Quality Improvement to Address Surgical Burden of Disease at a Large Tertiary Public Hospital in Peru.

BACKGROUND: In resource-limited settings, there is a unique opportunity for using process improvement strategies to address the lack of access to surgical care. By implementing organizational changes in the surgical admission process, we aimed to decrease wait times, increase surgical volume, and improve patient satisfaction for elective general surgery procedures at a public tertiary hospital in Lima, Peru. METHODS: During the first phase of the intervention, Plan-Do-Study-Act (PDSA) cycles were performed to ensure the surgery waitlist included up-to-date clinical information. In the second phase, Lean Six Sigma methodology was used to adapt the admission and scheduling process for elective general surgery patients. After six months, outcomes were compared to baseline data using Wilcoxon rank-sum test. RESULTS: At the conclusion of phase one, 87.0% (488/561) of patients on the new waitlist had all relevant clinical data documented, improved from 13.3% (2/15) for the pre-existing list. Time from admission to discharge for all surgeries improved from 5 to 4 days (p<0.05) after the intervention. Median wait times from admission to operation for elective surgeries were unchanged at 4 days (p=0.076) pre- and post-intervention. There was a trend toward increased weekly elective surgical volume from a median of 9 to 13 cases (p=0.24) and increased patient satisfaction rates for elective surgery from 80.5 to 83.8% (p=0.62), although these were not statistically significant. CONCLUSION: The process for scheduling and admitting elective surgical patients became more efficient after our intervention. Time from admission to discharge for all surgical patients improved significantly. Other measured outcomes improved, though not with statistical significance. Main challenges included gaining buy-in from all participants and disruptions in surgical services from bed shortages.

Inhaled Methoxyflurane Provides Greater Analgesia and Faster Onset of Action Versus Standard Analgesia in Patients With Trauma Pain: InMEDIATE: A Randomized Controlled Trial in Emergency Departments.

STUDY OBJECTIVE: The objective of the InMEDIATE study was to evaluate the change in intensity of traumatic pain over the first 20 min in adult patients treated with methoxyflurane versus standard analgesic treatment in Spain. This the first randomized, active-controlled, multicenter trial of methoxyflurane in the emergency setting in Europe. METHODS: This was a randomized, controlled study that enrolled adult patients with acute moderate to severe (score ≥4 on the 11-point Numeric Rating Scale) trauma-associated pain in 14 Spanish emergency departments. Patients were randomized 1:1 to methoxyflurane (up to 2×3 mL) or standard analgesic treatment. Coprimary endpoints were the change from baseline in Numeric Rating Scale pain intensity score during the first 20 minutes of treatment and time to first pain relief. RESULTS: Three hundred five patients were randomized (methoxyflurane 156; standard analgesic treatment 149). Most patients in the standard analgesic treatment group (70%) received intravenous first-step analgesics and 9.4% of patients were treated with opioids. Mean decrease from baseline in Numeric Rating Scale pain intensity score was greater for methoxyflurane than standard analgesic treatment at all points, with a significant treatment difference overall up to 20 minutes (repeated-measures model 2.47 versus 1.39; treatment difference 1.00; 95% confidence interval 0.84 to 1.32). Median time to first pain relief was significantly shorter for methoxyflurane than standard analgesic treatment (3 versus 10 minutes). Methoxyflurane achieved better patient and clinician ratings for pain control and comfort of treatment than standard analgesic treatment and exceeded patient and clinician expectations of treatment in, respectively, 77% and 72% of cases compared with 38% and 19% for standard analgesic treatment. CONCLUSION: These results support consideration of methoxyflurane as a nonnarcotic, easy-to-administer, rapid-acting, first-line alternative to currently available analgesic treatments for trauma pain.

Heads of household programme in Argentina: a human rights-based policy?

This study analyses the consultative councils (CC) of the Argentinian conditional cash transfer heads of household programme as an institutional innovation directed to put into practice some of the principles of the human rights' approach for eradicating poverty. Since the main responsibilities assigned to the CCs coincided with some of the main principles of the human rights' approach, the research is focused on how CCs responded in practice. Using a case study methodology we show that even when, in theory, the CCs incorporate some of the principles of the human rights' approach to the programme, they deviated from this purpose due to a persistent phenomenon in the social policy arena in developing countries: political clientelism. Policy recommendations are formulated in order to deal with clientelism in the framework of the human rights' approach.

Valor diagnóstico de la prueba de suero en frío en las hiperlipoproteinemias / Diagnostic value of cold seru test in the hyperlipoproteinemias

Se estudian la relación que existe entre la positividad de la prueba de suero en frio (PSF) y la elevación de los triglicéridos y las lipoproteínas, así como también la correlación entre los triglicéridos y sus proteínas transportadoras, en 150 pacientes diabéticos. Se demuestra la utilidad de la PSF en el diagnóstico inicial de las hipertrigliceridemias y la relación que existe entre la turbidez del plasma y la elevación de los triglicéridos y de las lipoproteínas de movimiento electroforético prebeta (AU)

Valor diagnóstico de la prueba de suero en frío en las hiperlipoproteinemias / Diagnostic value of cold serum test in the hyperlipoproteinemias

Se estudian la relación que existe entre la positividad de la prueba de suero en frio (PSF) y la elevación de los triglicéridos y las lipoproteínas, así como también la correlación entre los triglicéridos y sus proteínas transportadoras, en 150 pacientes diabéticos. Se demuestra la utilidad de la PSF en el diagnóstico inicial de las hipertrigliceridemias y la relación que existe entre la turbidez del plasma y la elevación de los triglicéridos y de las lipoproteínas de movimiento electroforético prebeta