Agreement Between Epigastric Auscultation and pH Measurement in the Confirmation of Nasoenteral Tube Placement.

AIM: This study aimed to evaluate the agreement between epigastric auscultation and pH measurement in the confirmation of nasoenteral tube placement. METHOD: A cross-sectional study carried out in a medium-sized private hospital in the interior of the state of São Paulo. Forty-nine patients who were submitted to ninety insertion procedures and confirmation of tube placement. aimed at evaluating the agreement of clinical methods used by nurses to confirm the positioning of a nasoenteral tube inserted blindly at the bedside, by measuring the parameters of sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: The epigastric auscultation was the method that presented the highest sensitivity (100.0%), but lower specificity (2.0%). The measurement of the pH presented lower sensitivity (63.0%) than the auscultation, however, higher specificity (58%). Moreover, the positive predictive value of the pH measurement was 55% and the negative predictive value was 66%. There was no agreement between the epigastric auscultation and the pH measurement with the radiography. CONCLUSION: The pH measurement did not allow for distinguishing between gastric and enteric positioning, due to the similarity of the esophageal and pulmonary pH with the pH of the intestine. Furthermore, external factors such as the use of medication and reduced fasting time may interfere with the pH value.

Impact of a quality improvement programme on the preparation and administration of medications via a nasoenteral feeding tube: 2014-2019 intervention study.

AIMS: Evaluate the impact of a quality improvement programme on the reduction of feeding tube obstruction frequencies, analyse the predictive variables of this safety incident, and estimate the economic costs related to the quality improvement programme during the period from 2014 to 2019. METHODS: Plan-Do-Study-Act cycles were performed to test the changes in drug preparation and administration processes via a nasoenteral feeding tube and to evaluate the outcome, process and balance measures. Statistical control charts were elaborated, and the bottom-up direct costing methodology was used to estimate the costs of the improvement programme. The impact of the programme on the monitoring measures was evaluated using logistic regression analysis. INTERVENTIONS: The following changes were tested in the hospital participating in the study: acquisition of the Easy Crush equipment for tablet crushing, use of appropriate packaging to crush hard tablets, standardise procedures for scheduling administration times and/or substitution of the pharmaceutical form, educational activities for the nursing team and elaboration and availability of infographics for the nursing team, patients and/or family/caregivers. RESULTS: There was a significant improvement in the frequency of tube obstructions, from 41.1% in 2014 to 57.9% in 2015-2017 and 9.6% in 2018-2019 (p=0.0010). After the execution of the improvement programme, it was estimated that the cost of dose preparation was reduced from R$1067.50 in 2014 to R$719.80 in 2015-2017 and R$433.10 in 2015-2019. CONCLUSION: By re-establishing the processes of drug preparation and administration via a nasoenteral feeding tube, through the acquisition of appropriate equipment for crushing hard tablets, together with educational activities for the nursing team, we could observe a reduction in tube obstructions and the cost of processes.

mpacto de um programa de melhoria da qualidade nos erros de preparo e administração de medicamentos orais via sonda nasoenteral: estudo de intervenção / Impact of a quilite improvement program on errors in the preparation and administration of oral drugs via nasoenteral probe: intervention study

Objetivo: A presente tese é apresentada em forma de quatro artigos que se articulam por meio do objetivo geral: Avaliar o impacto de um programa de melhoria da qualidade nos erros de preparo e administração de medicamentos via sonda nasoenteral. Os objetivos específicos dos artigos foram: (artigo 1) Desenvolver um guia de boas práticas voltado para o preparo e para a administração de medicamentos orais via sonda nasoenteral, a fim de apoiar prescritores e enfermeiros na prestação de cuidados de qualidade e seguros aos pacientes hospitalizados; (artigo 2) Avaliar um programa de melhoria da qualidade para reduzir a proporção de erros no preparo e na administração de medicamentos via sonda nasoenteral; (artigo 3) avaliar a implementação de uma tomada de decisão multicritério em grupo associado a um ciclo Plan-Do-Study-Act (PDSA) dentro de um programa de qualidade para a segurança no uso de medicamentos por toda a equipe de enfermagem para o preparo dos comprimidos (trituração e reconstituição do pó) e do equipamento a ser utilizado para a lavagem da sonda durante a administração de medicamento enteral, dentro de um ciclo PDSA; (artigo 4) Avaliar o impacto de um programa de melhoria da qualidade na redução das frequências de obstruções, analisar as variáveis preditoras deste incidente de segurança e a estimativa econômica dos custos relacionados ao programa de melhoria da qualidade no período de 2014-2019. Métodos: No artigo 1, foi realizado estudo descritivo, em duas fases. Na primeira, foi realizada revisão integrativa da literatura nas bases de dados: LILACS, MEDLINE, Web of Science, MICROMEDEX® Solutions, além de busca manual no site da Agência Nacional de Vigilância Sanitária (ANVISA), em guidelines, livros texto relacionados ao assunto, teses e dissertações. Na segunda fase, o guia foi refinado para uso no hospital por meio de reuniões com a equipe multidisciplinar. No artigo 2, foi realizado estudo de intervenção voltado para a comparação de medidas de resultados antes (linha de base) e depois da implementação do programa de melhoria da qualidade voltado para a redução de erros no preparo e na administração de medicamentos orais via sonda nasoenteral. Foram utilizados os ciclos PDSA para o planejamento e para a ação do programa de melhoria. As intervenções testadas incluíram: desenvolvimento e implementação de um guia de boas práticas para auxiliar a equipe de enfermagem no preparo e na administração de medicamentos orais via sonda nasoenteral; capacitação da equipe de enfermagem com relação à utilização do guia; disponibilização, para os enfermeiras e médicos, de uma lista impressa com os medicamentos orais que não podem ser triturados e administrados via sonda nasoenteral. No artigo 3, foi utilizada uma abordagem participativa, por meio da aplicação de um Modelo de Tomada de Decisão em Grupo (MTDG), como parte do ciclo PDSA, em um hospital brasileiro, para apoiar a equipe de enfermagem na tomada de decisão sobre os processos de preparo e administração de medicamentos orais via sonda. No artigo 4, foi realizado estudo de intervenção para testar o uso de um equipamento (Easy Crush®) na tritura de comprimidos até pó fino e homogêneo. Nesta fase, medidas de resultado, de processo e de equilíbrio foram selecionadas e monitoradas ao longo do tempo, por meio de cinco ciclos PDSA. O impacto do programa de melhoria da qualidade, que ocorreu entre os anos de 2014 a 2019, foi avaliado por meio de análise de regressão logística. Além disso, foi realizada estimativa dos custos do programa de melhoria de qualidade nesse mesmo período. Resultados: Artigo 1: Na fase 1, das 104 referências encontradas, sete atenderam aos critérios de inclusão propostos para o estudo e foram lidas na íntegra. Dessa revisão, resultou a primeira versão do guia de boas práticas no preparo e na administração de medicamentos orais via sonda nasoenteral. Na fase 2, foram realizadas quatro reuniões para adaptar o guia de boas práticas ao contexto do hospital. Participaram das reuniões: três enfermeiros, uma nutricionista, uma farmacêutica e dois médicos. No artigo 2, foi observada melhora nas seguintes medidas: triturou comprimido com revestimento entérico e misturou mais de um medicamento durante o preparo (de 54,9% na Fase I para 25,6% na Fase II; p 0,0010) e triturou forma farmacêutica de ação modificada ou drágea (de 32,8% na Fase I para 19% na Fase II; p 0,0010). Contudo, piora foi verificada nas seguintes medidas: não triturou comprimido até pó fino e homogêneo (de 7,4% na Fase I para 95,3% na Fase II; p 0,0010) e sondas obstruídas (de 41,8% na Fase I para 53% na Fase II; p 0,0950). No artigo 3, participaram do processo de decisão, profissionais envolvidos no preparo e na administração de medicamentos orais via sonda nasoenteral, ou seja, a equipe de enfermagem e farmacêutica. Foram realizadas duas negociações sobre as técnicas e foi discutida a necessidade de aquisição de um novo equipamento para preparar, de modo mais eficiente, os comprimidos. Ao analisar o ciclo PDSA anterior, sem qualquer participação na tomada de decisão, com o ciclo PDSA em conjunto com o método do MTDG, aumentou as chances de implementação efetiva das práticas de melhoria da qualidade, principalmente quanto à técnica de trituração de comprimidos (de 95,3% de não conformidade no ciclo PDSA sem método MTDG para 0% de não conformidade no ciclo PDSA com método MTDG). No artigo 4, foi observada melhora na medida de resultado obstrução da sonda (de 41,8% em 2014 para 53% em 2017 e para 9,6% em 2019). Nas medidas de processo, também observamos uma redução do número de medicamentos orais prescritos via sonda nasoenteral, em 24 horas, (de 4,9% em 2014 para 5,6% em 2017 para 4,5% em 2019). Em relação ao número de medicamentos orais aprazados para o mesmo horário, também verificamos uma redução (de 3,3% em 2014 para 2,3% em 2017 para 1,3% em 2019). Na medida de equilíbrio, foi identificada melhora na seguinte medida: comprometimento de aspectos biofarmacêuticos durante a tritura de medicamentos sólidos (de 11,6% em 2014 para 12,3% em 2017 e para 0% em 2019). Na análise de regressão logística, foi verificado impacto significativo do programa de melhoria da qualidade na redução de sondas obstruídas (p=0,0010). Também foi verificado impacto positivo do programa de melhoria da qualidade no custo do preparo das doses: de R$ 1.067,50 em 2014, para R$ 719,80 em 2017 e R$ 433,10 em 2019. Conclusão: Os resultados dos estudos desenvolvidos na presente tese destacam a importância de programas de melhoria da qualidade para reduzir erros relacionados aos processos de preparo e de administração de medicamentos orais via sonda nasoenteral. As mudanças testadas por meio de ciclos PDSA impactaram significativamente os processos e resultou em redução de custos para a instituição

Objective: This thesis is presented in the form of four articles that are articulated through the general objective: To evaluate the impact of a quality improvement program on the errors of preparation and administration of drugs via nasoenteral probe. The specific objectives of the articles were: (Article 1) To involve a guide of good practices aimed at the preparation and administration of oral drugs via nasoenteral probe, in order to support prescribers and nurses in providing quality and safe care to hospitalized patients; (Article 2) Evaluate a quality improvement program to reduce the proportion of errors in the preparation and administration of drugs via nasoenteral probe; (Article 3) evaluate the implementation of a multi-criteria group decision-making associated with a Plan-Do-Study-Act (PDSA) cycle within a quality program for the safety of the use of medicines by the entire nursing team for the preparation of tablets (grinding and reconstitution of powder) and the equipment to be used for washing the probe during enteral drug administration, within a PDSA cycle; (Article 4) Evaluate the impact of a quality improvement program on reducing the frequencies of obstructions, analyze the predictor variables of this safety incident and the economic estimation of costs related to the quality improvement program in the period 2014-2019. Method: In Article 1, a descriptive study was conducted in two phases. In the first, an integrative review of the literature was performed in the databases: LILACS, MEDLINE, Web of Science, MICROMEDEX® Solutions, in addition to manual search on the website of the National Health Surveillance Agency (ANVISA), in guidelines, textbooks related to the subject, theses and dissertations. In the second phase, the guide was refined for non-hospital use through meetings with the multidisciplinary team. In Article 2, an intervention study was conducted aimed at comparing measures of results before (baseline) and after the implementation of the quality improvement program aimed at reducing errors, not preparing and administering oral medications via nasoenteral probe. Foram used PDSA cycles for planning and for the action of the improvement program. The interventions tested included: development and implementation of a good practice guide to assist the nursing team in the preparation and administration of oral medications via nasoenteral probe; training of the nursing team in relation to the use of the guide; availability, for nurses and physicians, of a printed list with oral medications that cannot be crushed and administered via nasoenteral probe. In Article 3, a participatory approach was used, through the application of a Group Decision Making Model (MTDG), as part of the PDSA cycle, in a Brazilian hospital, to support the nursing team in decision-making on the processes of preparation and administration of oral drugs via probe. In article 4, an intervention study was carried out to test the use of an equipment (Easy Crush®) in the grinding of tablets to fine and homogeneous powder. In this phase, results, process and equilibrium were selected and monitored over time, through five PDSA cycles. The impacto of the quality improvement program, which occurred between 2014 and 2019, was evaluated by logistic regression analysis. In addition, the costs of the quality improvement program were estimated in the same period. Results: Article 1: In phase 1, in the 104 references found, seven met the inclusion criteria proposed for the study and were read in full. This review resulted in the first version of the guide of good practices in the preparation and administration of oral drugs via nasoenteral tube. In phase 2, four meetings were held to adapt the guide of good practices to the hospital context. Three nurses, one nutritionist, one pharmacist and two physicians participated in the meetings. In Article 2, improvement was observed in the following measures: triturou tablet with enteric coating and mixed more than one drug during preparation (from 54.9% in Phase I to 25.6% in Phase II; p 0.0010) and crushed pharmaceutical form of modified or drágea action (from 32.8% in Phase I to 19% in Phase II; p 0.0010). However, worsening was observed in the following measures: it did not grind tablet to fine and homogeneous powder (from 7.4% in Phase I to 95.3% in Phase II; p 0.0010) and obstructed probes (from 41.8% in Phase I to 53% in Phase II; p 0.0950). In Article 3, professionals involved in the preparation and administration of oral medications via nasoenteral probe, i.e., the nursing and pharmaceutical team, were based in the decision-making process. Two negotiations were held on the techniques and the need to purchase new equipment was discussed to prepare the tablets more efficiently. By analyzing the previous PDSA cycle, without any participation in decision making, with the PDSA cycle in conjunction with the MTDG method, the chances of effective implementation of quality improvement practices increased, especially regarding the tablet crushing technique (95.3% non-conformity in the PDSA cycle without PARA MTDG method 0% non-conformity in the PDSA cycle with MTDG method). In Article 4, an improvement was observed in the measurement of probe obstruction result (from 41.8% in 2014 to 53% in 2017 and to 9.6% in 2019). In the process measures, we also observed a reduction in the number of oral drugs prescribed via nasoenteral tube in 24 hours (from 4.9% in 2014 to 5.6% in 2017 to 4.5% in 2019). Regarding the number of oral medicines available for the same time, we also found a reduction (from 3.3% in 2014 to 2.3% in 2017 to 1.3% in 2019). In the equilibrium measure, improvement was identified in the following measure: impairment of biopharmaceutical aspects during the crushing of solid drugs (from 11.6% in 2014 to 12.3% in 2017 and to 0% in 2019). In the logistic regression analysis, a significant impact of the quality improvement program on the reduction of obstructed probes was verified (p=0.0010). It was also verified a positive impact of the program to improve the quality of the cost of preparing doses: from R$ 1,067.50 in 2014, to R$ 719.80 in 2017 and R$ 433.10 in 2019. Conclusion: The results of the studies developed in this thesis highlight the importance of quality improvement programs to reduce errors related to the processes of preparation and administration of oral drugs via nasoenteral probe. The changes tested through PDSA cycles significantly impacted the processes and resulted in cost reduction for the institution

Programa de melhoria da qualidade na administração de medicamentos via sonda nasoenteral / Programa de mejora de la calidad en la administración de medicamentos por sonda nasoenteral / Quality improvement program in medication administration through nasogastric tube

Resumo Objetivo Avaliar o impacto de um programa de melhoria da qualidade relacionado aos indicadores de frequência de sondas nasoenterais obstruídas, do tempo despendido pela equipe de enfermagem no preparo e na administração de medicamentos orais por essa via, e dos custos associados ao incidente. Método Estudo de intervenção voltado para a comparação pré (Fase I) e pós (Fase II) implementação de um Programa Melhoria da Qualidade, proposto pelo Institute for Healthcare Improvement . Foram observadas 92 doses de medicamentos na Fase I e 66 doses na Fase II. Foram necessários quatro ciclos Plan-Do-Study-Act (PDSA) para atingir a meta proposta para o programa de melhoria. Resultados Houve redução no tempo médio gasto pelo profissional no preparo e na administração de medicamentos sólidos via sonda nasoenteral em ambas as fases. As frequências de sondas obstruídas reduziram de 33,3% (Fase I) para 7,4% (Fase II) e nenhuma sonda apresentou-se obstruída durante os ciclos 1, 2 e 4. O custo médio da obstrução por paciente foi de R$ 1.251,05 ao mês na Fase I e de R$ 23,31 na Fase II. Após as mudanças testadas, foi verificada economia de tempo para a equipe de enfermagem e de custo para a instituição. Conclusão Os ciclos PDSA foram eficazes na redução de não conformidades no preparo e na administração de medicamentos via sonda nasoenteral. Tal melhoria impactou a frequência de obstrução, os custos relacionados e o tempo médio gasto pelo profissional de enfermagem durante o preparo e a administração das doses.

Resumen Objetivo Evaluar el impacto de un programa de mejora de la calidad relacionado con los indicadores de frecuencia de sondas nasoenterales obstruidas, del tempo invertido por el equipo de enfermería en la preparación y en la administración de medicamentos orales por esa vía y de los costos asociados con el incidente. Métodos Estudio de intervención direccionado para la comparación previa (Fase I) y posterior (Fase II) a la implementación de un Programa Mejora de la Calidad, propuesto por el Institute for Healthcare Improvement . Se observaron 92 dosis de medicamentos en la Fase I y 66 dosis en la Fase II. Se necesitaron cuatro ciclos Plan-Do-Study-Act (PDSA) para alcanzar la meta propuesta para el programa de mejora. Resultados Hubo reducción del tiempo promedio consumido por el profesional en la preparación y en la administración de medicamentos sólidos por sonda nasoenteral en ambas fases. La frecuencia de la obstrucción de las sondas se redujo del 33,3 % (Fase I) para el 7,4 % (Fase II) y ninguna sonda presentó obstrucción durante los ciclos 1, 2 y 4. El costo promedio de la obstrucción por paciente fue de R$ 1.251,05 al mes en la Fase I y de R$ 23,31 en la Fase II. Después de someter a pruebas los cambios, se verificó un ahorro de tiempo para el equipo de enfermería y de costo para la institución. Conclusión Los ciclos PDSA fueron eficaces en la reducción de no conformidades en la preparación y en la administración de medicamentos por sonda nasoenteral. Esa mejora impactó la frecuencia de obstrucción, los costos relacionados y el tiempo promedio consumido por el profesional de enfermería durante la preparación y la administración de las dosis.

Abstract Objective Evaluate the impact of a quality improvement program related to the frequency indicators of obstructed nasogastric tubes, the time the nursing team spent on oral medication preparation and administration through this route, and the costs associated with the incident. Method Intervention study aimed at comparing pre (Phase I) and post (Phase II) implementation of a Quality Improvement Program, proposed by Institute for Healthcare Improvement . Ninety-two medication doses were observed in Phase I and 66 doses in Phase II. Four Plan-Do-Study-Act (PDSA) cycles were needed to achieve the proposed target for the improvement program. Results The average time the professional spent on solid medication preparation and administration through nasogastric tube decreased in both phases. Frequencies of obstructed tubes dropped from 33.3% (Phase I) to 7.4% (Phase II) and no probe was obstructed during cycles 1, 2, and 4. The average cost of the obstruction per patient was R$ 1,251.05 per month in Phase I and R$ 23.31 in Phase II. After testing the changes, time savings for the nursing team and cost savings for the institution were verified. Conclusion The PDSA cycles were effective in reducing non-conformities in medication preparation and administration via nasogastric tube. This improvement influenced the obstruction frequency, related costs, and the average time the nursing professional spent on the preparation and administration of the medication doses.

Construção e validação de cartilha para cuidados paliativos domiciliares após alta hospitalar / Elaboración y validación de cartilla para cuidados paliativos domiciliarios después del alta hospitalaria / Construction and validation of a booklet for home palliative care after hospital discharge

Resumo Objetivo Construir e validar cartilha educativa para cuidados paliativos domiciliares após a alta hospitalar. Métodos Estudo metodológico desenvolvido em três etapas: levantamento bibliográfico, construção da cartilha educativa e validação do material por especialistas em cuidados paliativos e cuidadores de pacientes. O processo de validação foi realizado por 8 especialistas e 12 representantes do público-alvo, selecionados por conveniência. Considerou-se o Índice de Validade de Conteúdo mínimo de 0,80, para validação de conteúdo e concordância mínima de 75% para validação de aparência. Resultados A cartilha intitulada "Eu cuido, nós cuidamos - cuidados domiciliares a pacientes em cuidados paliativos" é composta por 28 páginas. Na validação de conteúdo pelos especialistas, o IVC global obtido foi 1,0 e a cartilha foi aprovada por unanimidade pelos representantes do público-alvo, com índice de concordância 1,0. Conclusão A cartilha educativa foi validada quanto ao conteúdo e aparência, podendo ser utilizada por cuidadores na realização de cuidados paliativos domiciliares e por enfermeiros para as orientações na alta hospitalar.

Resumen Objetivo Elaborar y validar cartilla educativa para cuidados paliativos domiciliarios después del alta hospitalaria. Métodos Estudio metodológico desarrollado en tres etapas: recopilación bibliográfica, elaboración de cartilla educativa y validación del material por especialistas en cuidados paliativos y cuidadores de pacientes. El proceso de validación fue realizado por ocho especialistas y 12 representantes del público destinatario, seleccionados por conveniencia. Se consideró el Índice de Validez de Contenido mínimo de 0,80 para la validación de contenido, y concordancia mínima de 75 % para validación de apariencia. Resultados La cartilla titulada "Yo cuido, nosotros cuidamos: cuidados domiciliarios a pacientes en cuidados paliativos" está compuesta por 28 páginas. En la validación de contenido por los especialistas, el IVC global obtenido fue 1,0 y la cartilla fue aprobada por unanimidad por los representantes del público destinatario, con un índice de concordancia de 1,0. Conclusión La cartilla educativa fue validada respecto al contenido y apariencia y puede ser utilizada por cuidadores en la realización de cuidados paliativos domiciliarios y por enfermeros para dar instrucciones en el alta hospitalaria.

Abstract Objective To construct and validate an educational booklet for home palliative care after hospital discharge. Methods This is a methodological study developed in three stages: bibliographic survey, booklet construction and material validation by palliative care experts and patient caregivers. The validation process was carried out by 8 experts and 12 target audience representatives, selected for convenience. The Minimum Content Validity Index of 0.80 was considered for content validation and minimum agreement of 75% for appearance validation. Results The booklet "Eu cuido, nós cuidamos - cuidados domiciliares a pacientes em cuidados paliativos" consists of 28 pages. In the content validation by experts, the global CVI obtained was 1.0 and the booklet was unanimously approved by the target audience representatives, with agreement index of 1.0. Conclusion The educational booklet was validated regarding content and appearance, and can be used by caregivers in the performance of home palliative care and by nurses for guidance at hospital discharge.

Adherence to safety barriers in medication administration: patients' perception.

OBJECTIVE: to analyze the perception of patients about health professionals' adherence to safety barriers in medication administration. METHOD: cross-sectional and correlational study carried out in a hospital in the countryside of São Paulo, with a total of 249 adult patients admitted to the medical clinic. An electronic form developed by the researcher was used. Quantitative variables were analyzed in mean, median and standard deviation. Likert-type variables were calculated according to the perception score and the Bayesian Information criterion was used. The cutoff point for positive assessment of the patients' perception was 0.75. RESULTS: the average perception score was 0.29 and, of the 15 barriers analyzed, eight are never adhered by professionals, in the opinion of most patients. Also, age was the only variable with statistical significance. CONCLUSION: the younger the patient, the better their perception of health professionals' adherence to safety barriers in medication administration.

Adherence to safety barriers in medication administration: patients' perception / Adhesión a las barreras de seguridad en la administración de medicamentos: percepción del paciente / Adesão às barreiras de segurança na administração de medicamentos: percepção do paciente

Objective: to analyze the perception of patients about health professionals' adherence to safety barriers in medication administration. Method: cross-sectional and correlational study carried out in a hospital in the countryside of São Paulo, with a total of 249 adult patients admitted to the medical clinic. An electronic form developed by the researcher was used. Quantitative variables were analyzed in mean, median and standard deviation. Likert-type variables were calculated according to the perception score and the Bayesian Information criterion was used. The cutoff point for positive assessment of the patients' perception was 0.75. Results: the average perception score was 0.29 and, of the 15 barriers analyzed, eight are never adhered by professionals, in the opinion of most patients. Also, age was the only variable with statistical significance. Conclusion: the younger the patient, the better their perception of health professionals' adherence to safety barriers in medication administration.

Objetivo: analizar la percepción de pacientes sobre la adhesión de los profesionales de salud a las barreras de seguridad en la administración de medicamentos. Método: estudio transversal y correlacional realizado en un hospital del interior de São Paulo, con 249 pacientes adultos hospitalizados en la clínica médica. Se utilizó un formulario electrónico desarrollado por la investigadora. Las variables cuantitativas se analizaron en términos de media, mediana y desviación estándar. Las variables tipo Likert se calcularon según el puntaje de percepción y se utilizó el criterio de Información Bayesiana. El punto de corte para la evaluación positiva de la percepción del paciente fue 0,75. Resultados: el puntaje de percepción promedio fue de 0,29 y, de las 15 barreras analizadas, ocho nunca son adheridas por los profesionales, en la opinión de la mayoría de los pacientes. Además, la edad fue la única variable con significación estadística. Conclusión: cuanto más joven es el paciente, mejor es su percepción de la adhesión de los profesionales de salud a las barreras de seguridad en la administración de medicamentos.

Objetivo: analisar a percepção de pacientes sobre a adesão dos profissionais de saúde às barreiras de segurança na administração de medicamentos. Método: estudo transversal e correlacional, realizado em um hospital do interior de São Paulo, com 249 pacientes adultos internados na clínica médica. Utilizou-se um formulário eletrônico desenvolvido pela pesquisadora. As variáveis quantitativas foram analisadas em termos de média, mediana e desvio-padrão. As variáveis do tipo Likert foram calculadas de acordo com o escore de percepção, utilizando-se o critério de Informação Bayesiana. O ponto de corte à apreciação positiva da percepção do paciente foi 0,75. Resultados: a média do escore de percepção foi 0,29, sendo que, das 15 barreiras analisadas, oito nunca são aderidas pelos profissionais, na visão da maioria dos pacientes. Além disso, a idade foi a única variável com significância estatística. Conclusão: Quanto mais jovem o paciente, melhor a sua percepção sobre a adesão dos profissionais de saúde às barreiras de segurança na administração de medicamentos.

Accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement: a study protocol for a prospective study.

INTRODUCTION: Patients using a nasogastric tube (NGT) are vulnerable to adverse events, therefore proper assessment of these patients, verification of the correct tube placement and constant monitoring by the nursing staff are strategies that can reduce adverse events and risks associated with the care. The aim of this study will be to assess the accuracy of the combined method (auscultation and pH measurement) and ultrasonography for confirmation of gastric tube placement compared with the X-ray method. A further aim will be to measure and provide evidence for the direct costs of each method of confirming NGT placement and to evaluate the impact of each method on the mean direct cost of the patient. METHODS AND ANALYSIS: This is a prospective, single-centre study of diagnostic accuracy. Data will be collected in the clinical and surgical wards, intensive care unit and coronary care unit of a Brazilian teaching hospital. The sample will consist of 385 assessments, performed in adult patients that agree to participate in the study and that receive an NGT. The combined method and the ultrasound will be the index tests and will be performed on all study participants for later comparison with an X-ray examination, considered the reference standard and the gold standard to distinguish between gastric and pulmonary placement. Sensitivity, specificity, positive predictive value and negative predictive value will be calculated to assess the diagnostic accuracy of the methods investigated in this study, with Cohen's kappa analysis used to evaluate the degree of concordance. ETHICS AND DISSEMINATION: The study was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, registration number: 83087318.4.0000.5393. The findings will be reported through academic journals, seminars and conference presentations, social media, print media, the internet and community/stakeholder engagement activities.

Quality improvement programme reduces errors in oral medication preparation and administration through feeding tubes.

BACKGROUND: Patients with nasogastric/nasoenteric tube (NGT/NET) are at increased risk of adverse outcomes due to errors occurring during oral medication preparation and administration. AIM: To implement a quality improvement programme to reduce the proportion of errors in oral medication preparation and administration through NGT/NET in adult patients. METHODS: An observational study was carried out, comparing outcome measures before and after implementation of the integrated quality programme to improve oral medication preparation and administration through NGT/NET. A collaborative approach based on Plan-Do-Study-Act (PDSA) cycle was used and feedback was given during multidisciplinary meetings. INTERVENTIONS: Good practice guidance for oral medication preparation and administration through NGT/NET was developed and implemented at the hospital sites; nurses were given formal training to use the good practice guidance; a printed list of oral medications that should never be crushed was provided to all members of the multidisciplinary team, and a printed table containing therapeutic alternatives for drugs that should never be crushed was provided to prescribers at the prescribing room. RESULTS: Improvement was observed in the following measures: crushing enteric-coated tablets and mixing drugs during medication preparation (from 54.9% in phase I to 26.2% in phase II; p 0.0010) and triturating pharmaceutical form of modified action or dragee (from 32.8 in phase I to 19.7 in phase II; p 0.0010). Worsening was observed though in the following measures: crush compressed to a fine and homogeneous powder (from 7.4%% in phase I to 95% phase II; p 0.0010) and feeding tube obstruction (from 41.8% in phase I to 52.5% phase II; p 0.0950). CONCLUSION: Our results highlight how a collaborative quality improvement approach based on PDSA cycles can meet the challenge of reducing the proportion of errors in oral medication preparation and administration through NGT/NET in adult patients. Some changes may lead to unintended consequences though. Thus, continuous monitoring for these consequences will help caregivers to prevent poor patient outcomes.

Avaliação da microdureza de resina composta polimerizada com fontes de luz halógena e LED, em função da densidade de energia luminosa irradiada / Knoop hardness analisys of a resin composite activated by halogen lamp and LED, varying the luminous density

No presente estudo, avaliou-se a microdureza da resina composta Z250 (3M ESPE), quando ativada em diferentes tempos (s), diferentes densidades de potência (mW/cm²), em relação à quantidade de energia irradiada (8, 12 e 16 J/cm²), com a finalidade de estabelecer uma densidade de energia luminosa mínima capaz de polimerizar adequadamente os compósitos. Foi utilizado um aparelho com fonte de luz halógena Degulux-Degussa, com 600 mW/cm² e dois aparelhos de fonte de luz LED, Ultraled XP (Dabi-Atlante) com 150 mW/cm² e LED Ultrablue-IS (DMC) com 300 mW/cm² e 600 mW/cm². Duas matrizes bipartidas de PTFE, de 1 e de 2 mm de espessura e um orifício central de 5 mm de diâmetro, foram usadas para confeccionar 60 corpos-de-prova, 5 em cada grupo. As duas partes da matriz foram contidas em um anel metálico com as mesmas espessuras. O material foi inserido na matriz e fotoativado de acordo com os diferentes tempos e a quantidade de densidade de energia luminosa para cada fonte de luz. Para obter os valores de microdureza Knoop, os espécimes foram levados ao microdurômetro Shimadzu HMV-2, com carga estática de 300 g por 5 segundos, para aferir as superfícies exposta (topo) e oposta (base) à fonte de luz, totalizando 120 medições. Os resultados foram submetidos aos testes ANOVA e Tukey, com nível de significância de 5%. Com os dados obtidos foi possível concluir que, com valores a partir de 16 J/cm² e 12 J/cm² de densidade de energia luminosa, espessuras de 2 mm de resina composta podem ser adequadamente polimerizadas utilizando-se fonte de luz halógena (600 mW/cm²) e LED (a partir de 300 mW/cm²) respectivamente. Contudo, estudos clínicos adicionais ainda são necessários para complementar este estudo.

At this study it was evaluated the microhardness of the Z250 (3M ESPE) resin composite, when light cured for different periods of time (s), with different power densities (mW/cm²), related to the irradiated luminous energy density (8 J/cm², 12 J/cm² and 16 J/cm²), in order to establish a minimal energy density capable of adequately polymerize the composites. One halogen light curing unit Degulux- Degussa, with 600 mW/cm² of power density and two light-emitting diodes curing units Ultraled XP (Dabi-Atlante) with 150 mW/cm² and LED Ultrablue-IS (DMC) with 300 mW/cm² and 600 mW/cm² were used. Two bipartite PTFE matrices, with 1 and 2 mm of depth and a central orifice of 5 mm diameter, were used to make 60 specimens, 5 per group. The halves of the matrix were positioned inside a brass ring with both depths to prepare the specimens. The resin composite was inserted and light-activated according to the different periods and energy densities of each lightcuring unit. To evaluate Knoop microhardness, specimens were taken to a microdurometer Shimadzu HMV-2 with a static load of 300 g for 5 seconds, evaluating both exposed to light (surface) and opposite to light (base) exposition surfaces, totalizing 120 measurements. Results were submitted to ANOVA and Tukey’s test with 5% significance level. Based on the obtained results, it was concluded that, starting from 16 J/cm² and 12 J/cm² of energy luminous density, 2 mm depth resin composite can be adequately polymerized utilizing halogen (600 mW/cm²) and LED ( starting from 300 mW/cm²) curing-units respectively. However, additional clinical studies are necessary to complement this investigation.

Comparative analysis of the shrinkage stress of composite resins.

The aim of this study was to compare the shrinkage stress of composite resins by three methods. In the first method, composites were inserted between two stainless steel plates. One of the plates was connected to a 20 kgf load cell of a universal testing machine (EMIC-DL-500). In the second method, disk-shaped cavities were prepared in 2-mm-thick Teflon molds and filled with the different composites. Gaps between the composites and molds formed after polymerization were evaluated microscopically. In the third method, the wall-to-wall shrinkage stress of the resins that were placed in bovine dentin cavities was evaluated. The gaps were measured microscopically. Data were analyzed by one-way ANOVA and Tukey's test (alpha=0.05). The obtained contraction forces were: Grandio = 12.18 +/- 0.428N; Filtek Z 250 = 11.80 +/- 0.760N; Filtek Supreme = 11.80 +/- 0.707 N; and Admira = 11.89 +/- 0.647 N. The gaps obtained between composites and Teflon molds were: Filtek Z 250 = 0.51 +/- 0.0357%; Filtek Supreme = 0.36 +/- 0.0438%; Admira = 0.25 +/- 0.0346% and Grandio = 0.16 +/- 0.008%. The gaps obtained in wall-to-wall contraction were: Filtek Z 250 = 11.33 +/- 2.160 microm; Filtek Supreme = 10.66 +/- 1.211 microm; Admira = 11.16 +/- 2.041 microm and Grandio = 10.50 +/- 1.224 microm. There were no significant differences among the composite resins obtained with the first (shrinkage stress generated during polymerization) and third method (wall-to-wall shrinkage). The composite resins obtained with the second method (Teflon method) differed significantly regarding gap formation.

Comparative analysis of the shrinkage stress of composite resins

The aim of this study was to compare the shrinkage stress of composite resins by three methods. In the first method, composites were inserted between two stainless steel plates. One of the plates was connected to a 20 kgf load cell of a universal testing machine (EMIC-DL-500). In the second method, disk-shaped cavities were prepared in 2-mm-thick Teflon molds and filled with the different composites. Gaps between the composites and molds formed after polymerization were evaluated microscopically. In the third method, the wall-to-wall shrinkage stress of the resins that were placed in bovine dentin cavities was evaluated. The gaps were measured microscopically. Data were analyzed by one-way ANOVA and Tukey's test (alpha=0.05). The obtained contraction forces were: Grandio = 12.18 ± 0.428N; Filtek Z 250 = 11.80 ± 0.760N; Filtek Supreme = 11.80 ± 0.707 N; and Admira = 11.89 ± 0.647 N. The gaps obtained between composites and Teflon molds were: Filtek Z 250 = 0.51 ± 0.0357 percent; Filtek Supreme = 0.36 ± 0.0438 percent; Admira = 0.25 ± 0.0346 percent and Grandio = 0.16 ± 0.008 percent. The gaps obtained in wall-to-wall contraction were: Filtek Z 250 = 11.33 ± 2.160 µm; Filtek Supreme = 10.66 ± 1.211µm; Admira = 11.16 ± 2.041 µm and Grandio = 10.50 ± 1.224 µm. There were no significant differences among the composite resins obtained with the first (shrinkage stress generated during polymerization) and third method (wall-to-wall shrinkage). The composite resins obtained with the second method (Teflon method) differed significantly regarding gap formation.

Transmission of composite polymerization contraction force through a flowable composite and a resin-modified glass ionomer cement

The purpose of this study was to evaluate the individual contraction force during polymerization of a composite resin (Z-250), a flowable composite (Filtek Flow, FF) and a resin-modified glass ionomer cement (Vitrebond, VB), and the transmission of Z-250 composite resin polymerization contraction force through different thicknesses of FF and VB. The experiment setup consisted of two identical parallel steel plates connected to a universal testing machine. One was fixed to a transversal base and the other to the equipment's cross head. The evaluated materials were inserted into a 1-mm space between the steel plates or between the inferior steel plate and a previously polymerized layer of an intermediate material (either FF or VB) adhered to the upper steel plate. The composite resin was light-cured with a halogen lamp with light intensity of 500 mW/cm² for 60 s. A force/time graph was obtained for each sample for up to 120 s. Seven groups of 10 specimens each were evaluated: G1: Z-250; G2: FF; G3: VB; G4: Z-250 through a 0.5-mm layer of FF; G5: Z-250 through a 1-mm layer of FF; G6: Z-250 through a 0.5-mm of VB; G7: Z-250 through a 1-mm layer of VB. They were averaged and compared using one-way ANOVA and Tukey test at a = 0.05. The obtained contraction forces were: G1: 6.3N + 0.2N; G2: 9.8 + 0.2N; G3: 1.8 + 0.2N; G4: 6.8N + 0.2N; G5: 6.9N + 0.3N; G6: 4.0N + 0.4N and G7: 2.8N + 0.4N. The use of VB as an intermediate layer promoted a significant decrease in polymerization contraction force values of the restorative system, regardless of material thickness. The use of FF as an intermediate layer promoted an increase in polymerization contraction force values with both material thicknesses.

Transmission of composite polymerization contraction force through a flowable composite and a resin-modified glass ionomer cement.

The purpose of this study was to evaluate the individual contraction force during polymerization of a composite resin (Z-250), a flowable composite (Filtek Flow, FF) and a resin-modified glass ionomer cement (Vitrebond, VB), and the transmission of Z-250 composite resin polymerization contraction force through different thicknesses of FF and VB. The experiment setup consisted of two identical parallel steel plates connected to a universal testing machine. One was fixed to a transversal base and the other to the equipment's cross head. The evaluated materials were inserted into a 1-mm space between the steel plates or between the inferior steel plate and a previously polymerized layer of an intermediate material (either FF or VB) adhered to the upper steel plate. The composite resin was light-cured with a halogen lamp with light intensity of 500 mW/cm(2) for 60 s. A force/time graph was obtained for each sample for up to 120 s. Seven groups of 10 specimens each were evaluated: G1: Z-250; G2: FF; G3: VB; G4: Z-250 through a 0.5-mm layer of FF; G5: Z-250 through a 1-mm layer of FF; G6: Z-250 through a 0.5-mm of VB; G7: Z-250 through a 1-mm layer of VB. They were averaged and compared using one-way ANOVA and Tukey test at a = 0.05. The obtained contraction forces were: G1: 6.3N + 0.2N; G2: 9.8 + 0.2N; G3: 1.8 + 0.2N; G4: 6.8N + 0.2N; G5: 6.9N + 0.3N; G6: 4.0N + 0.4N and G7: 2.8N + 0.4N. The use of VB as an intermediate layer promoted a significant decrease in polymerization contraction force values of the restorative system, regardless of material thickness. The use of FF as an intermediate layer promoted an increase in polymerization contraction force values with both material thicknesses.

Ligas alternativas para restaurações metálicas fundidas / Alternative alloys for metal casting

Este trabalho apresenta uma breve revisão de literatura sobre os sistemas de ligas alternativas mais utilizados em restaurações metálicas fundidas. Ele demonstra que, apesar das limitações delas, quando comparadas às ligas áureas, se houver um planejamento correto e cuidados clínicos e laboratoriais, elas apresentarão um comportamento clínico satisfatório

[A comparative study of the parasitological techniques: Kato-Katz and coprotest]. / Estudo comparativo de técnicas parasitológicas: Kato-Katz e coprotest.

Parasitological diagnosis should be appropriately conducted with high sensitivity and specificity so that intestinal parasite can be detected as the specific treatment depends on this result. A comparative study was developed to evaluate the concordance between the Kato-Katz and coprotest methods in the detection of helminthes in 332 individuals in Pedro de Toledo. A significant difference was found in the case of the Trichuris trichiura - 16.2% with the Kato-Katz method and 7.5% with the coprotest method. Therefore, the positive and negative samples of the coprotest method were compared with the number of eggs per gram of feces (epg) obtained by the Kato-Katz method. When the coprotest method was negative, 65 epg of Trichuris trichiura were found by the Kato-Katz method and when the coprotest was positive the epg according to the Kato-Katz were far higher, 199 epg, which demonstrated that the coprotest was inferior to the Kato-Katz method regarding low intensity infections.

Estudo comparativo de técnicas parasitológicas: Kato-Katz e coprotest® / A comparative study of the parasitological techniques: Kato-Katz and coprotest®

O diagnóstico parasitológico deve ser realizado de maneira apropriada, com maior sensibilidade e especificidade para a detecção dos parasitas intestinais, uma vez que dele dependerá o tratamento específico. Foi desenvolvido um estudo comparativo para avaliar a concordância entre os métodos Kato-Katz e coprotest® na detecção de helmintos em 332 indivíduos do município de Pedro de Toledo. Destacou-se uma diferença significativa para Trichuris trichiura, 16,2 por cento no Kato-Katz e 7,5 por cento no coprotest®. Devido a essa diferença compararam-se amostras positivas e negativas do método de coprotest® com número de ovos por grama de fezes (opg) obtido pelo método de Kato-Katz. Quando o método de coprotest® era negativo, contaram-se 65 opg de Trichuris trichiura pelo Kato-Katz e quando o coprotest® era positivo, esse número foi maior, 199 opg. O coprotest® mostrou-se inferior ao Kato-Katz nas infecções de baixa carga parasitária.