Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit.

OBJECTIVE: The demonstration that cardiovascular mortality follows a circadian rhythm led us to verify whether patients dying at the intensive unit care (ICU) and at the non-intensive unit care (non-ICU) follow that rhythm. METHODS: All hospital's deaths occurring between January 1, 2006 and July 31, 2010 were analyzed. The circadian pattern of the time of death was analyzed in twelve 2 hour intervals. The Chi-square test was used to compare proportions, and Student's t test or ANOVA single factor to compare continuous variables. A p-value < 0.05 was considered statistically significant. RESULTS: During the study period 700 deaths occurred in the hospital, 211 (30.1%) at the ICU and 88 (12.6%) at the non-ICU. There were more deaths in the first hours of the day, between 6 am and 12 am, at the non-ICU in comparison to the ICU (38% vs. 21%; p = 0.004). In the ICU, we observed that 21% of the deaths occurred between 6 am and 12 pm, 30% between 12 pm and 6 pm, 26% between 6 pm and 12 am and 24% between 12 am and 6 am (p = 0.13), whereas, at the non-ICU, 38% of the deaths occurred between 6 am and 12 pm, 18% between 12 pm and 6 pm, 19% between 6 pm and 12 am and 25% between 12 am and 6 am (p = 0.005). CONCLUSION: At the non-ICU, deaths occur more often in the morning period and follow a circadian rhythm, which does not occur at the ICU.

Ritmo circadiano em óbitos hospitalares: comparação entre unidade de tratamento intensivo e unidade de tratamento não intensivo / Circadian rhythm of hospital deaths: comparison between intensive care unit and non-intensive care unit

OBJETIVO: A demonstração de que a mortalidade cardiovascular segue um ritmo circadiano fez com que fosse verificado se pacientes que falecem em unidade de tratamento intensivo (UTI) e unidade clínica (UC) obedecem a este ritmo. MÉTODOS: Foram analisados todos os óbitos hospitalares ocorridos entre 1º de janeiro de 2006 e 31 de julho de 2010. O padrão circadiano dos óbitos foi analisado dividindo-se as 24 horas do dia em períodos de 2 horas. Utilizou-se o teste do qui-quadrado para comparação de variáveis categóricas e o teste t de Student ou a análise da variância fator único para comparação de variáveis contínuas. Um valor de p < 0,05 foi considerado estatisticamente significante. RESULTADOS: No período estudado, foram registrados 700 óbitos, 211 (30,1 por cento) na UTI e 88 (12,6 por cento) na UC. Houve mais óbitos nas primeiras horas do dia, entre 6 e 12 h, na UC, em comparação à UTI (38 por cento vs. 21 por cento; p = 0,004). Na UTI, 21 por cento dos óbitos ocorreram entre 6 e 12 h, 30 por cento entre 12 e 18 h, 26 por cento entre 18 e 24 h e 24 por cento entre 24 e 6 h (p = 0,13). Enquanto, na UC, 38 por cento ocorreram entre 6 e 12 h, 18 por cento entre 12 e 18h, 19 por cento entre 18 e 24 h e 25 por cento entre 24 e 6 h (p = 0,005). CONCLUSÃO: Na UC, os óbitos ocorrem com maior frequência no período da manhã e seguem um padrão circadiano, enquanto na UTI esse fenômeno não ocorre.

OBJECTIVE: The demonstration that cardiovascular mortality follows a circadian rhythm led us to verify whether patients dying at the intensive unit care (ICU) and at the non-intensive unit care (non-ICU) follow that rhythm. METHODS: All hospital's deaths occurring between January 1, 2006 and July 31, 2010 were analyzed. The circadian pattern of the time of death was analyzed in twelve 2 hour intervals. The Chi-square test was used to compare proportions, and Student's t test or ANOVA single factor to compare continuous variables. A p-value < 0.05 was considered statistically significant. RESULTS: During the study period 700 deaths occurred in the hospital, 211 (30.1 percent) at the ICU and 88 (12.6 percent) at the non-ICU. There were more deaths in the first hours of the day, between 6 am and 12 am, at the non-ICU in comparison to the ICU (38 percent vs. 21 percent; p = 0.004). In the ICU, we observed that 21 percent of the deaths occurred between 6 am and 12 pm, 30 percent between 12 pm and 6 pm, 26 percent between 6 pm and 12 am and 24 percent between 12 am and 6 am (p = 0.13), whereas, at the non-ICU, 38 percent of the deaths occurred between 6 am and 12 pm, 18 percent between 12 pm and 6 pm, 19 percent between 6 pm and 12 am and 25 percent between 12 am and 6 am (p = 0.005). CONCLUSION: At the non-ICU, deaths occur more often in the morning period and follow a circadian rhythm, which does not occur at the ICU.

Evidência de melhora na qualidade do cuidado assistencial no infarto agudo do miocárdio / Evidence of healthcare quality improvement in acute myocardial infarction

FUNDAMENTO: A monitoração dos indicadores de qualidade no cuidado com a saúde (IQS) é um processo de fundamental importância na atenção à saúde dos pacientes. OBJETIVO: Avaliar se a monitoração dos IQS e a análise da causa-raiz melhoram a qualidade do cuidado no infarto agudo do miocárdio (IAM). MÉTODOS: Foi realizada uma análise transversal e comparativa dos IQS em pacientes com IAM nos anos de 2006 e 2007. Dos 1.461 pacientes admitidos com dor torácica, 172 (11,7 por cento) tiveram o diagnóstico de IAM e foram incluídos na análise. RESULTADOS: A taxa de angioplastia primária foi 8,47 por cento maior em 2007 (97,3 por cento) do que em 2006 (89,7 por cento), mas esta diferença não alcançou significado estatístico (p = 0,35). Também não houve diferença estatística no tempo de hospitalização (4 vs 5 dias, p = 0,15) e na mortalidade intra-hospitalar (7,8 por cento vs 5,1 por cento, p = 0,67) entre 2007 e 2006, respectivamente. No entanto, o tempo até o resultado da primeira troponina foi 27 por cento menor em 2007 (69 min.; IC 95 por cento = 44-94 min.) do que em 2006 (95 min.; 53-136 min.) (p = 0,025). O tempo porta-balão foi 12 por cento menor (72 ± 29 min. vs 109 ± 85 min.; p = 0,03), a taxa de prescrição de aspirina na alta foi 35 por cento maior (94,7 por cento vs 70,3 por cento; p = 0,002) e a taxa de APCP, menor do que 90 minutos, foi 52 por cento maior (78,3 vs 51,4 por cento; p = 0,03) em 2007, quando comparada a 2006. CONCLUSÃO: Nossos resultados sugerem que a estratégia de monitorar os IQS e a de implementação da metodologia de análise da causa-raiz melhora o processo de cuidado com a saúde no IAM.

BACKGROUND: The monitoring of healthcare quality indicators (HCQI) is a process of utmost importance in patient healthcare services. OBJECTIVE: To evaluate whether the monitoring of HCQI and the root-cause analysis improve the healthcare quality in acute myocardial infarction (AMI). METHODS: A cross-sectional and comparative analysis of HCQI was performed in patients with AMI in the years 2006 and 2007. Of the 1,461 patients admitted with chest pain, 172 (11.7 percent) had a diagnosis of AMI and were included in the analysis. RESULTS: The rate of primary angioplasty was 8.47 percent higher in 2007 (97.3 percent) when compared to that in 2006 (89.7 percent), but this difference was not statistically significant (p = 0.35). Moreover, there was no difference regarding the time of hospitalization (4 vs 5 days, p = 0.15) and the in-hospital mortality (7.8 percent vs 5.1 percent, p = 0.67) between 2007 and 2006, respectively. However, the time to the first troponin level was 27 percent shorter in 2007 (69 min.; 95 percentCI = 44-94 min.) when compared to 2006 (95 min.; 53-136 min.) (p = 0.025). The door-to-balloon time was 12 percent shorter (72 ± 29 min. vs 109 ± 85 min.; p = 0.03), the rate of ASA prescription at hospital discharge was 35 percent higher (94.7 percent vs 70.3 percent; p = 0.002) and the rate of PCA shorter than 90 minutes was 52 percent higher (78.3 vs 51.4 percent; p = 0.03) in 2007, when compared to 2006. CONCLUSION: Our results suggest that the strategy of monitoring the HCQI and the implementation of the root-cause analysis methodology can improve the healthcare process in patients with AMI.

[Evidence of healthcare quality improvement in acute myocardial infarction].

BACKGROUND: The monitoring of healthcare quality indicators (HCQI) is a process of utmost importance in patient healthcare services. OBJECTIVE: To evaluate whether the monitoring of HCQI and the root-cause analysis improve the healthcare quality in acute myocardial infarction (AMI). METHODS: A cross-sectional and comparative analysis of HCQI was performed in patients with AMI in the years 2006 and 2007. Of the 1,461 patients admitted with chest pain, 172 (11.7%) had a diagnosis of AMI and were included in the analysis. RESULTS: The rate of primary angioplasty was 8.47% higher in 2007 (97.3%) when compared to that in 2006 (89.7%), but this difference was not statistically significant (p = 0.35). Moreover, there was no difference regarding the time of hospitalization (4 vs 5 days, p = 0.15) and the in-hospital mortality (7.8% vs 5.1%, p = 0.67) between 2007 and 2006, respectively. However, the time to the first troponin level was 27% shorter in 2007 (69 min.; 95%CI = 44-94 min.) when compared to 2006 (95 min.; 53-136 min.) (p = 0.025). The door-to-balloon time was 12% shorter (72 +/- 29 min. vs 109 +/- 85 min.; p = 0.03), the rate of ASA prescription at hospital discharge was 35% higher (94.7% vs 70.3%; p = 0.002) and the rate of PCA shorter than 90 minutes was 52% higher (78.3 vs 51.4%; p = 0.03) in 2007, when compared to 2006. CONCLUSION: Our results suggest that the strategy of monitoring the HCQI and the implementation of the root-cause analysis methodology can improve the healthcare process in patients with AMI.

Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center.

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75%), the mean age was 65+/-11, and the EuroSCORE was 4+/-3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4+/-3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9% (95% confidence interval [CI] = 2.2 - 9.87%) was lower than the expected OM of 5.1% (95% CI = 1.4% to 14.37%), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95% CI = 0.485 - 0.919). LOS was 11+/-9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95% CI = 0.675 - 0.852). The RHR recorded was 2.1%. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Indicadores de qualidade assistencial na cirurgia de revascularização miocárdica isolada em centro cardiológico terciário / Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center

FUNDAMENTO: Indicadores de qualidade (IQ) em cirurgia cardíaca são importantes instrumentos de avaliação da assistência médica em centros hospitalares. OBJETIVO: Avaliar os IQ da cirurgia de revascularização miocárdica (CRVM) isolada em centro terciário cardiológico. MÉTODOS: Foram avaliados 144 pacientes consecutivos submetidos a CRVM isolada entre outubro de 2005 e março de 2007: 108 pacientes eram do sexo masculino (75 por cento), com média de idade de 65±11 anos e EuroSCORE de 4±3. Os IQ avaliados foram: intervalo de tempo entre a marcação e a realização da cirurgia (TMC); taxa de cancelamento (TxC) decorrentes de problemas ligados à infra-estrutura hospitalar; tempo de permanência hospitalar (TPH); mortalidade operatória (MO) e taxa de reinternação hospitalar por infecção em ferida cirúrgica (TxRH). RESULTADOS: O TMC (n=98) foi de 4±3 dias (mediana de 4 dias) e a TxC foi zero. A MO observada de 4,9 por cento (Intervalo de Confiança [IC] 95 por cento = 2,2 - 9,87 por cento) foi menor do que a MO esperada de 5,1 por cento (IC 95 por cento = 1,4 por cento a 14,37 por cento), mas sem significância estatística (p=0,65). A área sob a curva ROC do EuroSCORE para MO observada foi de 0,702 (IC 95 por cento = 0,485 - 0,919). O TPH foi de 11±9 dias. A área sob a curva ROC do EuroSCORE para TPH foi de 0,764 (IC 95 por cento = 0,675 - 0,852). A TxRH observada foi de 2,1 por cento. CONCLUSÃO: A avaliação dos IQ demonstrou que, em um centro com baixo número anual de CRVM, os resultados alcançados foram compatíveis com o perfil de risco da população envolvida.

BACKGROUND: Quality indicators (QI) for cardiac surgery are important instruments for measuring healthcare quality in hospital centers and allow comparison with high-quality healthcare centers. OBJECTIVE: To evaluate QIs in isolated myocardial revascularization procedures (CABG) performed at a tertiary cardiology center. METHODS: One hundred and forty-four consecutive patients who had undergone isolated CABG were evaluated between October 2005 and March 2007. One hundred and eight patients were men (75 percent), the mean age was 65±11, and the EuroSCORE was 4±3. The following QIs were measured: time elapsed between the surgery date-setting appointment and the actual day of the CABG (TDC); surgery cancellation rate (SCR) due to problems in hospital infrastructure; length of hospital stay (LOS); operative mortality (OM) and rate of readmission (RHR) for infection in the surgical wound. RESULTS: The TDC (n=98) was 4±3 days (median: 4 days) and the SCR was zero. The OM recorded of 4.9 percent (95 percent confidence interval [CI] = 2.2 - 9.87 percent) was lower than the expected OM of 5.1 percent (95 percent CI = 1.4 percent to 14.37 percent), but with no statistical significance (p=0.65). The area under the ROC curve of the EuroSCORE for the OM was 0.702 (95 percent CI = 0.485 - 0.919). LOS was 11±9 days. The area under the ROC curve of the EuroSCORE for the LOS was 0.764 (95 percent CI = 0.675 - 0.852). The RHR recorded was 2.1 percent. CONCLUSION: The measurement of the QIs showed that, in a medical center with a low annual volume of CABG, the results were compatible with the risk profile of the population involved.

Avaliação de marcadores prognósticos na síndrome coronariana aguda sem supradesnivelamento do segmento ST na sala de emergência / Evaluation of prognostic markers in acute coronary syndrome without ST segment elevation in the emergency room

Objetivo: Identificar marcadores prognósticos de risco de eventos em pacientes consecutivos não selecionados, admitidos na sala de emergência com SCA sem supradesenvolvimento do segmento ST.Métodos: estudo observacional prospectivo constituído de 124 pacientes, que foram acompanhados até 180 dias. Os eventos foram: morte, infarto, angina refratária ou recorrente, revascularização miocárdica de urgência, que foram combinados para maior poder estatístico. As análises estatísticas foram realizadas de forma uni e multivariada.Resultados: Nesta corte houve insucesso de seguimento em 7 pacientes (5,6 por cento). No período de 180 dias, foram encontrados 22 eventos combinados. A média de idade foi de 68,9 anos, predomínio do sexo masculino e elevada frequência de coronariopatia prévia (62,9 por cento) maior que em outros estados . Os pacientes que apresentavam insuficiência cardíaca manifesta (IVE)clínica apresentavam eventos com maior frequência (p igual 0,005), porém os pacientes com troponina I maior igual a 0,5 ng/ml ou a associação das troponinas T e I, não apresentaram correlação significativa com um número maior de eventos (p igual 0,053 e p igual 0,057, respectivamente). Os outros marcadores avaliados não se destacaram como marcadores de risco. O risco relativo daqueles pacientes que apresentavam IVE na admissão hospitalar foi de 3,16 (2,28 - 4,04 IC 95 por cento) e a razão de verossimilhança positiva (RVP) de 4,28. A análise multivariada identificou que apenas a presença de insuficiência ventricular esquerda clínica se relaciona com eventos (p igual 0,012) em um nível de significância de 5 por cento.Conclusões: Na prática emergencial, na estratégia de risco em pacientes com SCA sem supradesnivelamento de segmento ST, a presença de IVE comportou-se como variável independente na predição de eventos combinados