Interventions in overcrowding of emergency departments: an overview of systematic reviews.

OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED's team; (3) creation of new care zones; (4) change in ED's work processes. All studies observed positive effect on patient's length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.

Testagem de rastreio e busca ativa de infectados assintomáticos pelo SARS-COV-2: avisão do planejamento em saúde pública / Screening testing and active search for asymptomatic infected by SARS-COV-2: public health planning warning

Este artigo, tem como objetivo descrever evidências científicas da testagem para rastreamento de casos assintomáticos de Coronavírus. Examinaram-se artigos científicos, recomendações da Organização Mundial de Saúde e publicações em jornais. Conclui-se pela necessidade de adoção desta medida para o controle da pandemia e aponta-se para questões a serem respondidas para o planejamento do sistema de saúde. (AU)

Estratégias de Ensino-Aprendizagem para Formação Humanista, Crítica, Reflexiva e Ética na Graduação Médica: Revisão Sistemática / Teaching-Learning Strategies for Humanistic, Critical, Reflective and Ethical Undergraduate Medical Training: a Systematic Review

Resumo: Introdução: A medicina é uma área do conhecimento diretamente associada às relações humanas e influenciada por elas. A prática médica requer mais que conhecimento técnico, necessita de habilidades que possibilitem a aplicação adequada da técnica para a recuperação e promoção da saúde de um indivíduo. As Diretrizes Curriculares Nacionais (DCN) atuais trazem em seu texto as competências necessárias à formação médica, que vão além do campo técnico. As DCN orientam que a graduação médica deve ser pautada em uma formação generalista, humanista, crítica, reflexiva e ética. Nesse contexto, buscou-se com esta revisão identificar estratégias de ensino-aprendizagem utilizadas para o alcance das referidas competências psicossociais na graduação médica. Método: Foi realizada revisão sistemática, em que se pesquisaram artigos que apresentassem intervenções e/ou métodos pedagógicos para a aquisição, durante a graduação médica, de competências necessárias a uma formação médica generalista, humanista, crítica, reflexiva e ética. Os estudos selecionados foram sintetizados e analisados com base nos critérios do sistema Grading of Recommendations Assessment, Development and Evaluation (Grade). Resultados: A estratégia de busca inicialmente resultou em 98 artigos elegíveis, dos quais, após segunda avaliação, 11 artigos primários foram selecionados. Inicialmente, agruparam-se os artigos conforme a competência segundo a qual foram pesquisados e reorganizados de acordo com o critério conceitual em que se enquadraram. Assim, dos 11 artigos selecionados com a estratégia de busca, seis foram classificados como formação humanista, dois como formação crítica, dois como formação reflexiva e um como formação ética. Conclusões: Os estudos encontrados mostram que dimensões importantes da formação médica, muitas vezes deixadas de lado durante a graduação, podem ser abordadas de maneira sistemática e com métodos pedagógicos já validados na literatura, pois trata-se de métodos de ensino-aprendizagem efetivos que agregam habilidades fundamentais ao graduando em Medicina, retirando do currículo oculto competências fundamentais ao médico em formação. Com a passagem dessas competências para um currículo formal, torna-se possível avaliá-las e melhorar a qualidade da formação médica. Dessa forma, essas estratégias de ensino-aprendizagem incorporam atitudes que podem significar o sucesso ou insucesso profissional médico.

Abstract: Introduction: Medicine is an area of knowledge directly related to and influenced by human relationships. Medical practice requires not only technical knowledge but also skills that enable one to properly apply techniques for the recovery and promotion of an individual's health. The current Brazilian National Curricular Guidelines (DCN) outline the essential skills for medical training, which extend beyond the technical field. According to the DCN, undergraduate medical training should be based on a generalist, humanistic, critical, reflective and ethical formation. In view of this, the aim of this review was to identify teaching-learning strategies used to achieve these psychosocial competences in undergraduate medical training. Method: A systematic review of articles that present pedagogical interventions and/or methods used to teach the necessary competences for a generalist, humanistic, critical, reflexive and ethical medical training at undergraduate level. The selected studies were synthesized and analysed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. Results: The research strategy initially resulted in 98 eligible articles, of which, after a second evaluation, 11 primary articles were selected. The articles were initially grouped by the competence in relation to which they were researched and reorganized according to the conceptual criterion by which they were framed. Thus, of the 11 articles selected with the search strategy, six articles were classified as addressing humanist formation, two critical formation, two reflective formation and one ethical formation. Conclusion: The studies reviewed show that important dimensions of medical education, often disregarded during undergraduate training, can be approached in a systematic way and with validated pedagogical methods. These effective teaching-learning methods provide the medical student with fundamental skills that may have previously been part of the hidden curriculum. Incorporating such competencies into a formal curriculum allows for their evaluation and for improvement in the quality of medical training, thus leading to the adoption of attitudes key to success in the medical profession.

Interventions in overcrowding of emergency departments: an overview of systematic reviews

ABSTRACT OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED's team; (3) creation of new care zones; (4) change in ED's work processes. All studies observed positive effect on patient's length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.

The Unified Health System in the Federal District, Brazil (1960 to 2018): revisiting history to plan the future. / O Sistema Único de Saúde no Distrito Federal, Brasil (1960 a 2018): revisitando a história para planejar o futuro.

The analysis of health policy trajectories contributes to disclose the endogenous and exogenous elements that influence the management of health systems. This article aims to describe the trajectory of the Unified Health System of the Federal District (SUS-DF) from 1960 to 2018 and identify the challenges to expand the capacity for protection and health promotion of the population of the Federal District. A documentary analysis of plans, reports, and articles published from 1959 to 2018 and the collection of secondary data were carried out in databases of DATASUS and the Government of the Federal District. RESULTS The SUS-DF trajectory was delineated through care organization actions, health system management and health care personnel training and development. Health indicators such as infant mortality and life expectancy at birth have shown a positive development. There was an increase in health care servicesupply, with an increase in the number of beds, basic health units and professionals, although insufficient, given the population increase. CONCLUSION the actions indicate the growing complexity of health system management, with challenges related to the adaptation of the capacity to respond to the population'shealth needs and reveal internal potentials in the field of health training.

A análise do percurso das políticas de saúde contribui para desvelar os elementos endógenos e exógenos que influenciam na gestão dos sistemas de saúde. Este artigo tem como objetivo descrever a trajetória do Sistema Único de Saúde do Distrito Federal (SUS-DF) no período de 1960 a 2018 e identificar os desafios para ampliar a capacidade de proteção e promoção da saúde da população do DF. Realizou-se análise documental de planos, portarias, relatórios e artigos publicados no período de 1959 a 2018 e coleta de dados secundários em bases de dados do DATASUS e do Governo do Distrito Federal. RESULTADOS a trajetória do SUS-DF foi delineada por meio de ações de organização da assistência, da gestão do sistema de saúde e de formação e desenvolvimento de pessoal de saúde. Indicadores de saúde como a mortalidade infantil e a esperança de vida ao nascer evoluíram positivamente. Houve ampliação da oferta de serviços com aumento no número de leitos, de unidades básicas de saúde e de profissionais, embora insuficiente, dado o aumento populacional. CONCLUSÃO as ações sinalizam para a complexidade crescente da gestão do sistema de saúde, com desafios relacionados à adequação da capacidade de resposta às necessidades de saúde da população e desvelam potenciais internos no campo da formação em saúde.

O Sistema Único de Saúde no Distrito Federal, Brasil (1960 a 2018): revisitando a história para planejar o futuro / The Unified Health System in the Federal District, Brazil (1960 to 2018): revisiting history to plan the future

Resumo A análise do percurso das políticas de saúde contribui para desvelar os elementos endógenos e exógenos que influenciam na gestão dos sistemas de saúde. Este artigo tem como objetivo descrever a trajetória do Sistema Único de Saúde do Distrito Federal (SUS-DF) no período de 1960 a 2018 e identificar os desafios para ampliar a capacidade de proteção e promoção da saúde da população do DF. Realizou-se análise documental de planos, portarias, relatórios e artigos publicados no período de 1959 a 2018 e coleta de dados secundários em bases de dados do DATASUS e do Governo do Distrito Federal. Resultados a trajetória do SUS-DF foi delineada por meio de ações de organização da assistência, da gestão do sistema de saúde e de formação e desenvolvimento de pessoal de saúde. Indicadores de saúde como a mortalidade infantil e a esperança de vida ao nascer evoluíram positivamente. Houve ampliação da oferta de serviços com aumento no número de leitos, de unidades básicas de saúde e de profissionais, embora insuficiente, dado o aumento populacional. Conclusão as ações sinalizam para a complexidade crescente da gestão do sistema de saúde, com desafios relacionados à adequação da capacidade de resposta às necessidades de saúde da população e desvelam potenciais internos no campo da formação em saúde.

Abstract The analysis of health policy trajectories contributes to disclose the endogenous and exogenous elements that influence the management of health systems. This article aims to describe the trajectory of the Unified Health System of the Federal District (SUS-DF) from 1960 to 2018 and identify the challenges to expand the capacity for protection and health promotion of the population of the Federal District. A documentary analysis of plans, reports, and articles published from 1959 to 2018 and the collection of secondary data were carried out in databases of DATASUS and the Government of the Federal District. Results The SUS-DF trajectory was delineated through care organization actions, health system management and health care personnel training and development. Health indicators such as infant mortality and life expectancy at birth have shown a positive development. There was an increase in health care servicesupply, with an increase in the number of beds, basic health units and professionals, although insufficient, given the population increase. Conclusion the actions indicate the growing complexity of health system management, with challenges related to the adaptation of the capacity to respond to the population'shealth needs and reveal internal potentials in the field of health training.

Use of sodium-glucose cotransporter-2 inhibitors and urinary tract infections in type 2 diabetes patients: a systematic review.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are drugs that act by maintaining glycosuria. Recent studies have shown promising effects of these in the treatment of type 2 diabetes mellitus (DM2). However, there may be an increased risk of developing urinary tract infections (UTIs) in patients treated with these. Our study aims to analyze the association between the risk of UTI in patients treated with SGLT2i. A systematic review of the literature was carried out by randomized clinical trials, totalizing at the end of the selection 23 articles that were statistically evaluated. The incidence of UTI was generally demonstrated in articles and in different subgroups: patients on SGLT2i monotherapy or on combination therapy; according to specific comorbidities of each sample or according to the drug used. They noticed an increase in the chance of UTI in the SGLT2i groups compared to the control groups on placebo or other oral antidiabetic agents. This increased chance was found predominantly with the use of Dapagliflozin, Canagliflozin, and Tofogliflozin, regardless of the dosing. Lastly, stands out that the dimension of UTI chances for DM2 patients who use SGLT2i remains to be more strictly determined.

Use of sodium-glucose cotransporter-2 inhibitors and urinary tract infections in type 2 diabetes patients: a systematic review

SUMMARY Sodium-glucose cotransporter-2 inhibitors (SGLT2i) are drugs that act by maintaining glycosuria. Recent studies have shown promising effects of these in the treatment of type 2 diabetes mellitus (DM2). However, there may be an increased risk of developing urinary tract infections (UTIs) in patients treated with these. Our study aims to analyze the association between the risk of UTI in patients treated with SGLT2i. A systematic review of the literature was carried out by randomized clinical trials, totalizing at the end of the selection 23 articles that were statistically evaluated. The incidence of UTI was generally demonstrated in articles and in different subgroups: patients on SGLT2i monotherapy or on combination therapy; according to specific comorbidities of each sample or according to the drug used. They noticed an increase in the chance of UTI in the SGLT2i groups compared to the control groups on placebo or other oral antidiabetic agents. This increased chance was found predominantly with the use of Dapagliflozin, Canagliflozin, and Tofogliflozin, regardless of the dosing. Lastly, stands out that the dimension of UTI chances for DM2 patients who use SGLT2i remains to be more strictly determined.

RESUMO Os inibidores do cotransportador de sódio-glicose do tipo 2 (SGLT2i) são medicamentos que atuam mantendo a glicosúria. Estudos recentes têm demonstrado efeitos promissores desses no tratamento de diabetes mellitus tipo 2 (DM2). No entanto, pode haver um risco aumentado de desenvolver infecções do trato urinário (UTI) em pacientes tratados com essa classe de medicação. Nosso estudo tem como objetivo analisar a associação entre o risco de desenvolver UTI em pacientes tratados com SGLT2i. Uma revisão sistemática da literatura foi realizada por ensaios clínicos randomizados, totalizando, ao final da seleção, 23 artigos que foram avaliados estatisticamente. A incidência de UTI foi demonstrada genericamente de acordo com os dados dos artigos e em diferentes subgrupos: pacientes em monoterapia com SGLT2i ou em terapia combinada, de acordo com as comorbidades específicas de cada amostra ou de acordo com a droga utilizada. Verificou-se um aumento na chance de UTI nos grupos SGLT2i em comparação com os grupos de controle em placebo ou outros agentes antidiabéticos orais. Essa chance aumentada foi encontrada predominantemente com uso de Dapagliflozina, Canagliflozina e Tofoglifozina, independentemente da dosagem. Por fim, ressaltou-se que as chances de UTI em pacientes com DM2 em uso de SGLT2i ainda precisam ser mais bem determinadas.

Active health Ombudsman service: evaluation of the quality of delivery and birth care.

OBJECTIVE: To evaluate the active health Ombudsman service as an instrument to evaluate the quality of delivery and birth care in the Cegonha Network of the Federal District of Brazil. METHODS: This is a cross-sectional study of the telephone survey type carried out with 1,007 mothers with deliveries between October 15, 2013 and November 19, 2013 in the twelve public maternity hospitals that make up the Cegonha Network of the Federal District of Brazil. The instrument has 25 multiple choice or Likert scale questions, including sociodemographic data and acceptability evaluation in five domains: accessibility, relationship between the patient and health professionals, conditions of the structure of the service, information to the patient, and equity and opinion of the patient. We have studied qualitative or categorical variables according to the frequency and distribution of proportions. We have used the score transformed into a scale from zero to 100 for the analysis of the Likert-type scale questions. Results have been expressed as mean and standard deviation. RESULTS: Access to prenatal appointments was evaluated as good or excellent by 86.1% of the participants and laboratory tests was evaluated as good or excellent by 85.2% of them. The access to imaging tests was evaluations as good or excellent by 45.7% of the women; 79.5% of the interviewees had their delivery in the maternity hospital where they sought initial care and 18.3% received a home visit by a community health agent after discharge. Most women reported that newborns were placed skin-to-skin immediately after birth, 48.9% had a companion at the time of the delivery, 76.3% were advised about the first appointment of the newborn, and 94.8% were advised on breastfeeding in the maternity hospital. Regarding the evaluation of health professionals, 85.9% of the women considered reception and cordiality as good or excellent at the prenatal care and 94.8% considered it as good or excellent at the maternity hospital. CONCLUSIONS: The active health Ombudsman service has contributed to evaluate the quality of public management by allowing the incorporation of the perspective of users of the health service in the evaluation of the acceptability of the Cegonha Network in the Federal District of Brazil.

Active health Ombudsman service: evaluation of the quality of delivery and birth care / Ouvidoria ativa em saúde: avaliação da qualidade da atenção ao parto e nascimento

ABSTRACT OBJECTIVE To evaluate the active health Ombudsman service as an instrument to evaluate the quality of delivery and birth care in the Cegonha Network of the Federal District of Brazil. METHODS This is a cross-sectional study of the telephone survey type carried out with 1,007 mothers with deliveries between October 15, 2013 and November 19, 2013 in the twelve public maternity hospitals that make up the Cegonha Network of the Federal District of Brazil. The instrument has 25 multiple choice or Likert scale questions, including sociodemographic data and acceptability evaluation in five domains: accessibility, relationship between the patient and health professionals, conditions of the structure of the service, information to the patient, and equity and opinion of the patient. We have studied qualitative or categorical variables according to the frequency and distribution of proportions. We have used the score transformed into a scale from zero to 100 for the analysis of the Likert-type scale questions. Results have been expressed as mean and standard deviation. RESULTS Access to prenatal appointments was evaluated as good or excellent by 86.1% of the participants and laboratory tests was evaluated as good or excellent by 85.2% of them. The access to imaging tests was evaluations as good or excellent by 45.7% of the women; 79.5% of the interviewees had their delivery in the maternity hospital where they sought initial care and 18.3% received a home visit by a community health agent after discharge. Most women reported that newborns were placed skin-to-skin immediately after birth, 48.9% had a companion at the time of the delivery, 76.3% were advised about the first appointment of the newborn, and 94.8% were advised on breastfeeding in the maternity hospital. Regarding the evaluation of health professionals, 85.9% of the women considered reception and cordiality as good or excellent at the prenatal care and 94.8% considered it as good or excellent at the maternity hospital. CONCLUSIONS The active health Ombudsman service has contributed to evaluate the quality of public management by allowing the incorporation of the perspective of users of the health service in the evaluation of the acceptability of the Cegonha Network in the Federal District of Brazil.

RESUMO OBJETIVO Avaliar a ouvidoria ativa em saúde como ferramenta de avaliação da qualidade da atenção ao parto e nascimento da Rede Cegonha do Distrito Federal. MÉTODOS Estudo transversal, do tipo inquérito por via telefônica, em 1.007 puérperas com partos realizados entre 15/10/2013 e 19/11/2013, nas 12 maternidades públicas que compõem a Rede Cegonha no Distrito Federal. O instrumento continha 25 questões de múltipla escolha ou do tipo escala Likert, que incluiu dados sociodemográficos e avaliação da aceitabilidade em cinco domínios: acessibilidade, relacionamento entre o paciente e os profissionais de saúde, condições da estrutura do serviço, informação ao paciente, e equidade e opinião do paciente. Variáveis qualitativas ou categóricas foram estudadas de acordo com a frequência e distribuição de proporções. Utilizou-se o escore transformado para uma escala de zero a 100 para análise das questões do tipo escala Likert. Resultados foram expressos em média e desvio-padrão. RESULTADOS O acesso às consultas de pré-natal foi avaliado como bom ou ótimo por 86,1% das participantes e os exames laboratoriais como bom ou ótimo por 85,2%. O acesso aos exames de imagem teve 45,7% avaliações boas ou ótimas; 79,5% das entrevistadas realizaram o parto na maternidade onde buscaram atendimento inicial e 18,3% receberam visita domiciliar por agente comunitário de saúde após a alta. A maioria relatou que os recém-nascidos foram colocados em seus colos ou peitos imediatamente após o nascimento, 48,9% tiveram presença de acompanhante no momento do parto, 76,3% foram orientadas em relação à primeira consulta dos recém-nascidos e 94,8% sobre aleitamento materno na maternidade. Quanto à avaliação dos profissionais de saúde, 85,9% das mulheres consideraram o acolhimento e a cordialidade recebidos como bons ou ótimos no pré-natal e 94,8%, como bons ou ótimos na maternidade. CONCLUSÕES A ouvidoria ativa em saúde contribuiu para a avaliação da qualidade da gestão pública, possibilitando a incorporação da perspectiva das usuárias do serviço de saúde na avaliação da aceitabilidade da Rede Cegonha no Distrito Federal.

A superlotação dos serviços de emergência hospitalar como evidência de baixo desempenho organizacional / The overcrowding of hospital emergency services as evidence of low organizational performance

O estudo teve como objetivo investigar a superlotação nos serviços de emergência hospitalar (SEH). Para tal, foram elaborados dois artigos, já publicados. O primeiro, elaborado durante a crise dos serviços de emergência hospitalar de 2005, discutiu as características estruturantes do Programa QUALISUS do Ministério da Saúde do Brasil, em curso de implantação, analisou as especificidades desses serviços e fez algumas considerações sobre o sistema de saúde do município do Rio de Janeiro, sede do início do programa QUALISUS. Com a complexidade do cenário onde o programa era implementado, exemplificado pela grave crise na assistência àqueles que demandavam cuidados nos serviços de emergência, assim como as características da matriz da qualidade sugerida pelo programa, cuja ênfase é na reorganização da rede dos serviços de emergência e na recepção dos serviços de emergência hospitalar, voltados para o acolhimento e a classificação de risco, optou-se pelo aprofundamento do estudo sobre os SEH. A partir de uma revisão sistemática, discutiu-se as intervenções voltadas para solucionar o problema da superlotação dos Serviços de Emergência Hospitalar, e identificou-se evidências de baixo desempenho organizacional. A revisão sistemática partiu de um universo de 2.992 títulos, onde foram selecionados 822 títulos para análise de resumos e textos integrais, entre o período de 2000 a junho de 2007. A superlotação foi caracterizada como um fenômeno mundial, com causas e conseqüências. As intervenções que interferiram positivamente no principal indicador da superlotação, o tempo de permanência no SEH, apontaram para a melhoria do fluxo de saída dos pacientes dos serviços de emergência hospitalar, através do aumento do desempenho organizacional. Os resultados dessa revisão desmistificaram as soluções que aumentam as barreiras de acesso ou melhoram a estrutura...

The study aimed to investigate the overcrowding in the public hospitals emergency rooms (ER). For such, two articles had been elaborated and are already published. The first one is related to the crisis of the public hospitals emergency rooms services which took place in the year of 2005 in Brazil. It presents the major characteristics of the Ministry of Health QUALISUS Program, analyzes the specificities of these services and made some considerations about the city of Rio de Janeiro health system, QUALISUS headquarter. Given the complexity of the broad picture where the program was implemented, leaded by the serious crisis in the emergency rooms medical care, as well as the characteristics of the quality matrix suggested by the program, whose emphasis is the reorganization of the emergency services network and in the reception of the services of hospital emergency driven toward the shelter and the classification of risk, it was decided to deepen the research on the emergency room aspects. From a thorough systematic review based on a universe of 2.992 titles, 882 full articles and abstracts from the period between 2.000 and 2.007 were analyzed. Overcrowding was characterized as a world-wide phenomenon, with causes and consequences. Among the main aspects, this literature raise up a range of interventions to solve the emergency room overcrowding. Low organizational performance is a scientific finding. Interventions that had modified positively the main indicator of overcrowding, the time of permanence in the emergency room, dealt with the improvement of the patients discharge from emergency rooms through the increase of the organizational performance. The results of this systematic revision had demystified the solutions that increase access barriers...

[Interventions to solve overcrowding in hospital emergency services: a systematic review]. / Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática.

This review discusses interventions aimed at solving the problem of overcrowding in hospital emergency services (HES), characteristic of low organizational effectiveness. In free-access and restricted-access databases, the target descriptors were 'overcrowding; emergency; medicine; first aid'. The survey identified 66 citations of interventions, grouped in 47 related interventions. The majority of the studies used observational designs that evaluated the results before and after interventions. Of the 47 related interventions, 34 had results for organizational performance. Four were the most frequently cited: implementation of an observation unit for patients already hospitalized and awaiting diagnosis or clinical stabilization; designation of a dedicated nursing station for the patient's admission, discharge, or transfer; establishment of protocols with indicators of operational saturation and implementation of an emergency care unit. Analyzing 21 interventions that were intended to solve overcrowding in HES and with positive results for length-of-stay, 15 were related to patient stream improvement, interfering actively and positively in patient stream. Interventions that increased access barriers or that merely improved the HES structure were ineffective.

Intervenções para solucionar a superlotação nos serviços de emergência hospitalar: uma revisão sistemática / Interventions to solve overcrowding in hospital emergency services: a systematic review

Esta revisão discute as intervenções voltadas para solucionar o problema da superlotação dos Serviços de Emergência Hospitalar (SEH), como evidência de baixa efetividade organizacional. Em bases de dados eletrônicas de livre acesso e acesso restrito, os descritores buscados foram "superlotação; emergência; medicina; pronto-socorro". O levantamento identificou 66 citações de intervenções, agrupadas em 47 intervenções afins. A maioria dos trabalhos teve como desenho os estudos observacionais que avaliaram os resultados das intervenções antes e depois. As mais citadas: implantação da unidade de observação dos pacientes graves; implantação do serviço de enfermagem dedicado à admissão, alta e transferência do paciente; instituição de protocolos de saturação operacional e implantação da unidade de pronto-atendimento. Na análise das 21 intervenções para solucionar a superlotação nos SEH, que tiveram resultados favoráveis no evento principal - tempo de permanência no SEH -, 15 tinham relação com a melhoria do fluxo no próprio SEH ou nos setores do hospital, interferindo ativa e positivamente no fluxo interno dos pacientes. As intervenções que aumentaram as barreiras de acesso aos SEH, ou que apenas melhoram a estrutura dos SEH não foram efetivas.

This review discusses interventions aimed at solving the problem of overcrowding in hospital emergency services (HES), characteristic of low organizational effectiveness. In free-access and restricted-access databases, the target descriptors were "overcrowding; emergency; medicine; first aid". The survey identified 66 citations of interventions, grouped in 47 related interventions. The majority of the studies used observational designs that evaluated the results before and after interventions. Of the 47 related interventions, 34 had results for organizational performance. Four were the most frequently cited: implementation of an observation unit for patients already hospitalized and awaiting diagnosis or clinical stabilization; designation of a dedicated nursing station for the patient's admission, discharge, or transfer; establishment of protocols with indicators of operational saturation and implementation of an emergency care unit. Analyzing 21 interventions that were intended to solve overcrowding in HES and with positive results for length-of-stay, 15 were related to patient stream improvement, interfering actively and positively in patient stream. Interventions that increased access barriers or that merely improved the HES structure were ineffective.

[Quality in the public health services emergency and some considerations about recent events at Rio de Janeiro city]. / A qualidade nos serviços de emergência de hospitais públicos e algumas considerações sobre a conjuntura recente no município do Rio de Janeiro.

The main focus of the QUALISUS Program run by Brazil's Ministry of Health is the quest for quality in healthcare services, particularly in hospital emergency rooms. Taking as an example the crisis in health emergency services in Rio de Janeiro, this paper discusses some structural characteristics of this Program, emphasizing enhanced responsibility and a stronger team spirit for modified intake systems and building up of seamlessly integrated healthcare networks. Identifying possible solutions for this crisis based not only on funding, it suggests a quest for a new identity, redefining and integrating healthcare vocations, structuring flows and revising the work processes of healthcare services through a systemic approach focused on the user.

A qualidade nos serviços de emergência de hospitais públicos e algumas considerações sobre a conjuntura recente no município do Rio de Janeiro / Quality in the public health services emergency and some considerations about recent events at Rio de Janeiro city

A busca da qualidade nos serviços de saúde, em especial nos serviços de emergência, é o foco do Programa QUALISUS do Ministério da Saúde. Tomando como exemplo a crise dos serviços de emergência hospitalar no município do Rio de Janeiro, este artigo discute algumas das características estruturantes desse programa, com ênfase no aumento da responsabilização e vínculo das equipes, na modificação do acolhimento nos serviços de emergência e na integração e constituição de redes assistenciais. Identifica possibilidades de soluções para a crise do sistema de saúde localizadas não somente no âmbito do financiamento. Sugere a busca de uma nova identidade, de caráter sistêmico, como a redefinição e integração das vocações assistenciais, organização de fluxos, repactuando o processo de trabalho dos serviços de saúde, tendo como central o usuário.

The main focus of the QUALISUS Program run by Brazil's Ministry of Health is the quest for quality in healthcare services, particularly in hospital emergency rooms. Taking as an example the crisis in health emergency services in Rio de Janeiro, this paper discusses some structural characteristics of this Program, emphasizing enhanced responsibility and a stronger team spirit for modified intake systems and building up of seamlessly integrated healthcare networks. Identifying possible solutions for this crisis based not only on funding, it suggests a quest for a new identity, redefining and integrating healthcare vocations, structuring flows and revising the work processes of healthcare services through a systemic approach focused on the user.

índice cronotrópico-metabólico na doença de Chagas / Chronotropic-metabolic index in Chagas' disease

A insuficiência cronotrópica constitui achado comum entre os pacientes chagásicos. Novas metodologias estão sendo empregadas na avaliação da resposta cronotrópica em vários grupos de pacientes. O índice cronotrópico-metabólico, um desses novos métodos, quantifica a relação entre o aumento da freqüência cardíaca e o consumo máximo de oxigênio (VO2 max) durante o teste ergométrico. A resposta normal é linear, com índice em torno de 1,0. Objetivamos avaliar a resposta cronotrópica e em indivíduos saudáveis e pacientes chagásicos com e sem disfunção ventricular esquerda, utilizando-se do índice cronotrópico-metabólico. Foram avaliados 171 pacientes com doença de Chagas sem doenças associadas e 24 controles submetidos a protocolo clínico e ao teste ergométrico máximo. Os chagásicos foram divididos em dois grupos: Ch1= pacientes com fração de ejeção (FE) > 39 por cento e Ch 2= FE<40 por cento. A análise e o cálculo do índice cronotrópico-metabólico foram feitos pelo método de Wilkoff. Os pacientes chagásicos apresentaram maior idade e maior prevalência de bloqueio completo de ramo direito, assim como menor VO2 max ao teste ergométrico. Ambos os grupos de chagásicos apresentaram menor inclinação do índice cronotrópico-metabólico (Ch1: 0,91±0,10, Ch2: 0,89±0,08) do que os controles (1,0±0,12, p< 0,001). Pacientes com doença de Chagas com e sem disfunção ventricular esquerda podem apresentar resposta cronotrópica deprimida, manifesta por menor inclinação do índice cronotrópico-metabólico.

[Chronotropic-metabolic index in Chagas' disease]. / Indice cronotrópico-metabólico na doença de Chagas.

Chronotropic incompetence is a common feature in Chagas' disease patients. New methodologies are now available to evaluate the chronotropic response in different subsets. The chronotropic-metabolic index (CMI) is one of these new indexes and quantifies the relationship between the increment of heart rate and the maximal oxygen consumption (VO2 max) during exercise testing. In normal subjects there is linear response and the index is round 1.0. The aim of the study was to evaluate the chronotropic response in healthy controls and Chagas' disease patients with and without left ventricular dysfunction, using CMI. Twenty-four controls and 171 Chagas' disease patients underwent a clinical protocol and maximal exercise testing. Chagas' disease patients were divided into two groups: Ch1= patients with ejection fraction (EF) > 39% and Ch2 = EF < 40%. CMI was analyzed and calculated according to the Wilkoff method. Chagas' disease patients were older than controls and showed higher prevalence of right bundle branch block, as well as lower VO2 max during exercise. Both groups of Chagas' disease patients showed a less steep curve in the chronotropic-metabolic index (Ch1: 0.91+/-0.10, Ch2: 0.89+/-0.08) than controls (1.0+/-0.12, p < 0.001). Chagas' disease patients with and without left ventricular dysfunction chronotropic incompetence may exhibit reduced chronotropic response to exercise, expressed by a less steep chronotropic-metabolic index.

[Validation of a health survey questionnaire focusing on risk factors for coronary artery disease in a group of public employees in Juiz de Fora, Minas Gerais State, Brazil]. / Validação de inquérito de risco referido para vigilância em saúde de fatores de risco de doença arterial coronariana em servidores públicos estaduais de Juiz de Fora, Minas Gerais, Brasil.

The validity of a health survey questionnaire used in a family health promotion program to identify individuals at risk of developing coronary artery disease (CAD) was studied in a random sample of 297 State public employees in Juiz de Fora, Minas Gerais State, Brazil. The sample was stratified by sex, and subjects were 40 years of age or older. Results obtained in interviews were compared to laboratory and clinical data. We assessed the questionnaire's sensitivity, specificity, and positive and negative predictive values in relation to questions about current or previous history of diabetes, hypertension, smoking, and high cholesterol. Among individuals with at least one altered clinical or laboratory test, 81% (total sensitivity) were identified by the referred risk inquiry when reporting at least one risk factor. Sheffield and New Zealand tables were used to determine the individuals with increased risk of developing CAD and to assess if they would also be identified by the health survey questionnaire. The sensitivity for identifying this subgroup was 100%.

Validação de inquérito de risco referido para vigilância em saúde de fatores de risco de doença arterial coronariana em servidores públicos estaduais de Juiz de Fora, Minas Gerais, Brasil / Validation of a health survey questionnaire focusing on risk factors for coronary artery disease in a group of public employees in Juiz de Fora, Minas Gerais State, Brazil

Foi investigada a validade da Ficha de Saúde, inquérito de risco referido (INQ-RR) do Programa IPSEMG-Família, na identificação de pessoas em risco de desenvolver doença arterial coronariana (DAC) numa amostra aleatória, estratificada por sexo, de 297 segurados com idade igual e superior a 40 anos, de Juiz de Fora, Minas Gerais, Brasil. Os resultados obtidos em entrevistas realizadas pelas equipes de saúde da família foram comparados com dados de exames clínico-laboratoriais. Foram avaliados a sensibilidade, a especificidade e os valores preditivos positivos e negativos das questões sobre história atual ou prévia de diabetes mellitus, hipertensão arterial, colesterol elevado e tabagismo. Dentre os participantes que apresentavam pelo menos um exame clínico-laboratorial alterado, 81,0 por cento (sensibilidade total) foram identificados pelo inquérito de risco referido ao declarar ter pelo menos um fator de risco. Os padrões de Sheffield e da Nova Zelândia foram utilizados para determinar os segurados com risco elevado de adquirir doença coronariana e avaliar se estes seriam também identificados pela Ficha de Saúde. A sensibilidade para identificar esse subgrupo de pacientes foi de 100,0 por cento.

Value of the radiological study of the thorax for diagnosing left ventricular dysfunction in Chagas' disease.

OBJECTIVE: To determine the value of the radiological study of the thorax for diagnosing left ventricular dilation and left ventricular systolic dysfunction in patients with Chagas' disease. METHODS: A cross-sectional study of 166 consecutive patients with Chagas' disease and no other associated diseases. The patients underwent cardiac assessment with chest radiography and Doppler echocardiography. Sensitivity, specificity, and positive and negative predictive values of chest radiography were calculated to detect left ventricular dysfunction and the accuracy of the cardiothoracic ratio in the diagnosis of left ventricular dysfunction with the area below the ROC curve. The cardiothoracic ratio was correlated with the left ventricular ejection fraction and the left ventricular diastolic diameter. RESULTS: The abnormal chest radiogram had a sensitivity of 50%, specificity of 80.5%, and positive and negative predictive values of 51.2% and 79.8%, respectively, in the diagnosis of left ventricular dysfunction. The cardiothoracic ratio showed a weak correlation with left ventricular ejection fraction (r=-0.23) and left ventricular diastolic diameter (r=0.30). The area calculated under the ROC curve was 0.734. CONCLUSION: The radiological study of the thorax is not an accurate indicator of left ventricular dysfunction; its use as a screening method to initially approach the patient with Chagas' disease should be reevaluated.