The appropriate use of human albumin in a Brazilian University Hospital: therapeutic indication and dosage regimen

The objective of the study was to evaluate the use of human albumin in a Brazilian university hospital, in compliance with the institutional protocol and other clinical guidelines, taking into account the therapeutic indications and the dosage regimens. Data was obtained from the pharmacy dispensing records of human albumin, the requests for use it and, when available, the patient's records between January and October 2017. After evaluation the therapeutic indications and the dosage regimens were classified as "appropriate" and "inappropriate". The analysis of 98 requests showed that, when compared to the institutional protocol, 54 (55.1%) requests had an inappropriate therapeutic indication. However, when a comparison was made between 25 medical records (54 requests) and other clinical guidelines, it was observed that the therapeutic indication had none classified as inappropriate. In addition, 16 (29.7%) requests were considered inappropriate in relation to dosage regimens. From these results, it was possible to conclude that although the use of human albumin in the hospital was associated to a clinical protocol, it was outdated. Thus, it is possible to affirm that not only the adoption of a clinical protocol, but its periodical updating is an important strategy to promote the rational use of drugs.

A percepção de profissionais de saúde sobre cultura de segurança do paciente em hospital universitário / The perception of health professionals about patient safety culture in a university hospital

A Cultura de Segurança (CS) conceitua-se como o produto de valores, atitudes, competências e padrões de comportamento individuais e de grupo, os quais determinam o compromisso da administração de uma organização segura. O objetivo deste trabalho foi avaliar a CS do paciente em hospital universitário, por meio da aplicação do instrumento Hospital Survey on Patient Safety Culture (HSOPSC), que possui 42 itens divididos em 12 dimensões. O HSOPSC foi entregue aos funcionários de todos os departamentos do hospital e de diferentes níveis de escolaridade, no período de dezembro de 2016 à maio de 2017. Os percentuais de respostas positivas, neutras e negativas foram calculados para identificar áreas fortes e frágeis para CS. Dos 430 questionários distribuídos, 368 (86%) foram considerados válidos. A porcentagem geral de respostas positivas foi de 50,3%. A dimensão "Ações e expectativas sobre seu supervisor/chefe e ações promotoras da segurança do paciente" obteve o maior percentual de respostas positivas (67,1%), entretanto, nenhuma dimensão atingiu o valor acima de 75% para ser considerada uma "área forte" para segurança do paciente. A principal fragilidade para CS foi observada na dimensão "Respostas não punitivas aos erros", com menor porcentagem de respostas positivas (22,9%) e menor mediana (41,7%). A maioria dos profissionais (70,6%) não realizou notificação de eventos nos últimos 12 meses, os funcionários do departamento médico ou de nível superior de escolaridade foram os que apresentaram a menor frequência dessas notificações. Apesar disso, 69,5% dos participantes consideraram a segurança do paciente dentro da unidade/área de trabalho como "excelente" ou "muito boa". Conclui-se que a CS da instituição foi considerada mediana, sendo identificados dimensões frágeis, tais como: respostas não punitivas aos erros e adequação de profissionais. Assim, deve-se investir, principalmente, na promoção e disseminação de uma CS justa e não punitiva em todas as áreas do hospital

The Safety Culture (SC) is conceptualized as the product of values, actions, skills and patterns of behavior of individuals and group, which determine the commitment of the management of a safe organization. The objective of this study was to evaluate the SC oh the patient in a university hospital, through the application of the instrument Hospital Survey on Patient Safety Culture (HSOPSC), which has 42 items divided into 12 dimensions. The HSOPSC was delivered to employees in all hospital departments and at different educational levels from December 2016 to May 2017. The percentages of positive, neutral and negative responses were calculated to identify strong and fragile areas for SC. Of the 430 questionnaires distributed, 368 (86%) were considered valid. The overall percentage of positive responses was 50.3%. The dimension "Actions and expectations about your supervisor and actions that promote patient safety" obtained the highest percentage of positive responses (67.1%). However, no dimension reached a value above 75% so could be considered an "strong area" for patient safety. The main fragility for SC was observed in the dimension "Non-punitive responses to errors", with a lower percentage of positive responses (22.9%) and a lower median (41.7%). Most professionals (70.6%) did not report events in the last 12 months, the medical department or higher educational level employees presented the lowest frequency of these reports. Despite this, 69.5% of the participants considered patient safety within the unit/work area to be "excellent" or "very good". Our results showed that the SC of the institution was considered median, and fragile dimensions were identified, such as: non-punitive responses to errors and adequacy of professionals. Thus, it is necessary to invest mainly in promoting and disseminating a fair and non-punitive culture in all areas of the hospital

Antimicrobial susceptibility patterns among bacteria isolated from intensive care units of the largest teaching hospital at the northwest of Iran

ABSTRACT This study was conducted to determine the antimicrobial susceptibility patterns among common pathogens in the intensive care units (ICUs) of a university hospital in northwestern Iran. A retrospective study was done on laboratory records of patients with nosocomial infection who were admitted to five ICUs of Imam Reza Hospital during a 21-month period from March 2010 to January, 2012. A total number of 556 isolates from 328 patients were evaluated. The most common sites of infections included respiratory (51.7%), urinary (24.8%), and blood (10.4%). The most frequently isolated microorganisms were Enterobacter aerogenes (50.6%) followed by Escherichia coli (16.7%) and Pseudomonas aeruginosa (7.5%). Staphylococcus aureus was the most frequent pathogen among gram-positives (39.7%). The rate of methicillin-resistant Staphylococcus aureus (MRSA) was 87.5%. Multidrug-resistant (MDR) gram-negative bacteria were documented in 25.8% of Acinetobacter, 20% of Klebsiella, and 16.6% of Pseudomonas. The most active antimicrobials were vancomycin (93.5%) followed by amikacin (71.5%) and gentamicin (46%). The overall antibiotic susceptibility was as follows: 36% ciprofloxacin, 19% imipenem, 20% trimethoprim-sulfamethoxazole, 20.5% ceftazidime, and 12% ceftriaxone. Due to the high rate of antimicrobial resistance in the ICU setting, more surveillance and control of the use of antimicrobials is needed to combat infections.

Prevalence of methicillin-resistant Staphylococcus aureus in a University Hospital in the South of Brazil

Methicillin-resistant Staphylococcus aureus (MRSA) stand out as one of the main agents causing nosocomial and community infections. This retrospective study aimed to analyze the MRSA predominance in a university hospital in the south of Brazil and it was carried out for five years (from 2007 to 2011). 616 MRSA (33,3% of the total) were isolated and an important reduction in the MRSA predominance was observed along the study. Although it was registered a reduction in the MRSA predominance, male adult patients (41-70 years old), who were in the Medical Clinic and Adult ICU, had the highest infection rates and concerning MRSA isolates rates, these were higher in blood and tracheal aspirates. In conclusion, studies of this type are becoming relevant to recognize pathogens like MRSA and to determine its predominance.

Staphylococcus aureus resistentes à meticilina (MRSA) destacam-se mundialmente como um dos mais frequentes patógenos nosocomiais e comunitários. Este estudo retrospectivo teve por objetivo analisar a prevalência de MRSA em um hospital universitário no sul do Brasil. Durante cinco anos (2007 a 2011), 616 MRSA (33,3% do total de S. aureus) foram isolados, sendo que sua frequência de isolamento apresentou considerável redução no decorrer do estudo. Nossos resultados demonstraram que as maiores taxas de isolamento dos MRSA ocorreram em amostras de sangue e secreção traqueal. As infecções prevaleceram em pacientes adultos (41 a 70 anos), do sexo masculino, internados na Clínica Médica e UTI adulto. Estudos como este se tornam importantes para o reconhecimento de patógenos resistentes, como o MRSA, e para a determinação da sua prevalência.

The medicine selection process in four large university hospitals in Brazil: Does the DTC have a role?

Knowledge about evidence-based medicine selection and the role of the Drug and Therapeutics Committee (DTC) is an important topic in the literature but is scarcely discussed in Brazil. Our objective, using a qualitative design, was to analyze the medicine selection process performed in four large university hospitals in the state of Rio de Janeiro. Information was collected from documents, interviews with key informants and direct observations. Two dimensions were analyzed: the structural and organizational aspects of the selection process and the criteria and methods used in medicine selection. The findings showed that the DTC was active in two hospitals. The structure for decision-making was weak. DTC members had little experience in evidence-based selection, and their everyday functions did not influence their participation in DTC activities. The methods used to evaluate evidence were inadequate. The uncritical adoption of new medicines in these complex hospital facilities may be hampering pharmaceutical services, with consequences for the entire health system. Although the qualitative approach considerably limits the extent to which the results can be extrapolated, we believe that our findings may be relevant to other university hospitals in the country.

A produção de conhecimento sobre a seleção de medicamentos baseada em evidências e executada por Comissões de Farmácia e Terapêutica é ainda escassa no Brasil, apesar da ampla discussão sobre o tema em países desenvolvidos. Este estudo buscou conhecer e analisar os aspectos relacionados à seleção de medicamentos em quatro hospitais universitários de grande porte no Rio de Janeiro, por meio de abordagem qualitativa. Entrevistas, observação direta e análise documental instrumentaram a coleta de dados qualitativos e quantitativos. A análise considerou duas dimensões: (i) estrutura e organização para o processo de seleção e (ii) critérios e métodos utilizados para avaliação. Apenas dois hospitais possuíam Comissão de Farmácia e Terapêutica (CFT) ativa. A estrutura para a tomada de decisão era deficiente e os membros das Comissões apontaram pouca experiência e disponibilidade para a atividade. Os métodos de avaliação e critérios observados indicaram um processo de seleção acrítico nestes hospitais, comprometendo a assistência farmacêutica e potencialmente prejudicando o sistema de saúde. Apesar da metodologia qualitativa não permitir a extrapolação de resultados, é possível que este cenário seja parecido com o de outros hospitais universitários brasileiros.

Pharmaceutical care in transplant patients in a university hospital: pharmaceutical interventions

A descriptive and prospective study was conducted on the pharmaceutical care in the post-transplant outpatient clinic of Hospital Universitario Walter Cantidio of Universidade Federal do Ceará (HUWC/UFC), in Fortaleza- Ceará in the period of April to October of 2011. The aim of the present study was to describe the pharmaceutical interventions performed in a Pharmaceutical Care service structured in the liver and kidney transplant outpatient clinic of an academic hospital. The Pharmaceutical interventions (PI) were classified according to Sabater et al.(2005), with significance based on Riba et al.(2000) and the Negative Outcomes associated with Medication (NOM) established at the Third Consensus of Granada. Statistical analyses were performed using the Epi Info v.3.5.1 program and hypothesis tests were done with the SigmaPlot v.10.0 program. A chi-squared (X²) test was utilized for statistical analysis of the sample. A total of 97 patients were followed, where 54 problems related to medications were identified and 139 PI performed. The main PI were in education of the patient about treatment (n=111; 80%) (p<0.05), while the significance of all interventions were appropriate, where 83.4% (n=116) of PI performed in the study period were shown to be "significant" (p<0.05). Through pharmaceutical care, the pharmacist is capable of monitoring the pharmacotherapeutic treatment and intervening when necessary, while being part of the multiprofessional team caring for the transplant patient.

Trata-se de um estudo de descritivo e prospectivo, realizado durante o atendimento farmacêutico nos ambulatórios de pós-transplante do Hospital Universitário Walter Cantídio da Universidade Federal do Ceará (HUWC/UFC), em Fortaleza-Ceará no período de abril a outubro de 2011. O presente trabalho objetiva apresentar as intervenções farmacêuticas realizadas em um serviço de Atenção Farmacêutica (ATENFAR) estruturado nos ambulatórios do transplante hepático e renal de um Hospital Universitário. As intervenções farmacêuticas (IF) foram classificadas de acordo com Sabater et al.(2005), a significância baseadas em Riba et al.(2000) e os Resultados Negativos associados a Medicamentos (RNM) fundamentados no Terceiro Consenso de Granada. As análises estatísticas foram realizadas no programa Epi Info v.3.5.1 e os testes de hipótese foram feitos no programa SigmaPlot v.10.0. O teste estatístico utilizado para análise da amostra foi o qui-quadrado (X²). Foram acompanhados 97 pacientes, identificados 54 problemas relacionados aos medicamentos e realizadas 139 intervenções farmacêuticas. As principais IF realizadas foram na educação do paciente sobre o tratamento (n=111; 80%) (p<0,05), já enquanto a significância todas as intervenções foram apropriadas, sendo que 83,4% (n=116) das IF realizadas no período do estudo mostram ser "significantes" (p<0,05). O farmacêutico, através do exercício da ATENFAR, é capaz de monitorar o tratamento farmacoterapêutico e intervir, quando necessário, integrando-se a equipe multiprofissional no cuidado ao paciente transplantado.

Use of an indicator to evaluate physician adherence to prescription guidelines for the treatment of heart failure

The aim of this study was to use indicators to evaluate physician adherence to prescription guidelines for heart failure treatment in a university hospital. This was a prospective cohort study conducted in a university hospital. The information collected at the time of patient admission, including therapeutic indication, absolute contra indications and intolerance, was utilised for the formulation of a guideline adherence indicator (GAI). This indicator was calculated as follows: (the number of patients who used the medication/the number of eligible patients) x 100. The percentage of eligible patients was calculated using the following formula: (the number of eligible patients/the total number patients) x 100. The GAI was applied to a population of 53 patients. Inhibitors of angiotensin-converting enzyme/angiotensin receptor blocker (ACE-I/ARB) combination therapy were used in the greatest percentage of eligible patients (92.4%) and demonstrated the largest GAI value (73.5%). The percentages of patients who were eligible for beta-blockers, spironolactone and digitalis treatments were 81.1%, 52.8% and 60.4%, respectively. The GAI values for the use of beta-blockers, spironolactone and digitalis were 60.4%, 57.1% and 56.2%, respectively. For the studied patient population, the GAI was consistent with the proportion of patients who were eligible to receive digitalis and spironolactone.

O objetivo deste estudo foi utilizar indicadores para avaliar a adesão de médicos às diretrizes para tratamento da Insuficiência Cardíaca em um hospital universitário. Estudo de coorte prospectivo, conduzido em um hospital universitário. As variáveis coletadas na admissão do paciente foram: indicação terapêutica, contraindicações absolutas e intolerância, sendo utilizadas para elaboração de um indicador de adesão à diretriz (IAD). Este indicador foi calculado através da relação: (número de pacientes que utilizaram o medicamento/número de pacientes elegíveis) x 100. A % de pacientes elegíveis foi calculada da seguinte forma: (número de pacientes elegíveis/número total de pacientes) x 100. Os IAD foram aplicados para uma população de 53 pacientes. Os Inibidores da Enzima Conversora de Angiotensina/Bloqueadores dos Receptores de Angiotensina foram as classes farmacológicas que apresentaram maior % de pacientes elegíveis (92,4%) e apresentaram o melhor IAD (73,5%). A % de pacientes elegíveis para beta-bloqueadores, espironolactona e digitálicos foi de 81,1%, 52,8% e 60,4%, respectivamente. O IAD para beta-bloqueadores foi 60,4%, espironolactona 57,1% e digitálicos 56,2%. Na população estudada, o IAD foi compatível com a proporção de pacientes elegíveis para digitálicos e espironolactona.

Design, implementation, and comparison of methods for collecting implant registry data at different hospital types.

Practical issues surrounding the official establishment of a national arthroplasty registry in the United States remain. The purpose of this study was to compare compliance and accuracy rates associated with 3 methods for voluntarily collecting implant registry data at 3 different hospital types. Methods examined included (1) scannable paper forms, (2) online forms comprising keypunching for implant data input, and (3) the same electronic form but incorporating barcode scanning for implant data entry. Overall compliance was low (930/1761; 52.8%) and decreased with each successive data collection phase. Total accuracy rate was 62.5% (578/925) and varied significantly among sites (P < .001). Even with relatively simple reporting systems, compliance was poor. This emphasizes the need for direct surgeon involvement, strict oversight, and a feedback system to ensure validity, particularly if a volunteer-based system is used.

A national analysis of the relationship between hospital volume, academic center status, and surgical outcomes for abdominal hysterectomy done for leiomyoma.

BACKGROUND: Volume-to-outcomes relationships have been established for high-risk surgical procedures. To determine whether hospital volume and academic center status affect surgical outcomes in a lower-risk procedure, morbidity and mortality in patients undergoing abdominal hysterectomy for leiomyoma were evaluated. STUDY DESIGN: Administrative data from the National Inpatient Sample were used to conduct a retrospective analysis of 172,344 individuals who had primary diagnoses of leiomyomata (ICD-9 diagnosis codes of 218.x in the first 2 positions) and who underwent abdominal hysterectomy (ICD-9 procedure codes 68.4 in the first 2 positions) from 1999 to 2003. Comparison was made between teaching hospitals versus nonteaching hospitals and annual case volume in quintiles. Morbidity was considered to be any postoperative condition that is not an expected outcome of hysterectomy and defined as instances in which a patient suffered hemorrhage, ureteral injury, bladder injury, intestinal injury, wound dehiscence, wound infection, deep vein thrombosis, pulmonary embolism, or required blood transfusion. RESULTS: A total of 37 deaths were observed. Mortality was not significantly related to hospital volume or academic medical center status. In contrast, morbidity was found to have a positive association with academic medical center status (odds ratio = 1.34; 95% CI, 1.23 to 1.45), although an inverse relationship between volume and morbidity was observed for extended length of stay (> 3 days) and blood transfusion outcomes in the first 3 (lowest) volume quintiles and for pulmonary embolism in the highest-volume quintile. No important association with volume was found for hemorrhage, ureteral injury, bladder injury, or intestinal injury. CONCLUSIONS: Unlike high-risk procedures, such as esophagectomy, pediatric cardiac surgery, and pancreaticoduodenectomy, mortality for abdominal hysterectomy done for benign indication does not improve with hospital volume or academic center status. The statistically significant positive association between academic medical center status and morbidity merits additional characterization to target areas for improvement.

Efectividad de la implantación de una guía clínica sobre la angina inestable mediante una estrategia multifactorial. Ensayo clínico aleatorizado en grupos / Effectiveness of a multifactorial strategy for implementing clinical guidelines on unstable angina: cluster randomized trial

Introducción y objetivos. La práctica clínica en la angina inestable (AI) no está siempre basada en la mejor evidencia disponible. Las guías clínicas tienen el potencial de mejorar la calidad de la asistencia. Hasta el momento no hay ningún ensayo clínico aleatorizado para evaluar diversas estrategias de implantación de guías en el sistema sanitario público español. El objetivo de este artículo es comparar la efectividad de una estrategia multifactorial de implantación de una guía clínica (sesiones formativas interactivas, procesos de consenso local) en la AI frente a una estrategia de diseminación pasiva. Pacientes y método. El estudio se realizó en 10 unidades de 3 hospitales universitarios de Sevilla. Participaron 153 especialistas (cardiólogos, internistas) y sus pacientes admitidos por AI. La intervención se realizó de enero a abril de 1998. La recogida retrospectiva de datos se hizo en julio de 1999, tanto para los episodios preintervención como postintervención atendidos desde enero a octubre de 1997 y de septiembre 1998 a junio de 1999, respectivamente. En cuanto al diseño, fue un ensayo clínico aleatorizado por grupos, antes-después, pragmático. Los desenlaces fueron: cumplimiento de las recomendaciones de una guía sobre la utilización de la angiografía coronaria, pruebas de estrés y valoración de fracción de eyección. Resultados. La estrategia multifactorial comparada con la pasiva se asoció con una mejoría absoluta en la adecuación de uso de angiografía coronaria y de pruebas de estrés del 11% (intervalo de confianza [IC] del 95%, 0,85-21,1; p = 0,03). Para la valoración de la fracción de eyección no se encontró asociación: mejoría absoluta del 1,1% (IC del 95%, ­-15,9 a 18,1; p = 0,88). Conclusiones. Nuestros resultados muestran que una intervención combinada de sesiones formativas interactivas con procesos de consenso de local administrada a unidades asistenciales de facultativos puede mejorar la adecuación de uso de la angiografía coronaria y de las pruebas de estrés

Introduction and objectives. Clinical practice in unstable angina is not always based on best evidence. Guidelines have the potential to improve quality of health care. There are no randomised trials assessing implementation strategies in the public healthcare system of Spain yet. Objective: to compare the effectiveness of a multifaceted strategy (interactive educational meetings, local consensus process) for guideline implementation in unstable angina, with a passive dissemination strategy. Patients and method. Setting: 10 wards from 3 university hospitals in Sevilla. Participants: 153 specialists (cardiologists, internists) and their patients admitted for an unstable angina episode. Design: a pragmatic, before and after cluster randomized controlled trial. Intervention was delivered from January to April 1998. Retrospective data collection took place in July 1999, of those pre and post-intervention episodes attended from January to October 1997 and from September 1998 to June 1999, respectively. Outcomes: compliance with the guideline recommendations for coronary angiography and stress testing, and ejection fraction assessment. Results. The multifaceted strategy compared with the passive one, was associated with an absolute improvement in the appropriateness of use of coronary angiography and stress testing of 11% (95% CI, 0.85-21.1), P=.03. There was no association for the assessment of the ejection fraction: absolute improvement of 1.1% (95% CI, ­-15.9 to 18.1), P=.88. Conclusions. Our results show that a combination of interactive educational meetings and local consensus process delivered to wards of physicians may improve the appropriateness of use of coronary angiography and stress testing

Perfil de los tutores de un gran hospital universitario / Profile of the tutors of a large university hospital

Introducción: La tutoría es poco utilizada en España. La Conferencia Mundial sobre Enseñanza de la Medicina ha recalcado su importancia. El objetivo de este trabajo es conocer la situación actual, como base para definir cuáles deben ser las características del tutor ideal. Material y métodos: En los Hospitales Universitarios Virgen del Rocío, Sevilla, que cuentan con 326 residentes y 54 tutores, se pasó en 1999 un cuestionario a los tutores. Se recibieron 42 respuestas (78 per cent), realizándose análisis simple. Resultados: La edad media de los encuestados era de 47 años. De ellos, 34 (81 per cent) eran varones y 17 (41 per cent) doctores. La universidad de origen era la de Sevilla en 27 (64 per cent) y la de Granada en tres (7 per cent). El hospital Virgen del Rocío era el hospital de origen en 27 casos (64 per cent) y el Virgen Macarena en 8 (19 per cent). Tenían una experiencia como especialista superior a 15 años 30 encuestados (71 per cent); de 11 a 15 años, 7 (17 per cent); de 6 a 10 años, 4 (9 per cent) e inferior a 6 años, uno (2 per cent). En cuanto a la experiencia como tutor, era superior a 15 años en dos entrevistados (5 per cent); de 11 a 15 años en uno (2 per cent); de 6 a 10 años en 13 (31 per cent) e inferior a 6 años en 26 (62 per cent). Plantilla: 28 (67 per cent); adjuntos: 30 (71 per cent); jefes sección: 11 (26 per cent); jefe servicio: 1 (2 per cent). Las carencias sentidas según los encuestados eran compensaciones y reconocimiento (42; 100 per cent); recursos docentes (42; 100 per cent); tiempo (41; 98 per cent), y colaboración (6; 14 per cent). En cuanto a la cualificación de las carencias (0: mínimo; 10: máximo), el reconocimiento obtuvo 8,0; las ayudas docentes, 7,7; el tiempo, 7,5; las compensaciones, 6,1, y la colaboración, 5,7. La puntuación de la autovaloración fue de 7,6 en los resultados globales; de 6,8 en la programación; de 6,7 en la cumplimentación de actividades, y de 4,9 en la investigación. Conclusiones: a) reconocer la actividad de los tutores; b) disponer de tiempo para desarrollar sus funciones; c) darles formación en metodología docente, y d) concienciar a los hospitales sobre la docencia e investigación (AU)

Fiscal options for America's best hospitals.

A review of America's "best" teaching hospitals shows a huge disparity in their fiscal positions. Among the 15 hospitals studied, roughly half experience some fiscal distress. However, a somewhat similar fiscal analysis of the nation's largest investor-owned hospital chains, HMOs, and physician practice management corporations shows an even more serious weakness in operating margins and debt-equity ratios. Aside from raising possible ethical, quality, and cost issues, this financial analysis suggests that conversion from nonprofit to for-profit ownership of America's top teaching hospitals might not guarantee an improvement in their long-term fiscal outlook.