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1.
JAMA ; 322(3): 216-228, 2019 07 16.
Artigo em Inglês | MEDLINE | ID: mdl-31310297

RESUMO

Importance: The effects of intensive care unit (ICU) visiting hours remain uncertain. Objective: To determine whether a flexible family visitation policy in the ICU reduces the incidence of delirium. Design, Setting and Participants: Cluster-crossover randomized clinical trial involving patients, family members, and clinicians from 36 adult ICUs with restricted visiting hours (<4.5 hours per day) in Brazil. Participants were recruited from April 2017 to June 2018, with follow-up until July 2018. Interventions: Flexible visitation (up to 12 hours per day) supported by family education (n = 837 patients, 652 family members, and 435 clinicians) or usual restricted visitation (median, 1.5 hours per day; n = 848 patients, 643 family members, and 391 clinicians). Nineteen ICUs started with flexible visitation, and 17 started with restricted visitation. Main Outcomes and Measures: Primary outcome was incidence of delirium during ICU stay, assessed using the CAM-ICU. Secondary outcomes included ICU-acquired infections for patients; symptoms of anxiety and depression assessed using the HADS (range, 0 [best] to 21 [worst]) for family members; and burnout for ICU staff (Maslach Burnout Inventory). Results: Among 1685 patients, 1295 family members, and 826 clinicians enrolled, 1685 patients (100%) (mean age, 58.5 years; 47.2% women), 1060 family members (81.8%) (mean age, 45.2 years; 70.3% women), and 737 clinicians (89.2%) (mean age, 35.5 years; 72.9% women) completed the trial. The mean daily duration of visits was significantly higher with flexible visitation (4.8 vs 1.4 hours; adjusted difference, 3.4 hours [95% CI, 2.8 to 3.9]; P < .001). The incidence of delirium during ICU stay was not significantly different between flexible and restricted visitation (18.9% vs 20.1%; adjusted difference, -1.7% [95% CI, -6.1% to 2.7%]; P = .44). Among 9 prespecified secondary outcomes, 6 did not differ significantly between flexible and restricted visitation, including ICU-acquired infections (3.7% vs 4.5%; adjusted difference, -0.8% [95% CI, -2.1% to 1.0%]; P = .38) and staff burnout (22.0% vs 24.8%; adjusted difference, -3.8% [95% CI, -4.8% to 12.5%]; P = .36). For family members, median anxiety (6.0 vs 7.0; adjusted difference, -1.6 [95% CI, -2.3 to -0.9]; P < .001) and depression scores (4.0 vs 5.0; adjusted difference, -1.2 [95% CI, -2.0 to -0.4]; P = .003) were significantly better with flexible visitation. Conclusions and Relevance: Among patients in the ICU, a flexible family visitation policy, vs standard restricted visiting hours, did not significantly reduce the incidence of delirium. Trial Registration: ClinicalTrials.gov Identifier: NCT02932358.


Assuntos
Delírio/prevenção & controle , Família/psicologia , Unidades de Terapia Intensiva/organização & administração , Visitas a Pacientes , Ansiedade , Brasil , Esgotamento Profissional , Cuidados Críticos/psicologia , Estudos Cross-Over , Depressão , Feminino , Educação em Saúde , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
2.
Trials ; 19(1): 636, 2018 Nov 19.
Artigo em Inglês | MEDLINE | ID: mdl-30454019

RESUMO

BACKGROUND: Most adult intensive care units (ICUs) worldwide adopt restrictive family visitation models (RFVMs). However, evidence, mostly from non-randomized studies, suggests that flexible adult ICU visiting hours are safe policies that can result in benefits such as prevention of delirium and increase in satisfaction with care. Accordingly, the ICU Visits Study was designed to compare the effectiveness and safety of a flexible family visitation model (FFVM) vs. an RFVM on delirium prevention among ICU patients, and also to analyze its potential effects on family members and ICU professionals. METHODS/DESIGN: The ICU Visits Study is a cluster-randomized crossover trial which compares an FFVM (12 consecutive ICU visiting hours per day) with an RFVM (< 4.5 ICU visiting hours per day) in 40 Brazilian adult ICUs. Participant ICUs are randomly assigned to either an FFVM or RFVM in a 1:1 ratio. After enrollment and follow-up of 25 patients, each ICU is crossed over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome is the cumulative incidence of delirium measured by the Confusion Assessment Method for the ICU. Secondary and tertiary outcomes include relevant measures of effectiveness and safety of ICU visiting policies among patients, family members, and ICU professionals. Herein, we describe all primary statistical procedures that will be used to evaluate the results and perform exploratory and sensitivity analyses of this study. This pre-specified statistical analysis plan was written and submitted without knowledge of the study data. DISCUSSION: This a priori statistical analysis plan aims to enhance the transparency of our study, facilitating unbiased analyses of ICU visit study data, and provide guidance for statistical analysis for groups conducting studies in the same field. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02932358 . Registered on 11 October 2016.

3.
BMJ Open ; 8(4): e021193, 2018 04 13.
Artigo em Inglês | MEDLINE | ID: mdl-29654049

RESUMO

INTRODUCTION: Flexible intensive care unit (ICU) visiting hours have been proposed as a means to improve patient-centred and family-centred care. However, randomised trials evaluating the effects of flexible family visitation models (FFVMs) are scarce. This study aims to compare the effectiveness and safety of an FFVM versus a restrictive family visitation model (RFVM) on delirium prevention among ICU patients, as well as to analyse its potential effects on family members and ICU professionals. METHODS AND ANALYSIS: A cluster-randomised crossover trial involving adult ICU patients, family members and ICU professionals will be conducted. Forty medical-surgical Brazilian ICUs with RFVMs (<4.5 hours/day) will be randomly assigned to either an RFVM (visits according to local policies) or an FFVM (visitation during 12 consecutive hours per day) group at a 1:1 ratio. After enrolment and follow-up of 25 patients, each ICU will be switched over to the other visitation model, until 25 more patients per site are enrolled and followed. The primary outcome will be the cumulative incidence of delirium among ICU patients, measured twice a day using the Confusion Assessment Method for the ICU. Secondary outcome measures will include daily hazard of delirium, ventilator-free days, any ICU-acquired infections, ICU length of stay and hospital mortality among the patients; symptoms of anxiety and depression and satisfaction among the family members; and prevalence of burnout symptoms among the ICU professionals. Tertiary outcomes will include need for antipsychotic agents and/or mechanical restraints, coma-free days, unplanned loss of invasive devices and ICU-acquired pneumonia, urinary tract infection or bloodstream infection among the patients; self-perception of involvement in patient care among the family members; and satisfaction among the ICU professionals. ETHICS AND DISSEMINATION: The study protocol has been approved by the research ethics committee of all participant institutions. We aim to disseminate the findings through conferences and peer-reviewed journals. TRIAL REGISTRATION: NCT02932358.

4.
Divulg. saúde debate ; (51): 145-160, out.2014.
Artigo em Português | LILACS | ID: lil-771505

RESUMO

O Programa Nacional de Melhoria do Acesso e da Qualidade da Atenção Básica (PMAQ-AB) passou a destacar a Educação Permanente em Saúde (EPS) por sua relevância na consolidação da mudança de práticas e de padrões de qualidade avaliados pelo programa e incluiu, no instrumento de coleta de dados com as equipes de Saúde da Família (eSF), questões relativas às atividades educativas realizadas no ano anterior. Neste artigo, se faz uma revisão das questões relacionadas com a política nacional de educação e desenvolvimento para o Sistema Único de Saúde (SUS), onde a EPS é apresentada como prática de ensino aprendizagem inserida no trabalho, além de iniciativas que a apoiam no trabalho das eSF, em particular o Telessaúde. Analisa questões relativas ao ensino aprendizagem no cotidiano da Atenção Básica, conforme os dados coletados na etapa de avaliação externa do PMAQ-AB, cujo primeiro ciclo ocorreu em campo a partir de março de 2012. No País como um todo,aproximadamente 81% das eSF tiveram participação em atividades educativas, e dessas, aproximadamente 76% consideraram que contemplavam suas necessidades e demandas. Em ordem de frequência: Telessaúde, cursos presenciais, troca de experiências, educação a distância, tutoria/preceptoria e Rede Universitária de Telemedicina (Rute) ou outras atividades. No Telessaúde, principalmente a teleconsultoria, a segunda opinião formativa e o telediagnóstico. Concluiu-se que a EPS teve expansão e abrangência importantes na Atenção Básica; que as equipes têm se conectado com ofertas formativas; que ainda há evidência de processos educativos pontuais e de cunho informacional; e que as variações regionais de acesso às tecnologias de informação e comunicação são produzidas pelos problemas de infraestrutura, não pelo interesse e adesão. São formuladas considerações e recomendações para o fortalecimento da presença da EPS no cotidiano da Atenção Básica.


The National Program for Access and Quality Improvement in Primary Care(PMAQ-AB) went on to highlight the Permanent Health Education (EPS) for its relevance in the consolidation of changes on practices and quality standards evaluated by the programand included, in the data collect instrument with Family Health Teams (eSF), issues related to educational activities performed during the previous year. This article reviews the issues related to national education and development policy for the Unified Health System (SUS), where EPSis presented as a work-embedded teaching and learning practice. It also reviews initiatives that support it in the work of the eSF, in particular Telehealth. Moreover, this article analyses issues related to teaching and learning in primary care routine, according to data collected in PMAQ’sexternal evaluation phase, whose first field cycle started in March, 2012. In the country as a whole, approximately 81% of the eSF participated in educational activities, and approximately76% of them considered that they met their own needs and demands. Ordered by frequency: Telehealth, classroom courses, experience exchanges, distance learning, mentoring/preceptorshipand Telemedicine University Network (Rute) or other activities. In Telehealth, mainly teleconsultance, the second formative opinion and telediagnostic. It was concluded that the EPShad significant coverage and expansion and in primary care; teams have been connected with training opportunities; there is still evidence of specific educational processes of informational nature; and that regional variations in access to information and communication technologies are produced by infrastructure problems, not by the interest and adhesion. Considerations and recommendations for the strengthening of EPS’s presence of EPS in primary care routine are formulated.


Assuntos
Educação Continuada , Estratégia Saúde da Família , Educação em Saúde , Atenção Primária à Saúde
5.
Porto Alegre; s.n; 2011. 31 p.
Tese em Português | Coleciona SUS | ID: biblio-938632

RESUMO

Avaliar a associação entre balanço energético (BE) e protéico (BP) e indicadores de morbi-mortalidade em pacientes em ventilação mecânica (VM) e uso de nutrição enteral (NE) exclusiva de uma Unidade de Terapia Intensiva (UTI) de um hospital terciário de Porto Alegre. Estudo de coorte prospectivo com pacientes internados na UTI entre abril e outubro de 2011, em VM e uso de NE exclusiva. Características gerais e da NE, tempo de VM e de permanência na UTI e mortalidade foram coletadas dos prontuários. O BE e BP foram estimados a partir da diferença entre a quantidade de calorias e proteínas administradas e prescritas por um período de até 28 dias. As análises estatísticas foram realizadas no Programa SPSS 18.0. Resultados: Foram avaliados 27 pacientes (51,85% homens, 53,67±19,03 anos). A taxa de mortalidade foi igual a 48,1%. O valor energético (1531,52±323,52 kcal) e protéico (79,15±17,53) prescrito foi maior do que o valor energético (1094,50±318,16 kcal) e protéico(56,25±15,62) administrado (p< 0,05). Tempo de VM e tempo de permanência na UTI foram associados inversamente com BE e BP (r entre -0,427 e -0,700; p<0,05), mas não diferindo entre sobreviventes e não-sobreviventes [BE diário = -252 (-172,24 – -539,36) vs. -438,30 (-201,18 – -726,86), p = 0,304; BP diário = -16,36 (-7,26 – -26,10) vs. -25,18 (-16,45– -41,97),p =0,090]. Conclusão: Inadequacidade na oferta energética e protéica de pacientes críticos em ventilação mecânica e uso de nutrição enteral exclusiva foi observada, sendo o BE e BP associado com indicadores de morbidade, não diferindo entre sobreviventes e não sobreviventes.


Assuntos
Masculino , Feminino , Humanos , Nutrição Enteral , Pacientes Internados , Unidades de Terapia Intensiva , Saúde Pública , Sistema Respiratório , Sistema Único de Saúde
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