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Diabet Med ; 38(1): e14442, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33112438


AIMS: Inpatient care for people with diabetes can and must be improved. The COVID-19 pandemic has impacted the way care is delivered across the UK. Diabetes UK needed to understand how inpatient care for people with diabetes has been affected and to identify opportunities, areas of concerns and recommendations for the future. METHODS: We interviewed 28 healthcare professionals and hospital teams from across the UK to find out about their experiences of delivering inpatient diabetes care during the first peak of the COVID-19 pandemic. RESULTS: We found that disruption to inpatient diabetes services created positive environments and opportunities for new ways of working, but in the minority, impacted on the quality of care clinicians felt they were able to deliver. CONCLUSIONS: It is important that these positive ways of working be maintained and as a result of these experiences we have outlined urgent recommendations for the challenging winter months ahead.

/epidemiologia , Diabetes Mellitus/terapia , Pessoal de Saúde , Pacientes Internados , Assistência ao Paciente/métodos , /prevenção & controle , Diabetes Mellitus/epidemiologia , Humanos , Pandemias , Assistência ao Paciente/tendências , Qualidade da Assistência à Saúde/tendências , Reino Unido/epidemiologia
PLoS Med ; 17(9): e1003254, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32925906


BACKGROUND: Appropriate clinical management of malaria in children is critical for preventing progression to severe disease and for reducing the continued high burden of malaria mortality. This study aimed to assess the quality of care provided to children under 5 diagnosed with malaria across 9 sub-Saharan African countries. METHODS AND FINDINGS: We used data from the Service Provision Assessment (SPA) survey. SPAs are nationally representative facility surveys capturing quality of sick-child care, facility readiness, and provider and patient characteristics. The data set contained 24,756 direct clinical observations of outpatient sick-child visits across 9 countries, including Uganda (2007), Rwanda (2007), Namibia (2009), Kenya (2010), Malawi (2013), Senegal (2013-2017), Ethiopia (2014), Tanzania (2015), and Democratic Republic of the Congo (2018). We assessed the proportion of children with a malaria diagnosis who received a blood test diagnosis and an appropriate antimalarial. We used multilevel logistic regression to assess facility and provider and patient characteristics associated with these outcomes. Subgroup analyses with the 2013-2018 country surveys only were conducted for all outcomes. Children observed were on average 20.5 months old and were most commonly diagnosed with respiratory infection (47.7%), malaria (29.7%), and/or gastrointestinal infection (19.7%). Among the 7,340 children with a malaria diagnosis, 32.5% (95% CI: 30.3%-34.7%) received both a blood-test-based diagnosis and an appropriate antimalarial. The proportion of children with a blood test diagnosis and an appropriate antimalarial ranged from 3.4% to 57.1% across countries. In the more recent surveys (2013-2018), 40.7% (95% CI: 37.7%-43.6%) of children with a malaria diagnosis received both a blood test diagnosis and appropriate antimalarial. Roughly 20% of children diagnosed with malaria received no antimalarial at all, and nearly 10% received oral artemisinin monotherapy, which is not recommended because of concerns regarding parasite resistance. Receipt of a blood test diagnosis and appropriate antimalarial was positively correlated with being seen at a facility with diagnostic equipment in stock (adjusted OR 3.67; 95% CI: 2.72-4.95) and, in the 2013-2018 subsample, with being seen at a facility with Artemisinin Combination Therapies (ACTs) in stock (adjusted OR 1.60; 95% CI:1.04-2.46). However, even if all children diagnosed with malaria were seen by a trained provider at a facility with diagnostics and medicines in stock, only a predicted 37.2% (95% CI: 34.2%-40.1%) would have received a blood test and appropriate antimalarial (44.4% for the 2013-2018 subsample). Study limitations include the lack of confirmed malaria test results for most survey years, the inability to distinguish between a diagnosis of uncomplicated or severe malaria, the absence of other relevant indicators of quality of care including dosing and examinations, and that only 9 countries were studied. CONCLUSIONS: In this study, we found that a majority of children diagnosed with malaria across the 9 surveyed sub-Saharan African countries did not receive recommended care. Clinical management is positively correlated with the stocking of essential commodities and is somewhat improved in more recent years, but important quality gaps remain in the countries studied. Continued reductions in malaria mortality will require a bigger push toward quality improvements in clinical care.

Assistência à Saúde/métodos , Malária/tratamento farmacológico , Qualidade da Assistência à Saúde/tendências , África ao Sul do Saara/epidemiologia , Antimaláricos/uso terapêutico , Criança , Pré-Escolar , Estudos Transversais , Testes Diagnósticos de Rotina/estatística & dados numéricos , Feminino , Humanos , Lactente , Masculino
Anesthesiology ; 133(2): 350-363, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32433277


BACKGROUND: Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion. METHODS: A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein). RESULTS: The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (-3 h; 95% CI, -6, -0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (-11 h; 95% CI, -19, -6; P < 0.001) were shorter; opioid consumption was lower at day 1 (-57 mg; 95% CI, -130, -5; P = 0.030) without adversely affecting pain scores (-2; 95% CI, -3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037). CONCLUSIONS: Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

Vértebras Lombares/cirurgia , Cuidados Pós-Operatórios/normas , Cuidados Pré-Operatórios/normas , Qualidade da Assistência à Saúde/normas , Recuperação de Função Fisiológica/fisiologia , Fusão Vertebral/normas , Adulto , Idoso , Método Duplo-Cego , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/prevenção & controle , Cuidados Pós-Operatórios/tendências , Cuidados Pré-Operatórios/tendências , Estudos Prospectivos , Qualidade da Assistência à Saúde/tendências , Fusão Vertebral/tendências
Global Health ; 16(1): 28, 2020 03 30.
Artigo em Inglês | MEDLINE | ID: mdl-32228648


BACKGROUND: Available evidence on mental health and psychosocial problems in Lebanon is limited. Recent quantitative data suggests a high prevalence among Syrian refugees and their Lebanese host communities, with significant treatment gaps in both populations. This study aims to determine how Lebanese host and Syrian refugee communities perceive mental health, and identify health seeking behaviors and barriers to health access in two contrasting contexts of fragility. METHODS: A comparative qualitative study design was adopted whereby a total of 36 semi-structured interviews with Lebanese host and Syrian refugees' community members were conducted, followed by a series of four participatory group model building (GMB) sessions. Participants were recruited from two contrasting fragility contexts: Beirut and Beqaa regions. During these sessions, causal loop diagrams were elicited depicting shared understandings of factors prompting the onset of mental health and psychosocial issues; health seeking behaviors, pathways and elements affecting the rate of health improvement and maintenance were also identified. RESULTS: Community members in both settings had similar perceptions of factors contributing to mental health. Participants named long-term effects of exposure to wars, political and social effects of conflicts, and financial constraints at the household level as precipitating factors prompting the onset of mental health and psychosocial stressors. Gender and integration related challenges between communities were identified as factors that affect condition onset and associated care seeking. Pathways for health seeking were found to be shaped by trust, the advice and support of loved ones, and the need to ensure confidentiality of affected individuals. Recurrent themes in discussion highlighted major barriers to healthcare access including significant delays in health care seeking from the formal health system, widespread social stigma, prohibitive service costs, lack of health coverage, limited awareness of mental health service availability and limited trust in the quality of services available. CONCLUSION: Mental health and psychosocial support strategies need to be gender- and integration-sensitive, primarily focused on condition prevention and awareness raising in order to strengthen health-seeking behaviors.

Serviços Comunitários de Saúde Mental/tendências , Comportamento de Busca de Ajuda , Refugiados/psicologia , Adulto , Serviços Comunitários de Saúde Mental/métodos , Feminino , Acesso aos Serviços de Saúde/normas , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Líbano , Masculino , Pesquisa Qualitativa , Qualidade da Assistência à Saúde/normas , Qualidade da Assistência à Saúde/tendências , Refugiados/estatística & dados numéricos , Estigma Social , Guerra/psicologia , Guerra/estatística & dados numéricos
J Hepatol ; 73(2): 441-445, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32298769


The coronavirus disease 2019 (COVID-19) pandemic has shattered the meticulously developed processes by which we delivered quality care for patients with cirrhosis. Care has been transformed by the crisis, but enduring lessons have been learned. In this article, we review how COVID-19 will impact cirrhosis care. We describe how this impact unfolds over 3 waves; i) an intense period with prioritized high-acuity care with delayed elective procedures and routine care during physical distancing, ii) a challenging 'return to normal' following the end of physical distancing, with increased emergent decompensations, morbidity, and systems of care overwhelmed by the backlog of deferred care, and iii) a protracted period of suboptimal outcomes characterized by missed diagnoses, progressive disease and loss to follow-up. We outline the concrete steps required to preserve the quality of care provided to patients with cirrhosis. This includes an intensification of the preventative care provided to patients with compensated cirrhosis, proactive chronic disease management, robust telehealth programs, and a reorganization of care delivery to provide a full service of care with flexible clinical staffing. Managing the pandemic of a serious chronic disease in the midst of a global infectious pandemic is challenging. It is incumbent upon the entire healthcare establishment to be strong enough to weather the storm. Change is needed.

Betacoronavirus , Infecções por Coronavirus/prevenção & controle , Assistência à Saúde/tendências , Cirrose Hepática/terapia , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Qualidade da Assistência à Saúde/tendências , Carcinoma Hepatocelular/diagnóstico , Carcinoma Hepatocelular/etiologia , Tomada de Decisão Clínica/métodos , Infecções por Coronavirus/virologia , Humanos , Cirrose Hepática/complicações , Cirrose Hepática/mortalidade , Neoplasias Hepáticas/diagnóstico , Neoplasias Hepáticas/etiologia , Equipe de Assistência ao Paciente , Pneumonia Viral/virologia , Telemedicina/métodos
Rev. cuba. cir ; 59(1): e845, ene.-mar. 2020. tab, graf
Artigo em Espanhol | LILACS, CUMED | ID: biblio-1126406


RESUMEN Las infecciones del sitio quirúrgico constituyen un problema de calidad de los cuidados a la salud, las cuales son potencialmente prevenibles mediante la aplicación de guías de prevención basadas en evidencias. Se pretendedescribir la evolución histórica de las prácticas de uso profiláctico de antibióticos en cirugía de colon desde el siglo pasado. Se analizó literatura publicada en las últimas cinco décadas en MEDLINE, Infomed y otras fuentes secundarias. Se destaca la evolución del uso combinado de antimicrobianos (aminoglucósidos, penicilina, cefalosporinas y nitroimidazoles) asociados a la preparación enérgica del colon en la década de los 70 del pasado siglo. Numerosos antimicrobianos y prácticas han sido ensayados para demostrar que el uso de antibióticos para el control de las bacterias aerobias y anaerobias, administrados por vía oral e intravenosa, logra la prevención de hasta el 75 por ciento de las infecciones del sitio quirúrgico en cirugía de colon. Las evidencias científicas orientan hacia la necesidad del uso de profilaxis antibióticos orales más intravenosas asociados a la preparación mecánica del colon(AU)

ABSTRACT Surgical site infections are a concern with respect to quality of health care. Surgical site infections are potentially preventable through the application of evidence-based prevention guidelines. The aim is to describe the historical evolution of practicing prophylactic use of antibiotics in colon surgery since the last century. We analyzed the literature published in the last five decades in MEDLINE, Infomed and other secondary sources. The evolution is highlighted of the combined use of antimicrobials (aminoglycosides, penicillin, cephalosporins, and nitroimidazoles) associated with the vigorous preparation of the colon in the 1970s of the last century. Numerous antimicrobials and practices have been tested to demonstrate that the use of antibiotics to control aerobic and anaerobic bacteria, administered orally and intravenously, achieves the prevention of up to 75 percent of surgical site infections in colon surgery. Scientific evidence points to the need for the use of more intravenous oral antibiotic prophylaxis associated with mechanical preparation of the colon(AU)

Humanos , Qualidade da Assistência à Saúde/tendências , Infecção da Ferida Cirúrgica/prevenção & controle , Colo/cirurgia , Antibacterianos/uso terapêutico , Literatura de Revisão como Assunto
PLoS One ; 15(2): e0228714, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32040485


BACKGROUND: Family planning counseling is critical for women to make informed reproductive and sexual health decisions. Despite Ethiopia's success in expanding access to family planning services, information on the quality of family planning counseling is limited. The objectives of this study were to assess whether the quality of counseling from the female client´s perspective has changed over time (2014 to 2018) and to investigate determinants associated with the quality of counseling to provide a more nuanced understanding of disparities in sexual and reproductive health outcomes in Ethiopia. METHODS: Data were obtained from five rounds of the Ethiopian Performance Monitoring and Accountability 2020 female survey questionnaire. Quality of counseling was categorized into four levels based on the responses of the questions that compose the Method Information Index, a core Family Planning 2020 indicator that serves as a proxy for quality of counseling and reflects the extent to which women are informed about side effects and alternate methods. The proportion of female contraceptive users that received good counseling were examined over time by each region, demographic characteristics, and contraception method type and source. Ordinal logistic regression was applied to the last survey round (2018) to investigate determinants associated with counseling quality. RESULTS: The proportion of female contraception users that reported receiving information on all three questions did not significantly change over the period 2014 to 2018. Overall quality of counseling on family planning was low, with only 30% of women reporting receiving sufficient information during counseling. The likelihood of good quality counseling was the least among those who had no formal schooling when compared to those who had higher educational attainment (OR = 0.70, 95% CI: 0.50, 0.97). Women from the wealthiest quintile were 1.72 times more likely (95% CI: 1.10, 2.69) to receive good quality counseling when compared to women in the lower wealth quintile. Women from rural areas were 1.51 times more likely to have received good counseling when compared to those in urban areas (95% CI: 1.04, 2.18). Amhara residents were less likely to receive good counseling when compared to the SNNPR (OR: 0.51, 95% CI: 0.32, 0.81). Women who acquired their method from the private sector had worse counseling (OR: 0.31, 95% CI: 0.23, 0.41) when compared to the public sector. Those using short-acting methods were more at risk of receiving lesser quality counseling when compared to users of long-acting methods (OR: 0.58, 95% CI: 0.46, 0.72). CONCLUSION: The results of this analysis indicated that Ethiopia's overall progress in modern contraceptive use has not been accompanied by a corresponding increase in the quality of family planning counseling. Improving the quality of contraception counseling for women across all demographics, including wealth quintiles and education, is a crucial strategy to support positive reproductive health outcomes with a rights-based focus. Based on the findings of this study, it is essential to emphasize the need to do proper counseling for all methods including short-acting methods especially for those working the private sector and some of the regions which have lower prevalence of good counseling. Further community-based participatory and qualitative research should focus on understanding the root causes and barriers to the delivery of high-quality counseling in Ethiopia.

Anticoncepcionais Femininos/uso terapêutico , Aconselhamento/estatística & dados numéricos , Serviços de Planejamento Familiar/estatística & dados numéricos , Inquéritos Epidemiológicos , Qualidade da Assistência à Saúde/tendências , Adolescente , Adulto , Escolaridade , Etiópia , Feminino , Humanos , Renda , Estado Civil/estatística & dados numéricos , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Parto , População Rural/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Adulto Jovem
PLoS One ; 15(2): e0228927, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32059032


BACKGROUND: Mozambique is one of the countries with the deadly implementation gaps in the tuberculosis (TB) care and services delivery. In-hospital delays in TB diagnosis and treatment, transmission and mortality still persist, in part, due to poor-quality of TB care cascade. OBJECTIVE: We aimed to assess, from the healthcare workers' (HCW) perspective, factors associated with poor-quality TB care cascade and explore local sustainable suggestions to improve in-hospital TB management. METHODS: In-depth interviews and focus group discussions were conducted with different categories of HCW. Audio-recording and written notes were taken, and content analysis was performed through atlas.ti7. RESULTS: Bottlenecks within hospital TB care cascade, lack of TB staff and task shifting, centralized and limited time of TB laboratory services, and fear of healthcare workers getting infected by TB were mentioned to be the main factors associated with implementation gaps. Interviewees believe that task shifting from nurses to hospital auxiliary workers, and from higher and well-trained to lower HCW are accepted and feasible. The expansion and use of molecular TB diagnostic tools are seen by the interviewees as a proper way to fight effectively against both sensitive and MDR TB. Ensuring provision of N95 respiratory masks is believed to be an essential requirement for effective engagement of the HCW on high-quality in-hospital TB care. For monitoring and evaluation, TB quality improvement teams in each health facility are considered to be an added value. CONCLUSION: Shortage of resources within the national TB control programme is one of the potential factors for poor-quality of the TB care cascade. Task shifting of TB care and services delivery, decentralization of the molecular TB diagnostic tools, and regular provision of N95 respiratory masks should contribute not just to reduce the impact of resource scarceness, but also to ensure proper TB diagnosis and treatment to both sensitive and MDR TB.

Programas Nacionais de Saúde/tendências , Qualidade da Assistência à Saúde/tendências , Tuberculose/epidemiologia , Adulto , Atitude do Pessoal de Saúde , Equipamentos e Provisões Hospitalares/tendências , Feminino , Grupos Focais , Instalações de Saúde , Pessoal de Saúde/psicologia , Hospitais , Humanos , Masculino , Pessoa de Meia-Idade , Moçambique/epidemiologia , Programas Nacionais de Saúde/economia , Tuberculose/diagnóstico
J Med Syst ; 44(3): 60, 2020 Feb 05.
Artigo em Inglês | MEDLINE | ID: mdl-32020390


Health information technology capabilities in some healthcare sectors, such as nursing homes, are not well understood because measures for information technology uptake have not been fully developed, tested, validated, or measured consistently. The paper provides a report of the development and testing of a new instrument measuring nursing home information technology maturity and stage of maturity. Methods incorporated a four round Delphi panel composed of 31 nursing home experts from across the nation who reported the highest levels of information technology sophistication in a separate national survey. Experts recommended 183 content items for 27 different content areas specifying the measure of information technology maturity. Additionally, experts ranked each of the 183 content items using an IT maturity instrument containing seven stages (stages 0-6) of information technology maturity. The majority of content items (40% (n = 74)) were associated with information technology maturity stage 4, corresponding to facilities with external connectivity capability. Over 11% of the content items were at the highest maturity stage (Stage 5 and 6). Content areas with content items at the highest stage of maturity are reflected in nursing homes that have technology available for residents or their representatives and used extensively in resident care. An instrument to assess nursing home IT maturity and stage of maturity has important implications for understanding health service delivery systems, regulatory efforts, patient safety and quality of care.

Sistemas de Apoio a Decisões Clínicas/tendências , Tecnologia da Informação/tendências , Casas de Saúde/tendências , Qualidade da Assistência à Saúde/tendências , Humanos , Planejamento de Assistência ao Paciente/tendências
Rev. Rol enferm ; 43(1): 46-50, ene. 2020. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-193814


La calidad en la asistencia sanitaria se ha convertido en una pieza clave dentro de la práctica clínica. No solo es importante hacer las cosas bien, sino obtener el conocimiento objetivo de las personas que reciben nuestro cuidado. La perspectiva del paciente nos acerca a conocer dicho conocimiento, pero no es el único. Conocer las perspectivas de los profesionales que trabajan a diario es también un pilar fundamental que en ocasiones no recibe la importancia que se le debe. En el ámbito de la salud mental, el concepto de calidad adopta una especial relevancia, ya que la relación terapéutica que se establece entre paciente y profesional es singular y única. Sin embargo, el conocimiento de la calidad asistencial en este ámbito ha tenido poca repercusión. El concepto de calidad está ampliamente desarrollado en el ámbito médico, pero también en el ámbito de enfermería, representado por dos grandes pensadoras. Este trabajo conceptual pretende conocer la evolución del concepto de calidad desde el punto de vista tanto del paciente como del profesional asistencial de los servicios de salud mental

Quality in healthcare has become a key piece in clinical practice. It is not only important to do things well, but to obtain the objective knowledge of the people who receive our care. The patient's perspective brings us closer to knowing this knowledge, but it is not the only one. Knowing the perspectives of professionals who work daily is also a fundamental pillar that sometimes is not given the due importance. In the field of mental health, the concept of quality takes on special relevance because the therapeutic relationship established between patient and professional is unique and essential. However, knowledge of the quality of care in this area has had little impact.The concept of quality is widely developed in the medical field, but also in the field of nursing, represented by two great thinkers. This conceptual work aims to know the evolution of the concept of quality in order to focus on the concept of quality understood both by the patient and the professional of the mental health services perspective

Humanos , Qualidade da Assistência à Saúde/tendências , Serviços de Saúde Mental , Enfermagem Psiquiátrica
Rev. Rol enferm ; 43(1,supl): 90-96, ene. 2020. tab
Artigo em Português | IBECS | ID: ibc-193166


Introduction: Outpatient care philosophy has been growing in the past years. Looking to the premise of pediatric healthcare, the establishing of outpatient treatment has advantage, like shortening the deep impact caused by familiar environment detachment, everyday routines and habits. This paradigm implies an adaptation of nursing care services and practices, where quality improvement should focus on continuity of care at home. Objective: to identify recommendations evidence-based of good practices to child / family nursing interventions in an outpatient setting, that allows the definition of standards / quality indicators. Methodology: A Systematic Review of Literature was performed, supported on the Cochrane Handbook orientations of studies published between 2004-2017. The research was conducted on EBSCO and PUBMED databases and resulted in 97 studies. After applying relevance tests, 80 were excluded and 17 included in the methodology critical assessment, done independently by two reviewers and based on defined criteria. At end, five articles1,2,3,4,5 were included. Results: The recommendations identified for the quality of outpatient nursing care are mainly directed to surgical situations, namely, prevention and control of infections, given the high turnover of children; use of digital strategies for preoperative preparation, avoiding anxiety and promoting early discharge, by empowering the family; telephone contact to support and ensuring continuity of care; assessment of the post-surgical condition using the Ped-PADSS checklist, ensuring the early discharge. Conclusion: The results of this study allowed us to obtain recommendations for use in nursing practice of outpatient care and enable to the consequent quality improvement of nursing care provided to child and family

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Humanos , Enfermagem Pediátrica/tendências , Cuidado da Criança/tendências , Processo de Enfermagem/tendências , Assistência Ambulatorial/tendências , Avaliação de Eficácia-Efetividade de Intervenções , Padrões de Prática em Enfermagem/organização & administração , Qualidade da Assistência à Saúde/tendências