InsulinAPP application protocol for the inpatient management of type 2 diabetes on a hospitalist-managed ward: a retrospective study

ABSTRACT Objective: We assessed metrics related to inpatient glycemic control using InsulinAPP, an application available for free in Brazil, on the hospitalist-managed ward of our hospital. Subjects and methods: We performed a retrospective study of patients with type 2 diabetes (T2D) admitted from November 2018 to October 2019. InsulinAPP recommends NPH and regular insulins three times a day, in bolus-correction or basal-bolus schemes. Parameters that included BG within range of 70-180 mg/dL, insulin treatment regimen and frequency of hypoglycemia were evaluated. Results: A total of 147 T2D individuals (23% medicine and 77% surgery) were included (mean age 62.3 ± 12.7 years, HbA1c: 8.3 ± 3.0%). The initial insulin regimen was 50% bolus-correction, 47% basal-bolus and 3% with sliding scale insulin. During hospitalization, 71% patients required a bolus-basal regimen. In the first 10 days of the protocol, 71% BG measurements were between 70-180 mg/dL and 26% patients experienced one or more episodes of hypoglycemia < 70 mg/dL, and 5% with BG < 54 mg/dL. Conclusion: The results of this retrospective study indicate the InsulinAPP application using human insulin formulations was effective and safe for the management of hyperglycemia on a hospitalist-managed ward, with more than 70% BG measurements within the therapeutic range and a low rate of hypoglycemia.

Síndrome de burnout en médicos asistentes del Hospital Nacional Hipólito Unanue de Lima ­ Perú, 2018 / Burnout syndrome in physicians of the Hipolito Unanue National Hospital in Lima - Peru, 2018

Objetivos: Identificar la prevalencia y los factores asociados con el Síndrome de Burnout (SBO) en médicos asistentes del Hospital Nacional Hipólito Unanue de Lima-Perú, en el año 2018. Material y métodos: Estudio observacional, transversal y analítico. La población inicial estuvo constituída por 252 médicos. Se seleccionó una muestra con la técnica del muestreo aleatorio estratificado. Se registraron diferentes variables sociodemográficas y laborales por medio de una encuesta anónima. Para el diagnóstico de SBO se empleó el Maslach Burnout Inventory. Se determinaron las variables asociadas con el SBO mediante un modelo de regresión logística. Se consideró un valor de p < 0,05 como significativo. Resultados: De 150 médicos encuestados, 23 (15,3%) mostraron resultados compatibles con SBO. Sesenticinco (43,3%) de los encuestados tuvieron un nivel alto de cansancio emocional, 69 (46%) un nivel alto de despersonalización y 61 (41,7%) un nivel bajo de realización personal (p < 0,05). Las variables asociadas con el SBO fueron sexo masculino (OR = 6,12; IC95 %, 1,43 - 26,13, p = 0,01) como factor de riesgo y tener un trabajo adicional (OR = 0,15; IC95 %: 0,04 - 0,49, p = 0,002), mostró ser un posible factor de proteccción. Conclusiones: Se encontró una baja prevalencia de SBO entre médicos asistentes, aunque un subgrupo significativo mostró altos niveles de cansancio emocional y despersonalización con bajos niveles de realización personal. El sexo masculino se asoció al SBO, en tanto que tener un trabajo adicional, a un efecto protector.

Objectives: To identify the prevalence and factors associated with the Burnout Syndrome (BOS) in physicians of the Hipólito Unanue National Hospital in Lima-Peru, during 2018. Material and methods: Observational, transversal and analytical study. The initial study population was constituted by 252 doctors. A sample was selected by the stratified random sampling technique. Different socio-demographic and labor variables were recorded through an anonymous survey. For the diagnosis of BOS, the Maslach Burnout Inventory was used. The variables associated were determined by means of a logistic regression model. A value of p <0.05 was considered significant. Results: Out of 150 doctors surveyed, 23 (15.3%) showed results compatible with BOS. Sixty-five (43.3%) of the respondents reached a high level of emotional exhaustion, 69 (46%) a high level of depersonalization, and 61 (41.7%) a low level of personal accomplishment (p <0.05). The variables associated with the BOS were male sex (OR = 6.12; 95% CI: 1.43-26.13, p = 0.01) while having an additional job (OR = 0.15; 95% CI: 0.04 - 0.49, p = 0.002), could be considered a protective factor. Conclusions: A low prevalence of BOS was found among the physicians surveyed, although a significant group of them reported high levels of emotional exhaustion and depersonalization with low levels of personal accomplishment. Male sex was associated with BOS, while having an additional job showed a possible protective effect.

Current status and directions of resident education

A resident is a preliminary specialist with a medical license. It is also the status of an employee at a training hospital who is trained by clinical faculty. This duality makes the role of a resident unique, because its interpretation differs dramatically depending on whether one focuses on a resident's status as a trainee or as an employee. Issues regarding patient safety have emerged as residents have come to emphasize their role as employees in discussions of how to balance their work duties with their learning responsibilities. The workload that was taken for granted is no longer considered natural. Two years have elapsed since the enactment of the resident law, which was passed to improve the training environment and working conditions of residents, and limits them to 80 hours of work per week. However, confusion persists in the field. In order to solve problems regarding resident education, new education program with hospitalists and the financial and administrative support from hospitals and the government are important.

Development of the role of teaching hospitalists in the education of residents

Resident law was enacted to improve the training environment and working conditions. However, the law caused confusion in the field and resulted in a medical vacuum in inpatient care. It also resulted in a lack of training time. A hospitalist system was introduced to improve the quality of patient care and to cover the shortage of residents. This study aimed to outline a development strategy for hospitalists participation in resident education in Korea. The result of pilot study of the hospitalists in Korea showed that patients, nurses, and residents were satisfied with hospitalists. Eighty-five percent of surgical residents were helped in postoperative patient care and 70.7% of residents were willing to work with a hospitalist. The competency of surgical hospitalists includes understanding surgery and the appropriate management of postoperative complications. In order to shift the paradigm of resident education, the Korean government must pay the expenses for resident training. Through hospitalists' participation in the resident training, it may be possible to provide residents with more comprehensive and continuous education for inpatient care.

Introduction of Hospitalists and Their Role in Gastroenterology / 대한소화기학회지

A hospitalist system in Korea began in August 2016. Patient safety issues, resident law, and reduction of resident numbers in Korea are leading to an increase in the demand for hospitalist in Korea. The roles and responsibilities of GI hospitalists have not been established. Therefore, cooperation among the Korean society of gastroenterology, each hospital, and government is necessary. In particular, it is important to prepare an education program for gastroenterology hospitalists.

Introduction of Hospitalists and Their Role in Gastroenterology / 대한소화기학회지

A hospitalist system in Korea began in August 2016. Patient safety issues, resident law, and reduction of resident numbers in Korea are leading to an increase in the demand for hospitalist in Korea. The roles and responsibilities of GI hospitalists have not been established. Therefore, cooperation among the Korean society of gastroenterology, each hospital, and government is necessary. In particular, it is important to prepare an education program for gastroenterology hospitalists.

An Acute Medical Unit in a Korean Tertiary Care Hospital Reduces the Length of Stay and Waiting Time in the Emergency Department

A hospitalist-run acute medical unit (AMU) opened at a tertiary care hospital on August 2015 for the first time in Korea. Patients visiting the emergency department (ED) with acute medical problems are admitted to the AMU. They stay in that unit for less than 72 hours and are discharged or transferred to specialty wards if longer treatment is necessary. We reviewed 19,450 medical admissions through the ED from January 2014 to September 2016. The median length of stay (LOS) significantly decreased from 10.0 days (interquartile range [IQR], 5.5–16.7) to 9.1 days (IQR, 5.1–15.0) (P < 0.001) after the establishment of the AMU. The median waiting time in the ED significantly shortened by 40% (P < 0.001). Future studies on the impact of AMU on in-patient morbidity, mortality, re-admission rate, and patient or staff satisfaction are necessary.

Operating the hospitalist system

Recent changes in the Korean government's strategies for resident quotas and training condition results is creating a gap in the treatment of inpatients and threatening patient safety. The hospitalist system, which has been established and operates in the United States, has also been suggested as an alternative in Korea. In 2015, a pilot project for the implementation of a hospitalist system was successfully executed in three teaching hospitals. The most important factors for the successful implementation of a hospitalist system are to establish the job description and security of the hospitalist. In addition, securing finances and making medical insurance fee-for-service, a certification system for hospitalists, an education program, and proper salaries are needed. The introduction and management of a hospitalist system may be seen as necessary for the times, considering changing resident strategies and the reinforcement of responsibility for patient safety. The hospitalist system is a solution for the gap in the treatment of inpatients and is predicted to improve patient safety.

Trends of US Hospitalist and Suggestions for Introduction of Korean Hospitalist / 대한내과학회지

A gap in the number of physicians caring for inpatients is expected in 2014 based on the restricted working hours for Korean medical residents. One potential solution is the use of hospitalists. The US hospitalist movement has proliferated due to high-quality care and economics. This movement has brought positive changes including a shorter length of hospital stay, increased quality of care, and greater patient satisfaction. Because the Korean government controls all suppliers and maintains a low financial compensation level for universal coverage, hospitals do not have the financial resources to introduce hospitalists. Therefore, in contrast to the US, the use of hospitalists must be developed as a cost-compensated system in Korea. Institutional strategies must be introduced to develop a hospitalist system in Korea. A hospitalist system in Korea would be distinct from that in the US. Further studies and specific strategies are needed that consider Korea's circumstances to effectively introduce a hospitalist system.

Adesão às listas de medicamentos essenciais por médicos brasileiros em atuação no sistema único de saúde / Adherence to the essential medicines lists by brazilian physicians in the unified health system

OBJETIVO: Investigou-se a adesão de médicos brasileiros em atuação no SUS a listas de medicamentos essenciais (LME), buscando conhecer o papel das LME na prática prescritiva e identificar a aceitação e barreiras para sua utilização no Brasil. MÉTODOS: O estudo, de âmbito nacional, entrevistou médicos da Atenção Primária e da hospitalar de 30 unidades públicas de saúde de municípios com e sem LME definida. Na análise dos dados foram utilizadas técnicas da pesquisa qualitativa em saúde. As categorias finais de análise foram: (i) contato com diferentes LME; (ii) utilização das LME na prática clínica; (iii) percepção do conceito de medicamentos essenciais. RESULTADOS: Foram ouvidos 58 médicos, sendo 11 do Nordeste e do Centro-Oeste e 12 do Sudeste, Norte e Sul. Apenas 17 dos 58 médicos entrevistados informaram contato anterior com uma LME, a maior parte referindo-se à lista municipal. Quando perguntados se utilizavam a Rename em sua prática clínica, todos os entrevistados responderam que não. Dentre os motivos citados, estão (i) a indisponibilidade dos medicamentos (da lista) no momento requerido; (ii) a falta de orientação necessária para o uso; (iii) a impressão de que a composição da lista é inadequada à demanda clínica. CONCLUSÕES: Os resultados das falas expõem desconhecimento e baixa adesão a LME. Ainda que tenham tido algum contato prévio com uma LME, esta não é valorizada como fonte de informações para a prescrição baseada em evidências.

OBJECTIVE: To investigate the adherence to the essential medicines lists (EML) by Brazilian physicians practicing in the public health system and the role of the EML in prescribing practices, identifying barriers to their use in Brazil. METHODS: A nationwide study interviewed physicians from diverse public healthcare settings in 30 facilities, in municipalities with different statuses in regard to the existence of EMLs. Research data was analyzed through content analysis and perception analysis techniques. The final analytical categories were (i) physician's contact with different EMLs, (ii) use of EMLs in clinical practice and (iii) physician's perceptions regarding the essential medicines concept. RESULTS: A total of 58 physicians were interviewed, from all five Brazilian regions: eleven from the Northeast, eleven from the Mid-West, and twelve each from the Southeast, the North and the South. Seventeen of the 58 physicians reported previous contact with an EML, most of which had occurred with municipal lists. All physicians informed that they did not use the Brazilian Essential Medicines List (RENAME) in their clinical practices. Among the main reasons for this were: (i) unavailability of listed medicines at required moment, (ii) the lack of necessary information and training for adequate use of EML, and (iii) the perception that the composition of the EML is inadequate for clinical demands. CONCLUSIONS: Results from content analysis exposed low awareness regarding EMLs and the essential medicines concept, in addition to a low level of adherence to EMLs. Even though some physicians reported having previous contact with an EML, this tool is not valued as an evidence-based information source for writing prescriptions.

O imaginário coletivo de médicos que atuam em reprodução assistida / The Collective Imaginary of physicians working in Assisted Reproduction

Introdução: Em Reprodução Assistida toda a equipe compartilha com o casal o árduo caminho composto pelas fases do tratamento, porém, o presente estudo deteve-se a experiência do médico. Objetivos: Investigar o Imaginário Coletivo de médicos que atuam em Reprodução Assistida sobre as situações de difícil manejo em sua prática profissional. Métodos: Foram feitas entrevistas únicas individuais, utilizando o Procedimento de Desenho-Estória com Tema como instrumento dialógico. A partir das entrevistas foi criada uma narrativa transferencial ficcional preservando elementos essenciais da dramática humana estudada. Os registros foram interpretados à luz do método psicanalítico buscando a criação/encontro de campos de sentido afetivo-emocional. Resultados: Foram encontrados os seguintes campos: "Não deu certo!?", que organiza-se ao redor da ideia de que não alcançar o objetivo pretendido seria o equivalente a fracassar, mesmo diante de situações incertas; "Engole o choro!", que organiza-se mediante a crença de que é preciso conter os sentimentos diante de determinadas situações, não deixar-se emocionar; "Fora do comum", que organiza-se por meio da crença de que quem está em posição de cuidador é e/ou precisa ser excepcional. Conclusões: Para a formação e à prática médica é preciso incluir, além da visão científica-tecnológica, a abordagem da subjetividade. É necessária a criação de enquadres diferenciados que auxiliem o médico a aproximar-se emocionalmente de seu trabalho, facilitem a superação de dissociações, promovam a saúde mental, contribuindo para que o exercício da profissão seja gratificante e dotado de um sentido genuíno...

In Assisted Reproduction the whole team shares with the couple the hard journey through the phases of the treatment, however, this study is about the doctor's experience. Objectives: To investigate the Collective Imaginary of doctors working in Assisted Reproduction on some difficult situations in their professional practice. Methods: Individual interviews were conducted using the Thematic Story-Drawing Procedure as dialogical instrument. From the interviews a fictional narrative transference were created preserving essential elements of the human drama studied. The records were interpreted in light of the psychoanalytic method seeking the creation / gathering of affective-emotional sense fields. Results: The following fields were found: "It did not work!?", which is organized around the idea that not reaching the target would be equivalent to failing, even due to uncertain situations; "Swallow your crying!", Which is organized by the belief that one must contain the feelings before certain situations, not allowing themselves to get emotional; "Out of the ordinary", which is organized by the belief that who is in the position caregiver is and / or needs to be exceptional. Conclusions: For the training and medical practice is necessary to include, beyond the scientific-technological view, the approach of subjectivity. It is necessary to create different framings that help the doctor to approach their work emotionally, facilitate the overcoming of dissociations, promote mental health, this way contributing to the exercise of the profession so it can be rewarding and endowed with a genuine sense...

Medicina hospitalaria a 15 años de su implementación: ¿Cuáles son los potenciales beneficios en nuestro medio? / Hospital medicine in Chile

After 15 years of development of Hospital Medicine in Chile, there are several benefits of this discipline. Among others, a reduction in the length of hospital stay, readmissions, costs, and improved medical teaching of students, residents and fellows have been observed. However, in South América there are only isolated groups dedicated to Hospital Medicine in Chile, Argentina and Brazil, with a rather slow growth. The unjustifiedfear of competitionfrom sub specialists, and the fee for service system ofpayment in our environment may be importantfactors to understand this phenomenon. The aging of the population makes imperative to improve the safety of our patients and to optimize processes and resources within the hospital, to avoid squandering healthcare resources. The following is a detailed and evidence-based article, on how hospital medicine might benefit both thepublic and prívate healthcare systems in Chile.

Percepção de médicos sobre a Lista Nacional de Condições Sensíveis a Atenção Primária / Physicians` perception of the National List of Primary Care Sensitive Conditions

Embora amplamente utilizado em muitas partes do mundo,o indicador de internações com Condições Sensíveisà Atenção Ambulatorial (CSAA) ainda é pouco utilizadono Brasil e, somente em meados de 2008, o Ministério daSaúde apresentou uma relação oficial de tais afecções. Opresente estudo buscou avaliar, entre diferentes grupos demédicos, a percepção sobre a lista publicada pelo Ministérioda Saúde do Brasil. Nesse sentido, elaborou-se um instrumentoutilizando uma escala de Likert de cinco pontos, comperguntas fechadas, para cada uma das condições apresentadaspela lista oficial. As entrevistas foram realizadas com139 profissionais. A percepção dos médicos foi analisadae comparada através da média dos escores, usando o teste?t? de Student. A comparação entre as médias apontadaspelos médicos que atuam predominantemente na AtençãoPrimária e pelos médicos que atuam predominantementeem hospitais revelou que os primeiros tendem a umamaior concordância com a lista do Ministério da Saúde. Asdiferenças observadas destacam uma maior aceitação dosprofissionais da Atenção Primária de sua responsabilidadesobre o cuidado com afecções cujos desfechos podem gerarinternações desnecessárias.

Medicina hospitalaria / Hospital Medicine

Hospital medicine was created over 10 years ago aiming to provide an integral care to hospitalized patients. Hospital specialists are physicians mainly devoted to the global care of hospitalized patients. Their professional functions include patient care, teaching, clinical research and managing activities. The main difference with other specialties is their exclusive dedication to hospital work. The impact of this specialty on patient care has been demonstrated by a significant reduction in the hospitalization days and costs and higher level of patient satisfaction. In clinical hospitals, the presence of tutors during the complete working day, has resulted in better pre and postgraduate teaching activities and a higher availability of supervisors for trainees. Four years ago, hospital medicine was established as a discipline at the Clinical Hospital of Pontificia Universidad Católica de Chile. In this period, these specialists became essential for student training and an integral part of the faculty staff.

Prevalencia del "síndrome de quemarse por el trabajo" (burnout) en pediatras de hospitales generales / Burnout prevalence in pediatricians of general hospitals

OBJETIVO: Analizar la prevalencia del síndrome de quemarse por el trabajo (burnout) en pediatras de hospitales generales siguiendo criterios de diferentes países. MÉTODOS: Estudio transversal, no aleatorio, realizado en Buenos Aires, Argentina, en 2006. La muestra la formaron 123 pediatras que trabajaban en Servicios de Pediatría de hospitales generales, 89 fueron mujeres (72,4 por ciento) y 34 hombres (27,6 por ciento). Los datos fueron recogidos mediante un cuestionario anónimo y autoadministrado. El SQT fue diagnosticado utilizando el Maslach Burnout Inventory, con diferentes criterios para establecer su prevalencia. RESULTADOS: La prevalencia del SQT, varió en función del criterio utilizado: siguiendo los puntos de corte del manual de Estados Unidos, la prevalencia fue del 10,6 por ciento de 24,4 por ciento siguiendo los criterios de España, 37,4 por ciento siguiendo los criterios de Argentina y considerando los criterios clínicos establecidos en Holanda, el porcentaje fue del 3,2 por ciento. CONCLUSIONES: Los niveles de prevalencia variaron significativamente en función de los criterios aplicados debido a influencias transculturales.