quasi-experimental study in five public adult clinical-surgical ICUs, to reduce HAIs, through interventions using the BTS-IHI "Improvement Model", during 18 months. In the project, promoted by the Ministry of Health, Brazilian philanthropic hospitals certified for excellence (HE), those mostly private, certified as excellence and exempt from security contributions, regularly trained and monitored public hospitals in diagnostics, data collection and in developing cycles to improve quality and to prevent HAIs (bundles). In the analysis regarding the length of stay, mortality, the IDs of VAP, CLABSIs and CAUTIs over time, a Generalized Estimating Equation (GEE) model was applied for continuous variables, using the constant correlation (exchangeable) between assessments over time. The model estimated the average difference (ß coefficient of the model) of the measures analyzed during two periods: a period in the year 2017 (prior to implementing the project) and in the years 2018 and 2019 (during the project). RESULT: A mean monthly reduction of 0.427 in VAP ID (p = 0.002) with 33.8% decrease at the end of the period and 0.351 in CAUTI ID (p = 0.009) with 45% final decrease. The mean monthly reduction of 0.252 for CLABSIs was not significant (p = 0.068). Length of stay and mortality rates had no significant variation. CONCLUSIONS: Given the success in reducing VAP and CAUTIs in a few months of interventions, the achievement of the collaborative project is evident. This partnership among public hospitals/HE may be applied to other ICUs including countries with fewer resources.

Implementation and Evaluation of a Military-Civilian Partnership to Train Mental Health Specialists.

INTRODUCTION: Mental health specialists (MHS, or 68X) play a central role in meeting the growing demand for combat stress care among Service Members. Partnering with civilian institutions may enhance the MHS training experience beyond Advanced Individual Training (AIT). METHODS: We describe a novel military-civilian collaboration to train U.S. Army Reserve MHS's in the psychiatric emergency service (PES) of a public, safety-net hospital. Details of implementation are described. The training rotation was evaluated after 1 year through a comprehensive chart abstraction of patients seen as well as surveys of MHS's and civilian partners. RESULTS: The roles of MHS and physician officers in this rotation are described. Over 9 days in the PES, the MHS team evaluated 26 patients. MHS's described a high-quality training environment (83% rated very good or excellent) in which they frequently saw high-risk patients relevant to military practice. Experience with a certain patient presentation was correlated with comfort assessing and managing that presentation (p < 0.01). Many civilian staff (40%) felt the PES operated better with the presence of the Army team and 50% of civilians agreed their impression of the U.S. Army Reserve improved as a result of the partnership. Hundred percent of specialists and 80% of civilians reported very good to excellent rapport between military and civilian staff. Two civilian respondents (11%) expressed concern that the military team's presence impeded patient care. CONCLUSION: This is the first military-civilian training collaboration for behavioral health specialists, who have already completed AIT. This program provided well-received and mission-relevant training for MHS's without notable adverse effects on patient care or team functioning in a civilian environment. Our findings are based on a small sample size, and no other such programs exist against which to compare these results. We propose that such educational partnerships, which have long been effective for other clinical specialists, may benefit the military, civilian communities, and the country.

[Variation in hospital performance according to payment sources in the states of São Paulo and do Rio Grande do Sul, Brazil]. / Variação do desempenho hospitalar segundo fontes de pagamento nos estados de São Paulo e Rio Grande do Sul, Brasil.

In Brazil, the combined presence of public and private interests in financing and provision of healthcare services stands out clearly in hospital care. Financing arrangements adopted by hospitals (the public Brazilian Unified National Health System - SUS and/or health plans and/or out-of-pocket payment) can affect quality of care. Studies have analyzed the hospital standardized mortality ratio (HSMR) in relation to quality improvements. The objective was to analyze HSMR according to source of payment for the hospitalization and the hospital's financing arrangement. The study analyzed secondary data and causes that accounted for 80% of hospital deaths. HSMR was calculated for each hospital and payment source. Hospitals with worse-than-expected performance (HSMR > 1) were mostly large public hospitals. HSMR was higher in the SUS, including between admissions in the hospital. Despite the study's limitations, the findings point to inequalities in results of care. Efforts are needed to improve the quality of hospital services, regardless of the payment sources.

Variação do desempenho hospitalar segundo fontes de pagamento nos estados de São Paulo e Rio Grande do Sul, Brasil / Variation in hospital performance according to payment sources in the states of São Paulo and do Rio Grande do Sul, Brazil / Variación del desempeño hospitalario según fuentes de pago en los estados de São Paulo y de Río Grande do Sul, Brasil

Resumo: No Brasil, a convivência público-privado no financiamento e na prestação do cuidado ganha nítidos contornos na assistência hospitalar. Os arranjos de financiamento adotados pelos hospitais (Sistema Único de Saúde - SUS e/ou planos de saúde e/ou pagamento particular) podem afetar a qualidade do cuidado. Alguns estudos buscam associar a razão de mortalidade hospitalar padronizada (RMHP) a melhorias na qualidade. O objetivo foi analisar a RMHP segundo fonte de pagamento da internação e arranjo de financiamento do hospital. Analisaram-se dados secundários e causas responsáveis por 80% dos óbitos hospitalares. A RMHP foi calculada para cada hospital e fonte de pagamento. Hospitais com desempenho pior que o esperado (RMHP > 1) foram majoritariamente públicos de maior porte. A RMHP nas internações SUS foi superior, inclusive entre internações no mesmo hospital. Apesar dos limites, os achados indicam iniquidades no resultado do cuidado. Esforços voltados para a melhoria da qualidade de serviços hospitalares, independentemente das fontes de pagamento, são prementes.

Abstract: In Brazil, the combined presence of public and private interests in financing and provision of healthcare services stands out clearly in hospital care. Financing arrangements adopted by hospitals (the public Brazilian Unified National Health System - SUS and/or health plans and/or out-of-pocket payment) can affect quality of care. Studies have analyzed the hospital standardized mortality ratio (HSMR) in relation to quality improvements. The objective was to analyze HSMR according to source of payment for the hospitalization and the hospital's financing arrangement. The study analyzed secondary data and causes that accounted for 80% of hospital deaths. HSMR was calculated for each hospital and payment source. Hospitals with worse-than-expected performance (HSMR > 1) were mostly large public hospitals. HSMR was higher in the SUS, including between admissions in the hospital. Despite the study's limitations, the findings point to inequalities in results of care. Efforts are needed to improve the quality of hospital services, regardless of the payment sources.

Resumen: En Brasil, la convivencia público-privada en la financiación y en la prestación del cuidado empieza a definirse nítidamente en la asistencia hospitalaria. Los acuerdos de financiación adoptados por los hospitales (Sistema Único de Salud - SUS y/o planes de salud y/o pago particular) pueden afectar a la calidad del cuidado. Algunos estudios buscan asociar la razón de mortalidad hospitalaria padronizada (RMHP) a mejorías en la calidad. El objetivo fue analizar la RMHP según la fuente de pago del internamiento y acuerdos de financiación del hospital. Se analizaron datos secundarios y causas responsables de un 80% de los óbitos hospitalarios. La RMHP se calculó para cada hospital y fuente de pago. Los hospitales con un desempeño peor que el esperado (RMHP > 1) fueron mayoritariamente públicos y con un mayor número de pacientes. La RMHP en los internamientos SUS fue superior, incluyendo internamientos en el mismo hospital. A pesar de los límites, los hallazgos indican inequidades en el resultado del cuidado. Son necesarios esfuerzos dirigidos a la mejoría de la calidad de servicios hospitalarios, independientemente de las fuentes de pago de los mismos.

Lógica del capital y salud pública / The logics of capital and public health / A lógica do capital e a saúde pública

Uno de los problemas del sector de la salud es su conceptualización. Se presenta al sector como fragmentado y falto de coordinación. El ciclo del dinero en la circulación del capital permite entender que existe integración de capitales operando bajo la ley de valorización. Las obras sociales aparecen como una forma de pago indirecta que realiza el valor agregado incorporado por los servicios de atención médica. Los hospitales públicos están integrados al capital privado en la fase de compra de los medios de producción, transfi eren valor agregado como subsidios implícitos al dar atención a la población que tiene cobertura y confi guran un ciclo trunco del dinero que impide su recuperación provocando deterioro y subutilización del capital público. En el trabajo se buscan levantar dudas sobre la perspectiva de la fragmentación que es la que plantea falta de articulación entre sub-sectores. Los autores argumentan una integración entre salud pública y privada en condiciones de subordinación de lo público a la lógica de valoración del capital. No se plantea dicotomía, sino integración orientada a la realización del valor agregado de las empresas constructoras y fármaco-químicas, entre otros.

One of the problems of the health area is its conceptualization. The sector is presented as fragmented and lacking coordination. The money cycle in the circulation of capital lets us understand that there is integration of capitals taking place under the valorization law. Health care schemes appear as an indirect method of payment making the added value incorporated by health care services. Public hospitals are integrated to private capital in the stage of buying production means, they transfer added value as implicit subsidies when seeing patients with medical insurance and form and incomplete cycle of money which hinders recovery causing deterioration and under-usage of public capital. In this work we try to create doubts about the perspective of fragmentation which sets out the lack of articulation among the sub-sectors. The authors state there is integration between public and private health in conditions of subordination of the public to the logic of the valuation of capital. They do not set out a dichotomy, but integration oriented towards the achievement of added value of building, drug and chemical companies among others.

Um dos problemas do sector da saúde é a sua conceituação. Ele apresenta-se como fragmentado e descoordenado. O ciclo do dinheiro na circulação do capital permite-nos compreender que existe uma integração entre o capital operando sob a lei de valorização. Os Planos de Saúde aparecem como uma forma de pagamento indireto feito pelo valor acrescentado incorporado por serviços de saúde. Os hospitais públicos são integrados ao capital privado no processo de compra de meios de produção, transferem valor acrescentado como subsídios implícitos ao dar cuidados médicos à população que tem esta cobertura e defi nem um ciclo truncado de dinheiro que impede a sua recuperação causando deterioração e subutilização do capital público. Neste trabalho procura-se gerar dúvidas sobre a perspectiva de fragmentação que é representada pela falta de coordenação entre os subsectores. Os autores argumentam uma integração entre a saúde pública e a privativa em condições de subordinação do público à lógica de valorização do capital. Dicotomias não são apresentadas mas uma integração visando a realização do valor acrescentado das empresas da construção e fármaco químicas entre outras.

Public private partnership in vascular surgery.

OBJECTIVE: To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. METHODS: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide). RESULTS: A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide - was effective and cheaper. CONCLUSION: The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge.

Public private partnership in vascular surgery / Parceria público-privada em cirurgia vascular

Objective To describe and analyze the results of a public-private partnership between the Ministry of Health and a private hospital in a project of assistance and scientific research in the field of endovascular surgery. Methods: The flows, costs and clinical outcomes of patients treated in a the public-private partnership between April 2012 and July 2013 were analyzed. All patients underwent surgery and stayed at least one day at the intensive care unit of the private hospital. They also participated in a research protocol to compare two intravenous contrast media used in endovascular surgery (iodinated contrast and carbon dioxide). Results A total of 62 endovascular procedures were performed in 57 patients from the public healthcare system. Hospital and endovascular supplies expenses were significantly higher as compared to the amount paid by the Unified Health System (SUS - Sistema Único de Saúde) in two out of three disease groups studied. Among outpatients, the average interval between appointment and surgery was 15 days and, in hospitalized patients 7 days. All procedures were successful with no conversion to open surgery. The new contrast medium studied - carbon dioxide – was effective and cheaper. Conclusion The waiting time for patients between indication and accomplishment of surgery was significantly reduced. Public-private partnerships can speed up care of patients from public health services, and generate and improve scientific knowledge. .

Objetivo Descrever e analisar os resultados de parceria público-privada entre o Ministério da Saúde e um hospital privado em projeto de assistência e pesquisa científica na área de cirurgia endovascular. Métodos: Foram analisados fluxos, custos e resultados clínicos dos pacientes atendidos numa parceria público-privada entre abril de 2012 e julho de 2013. Todos os pacientes foram operados, ficaram pelo menos um dia na unidade de terapia intensiva do hospital privado e participaram de um protocolo de pesquisa para comparação entre dois contrastes endovenosos para cirurgia endovascular (contraste iodado e dióxido de carbono). Resultados Foram realizados 62 procedimentos endovasculares em 57 pacientes provenientes do sistema público. Os gastos hospitalares e com material endovascular mostraram-se significativamente maiores em relação ao que é pago pelo Sistema Único de Saúde (SUS) em dois dos três grupos de doenças estudados. Entre os pacientes ambulatoriais, o intervalo médio entre a consulta e a cirurgia foi de 15 dias e, nos internados, 7 dias. Todos os procedimentos foram bem sucedidos, sem conversão para cirurgia aberta. O novo contraste estudado, o dióxido de carbono, mostrou-se eficaz e mais barato. Conclusão O tempo de espera dos pacientes entre indicação cirúrgica e sua realização foi significativamente reduzido. Parcerias público-privadas podem trazer agilidade no atendimento dos pacientes do SUS, permitindo também geração de conhecimento científico. .

Interactions between spatially explicit conservation and management measures: implications for the governance of marine protected areas.

Marine protected areas are not established in an institutional and governance vacuum and managers should pay attention to the wider social-ecological system in which they are immersed. This article examines Islas Choros-Damas Marine Reserve, a small marine protected area located in a highly productive and biologically diverse coastal marine ecosystem in northern Chile, and the interactions between human, institutional, and ecological dimensions beyond those existing within its boundaries. Through documents analysis, surveys, and interviews, we described marine reserve implementation (governing system) and the social and natural ecosystem-to-be-governed. We analyzed the interactions and the connections between the marine reserve and other spatially explicit conservation and/or management measures existing in the area and influencing management outcomes and governance. A top-down approach with poor stakeholder involvement characterized the implementation process. The marine reserve is highly connected with other spatially explicit measures and with a wider social-ecological system through various ecological processes and socio-economic interactions. Current institutional interactions with positive effects on the management and governance are scarce, although several potential interactions may be developed. For the study area, any management action must recognize interferences from outside conditions and consider some of them (e.g., ecotourism management) as cross-cutting actions for the entire social-ecological system. We consider that institutional interactions and the development of social networks are opportunities to any collective effort aiming to improve governance of Islas Choros-Damas marine reserve. Communication of connections and interactions between marine protected areas and the wider social-ecological system (as described in this study) is proposed as a strategy to improve stakeholder participation in Chilean marine protected areas.