The Long-Term Effect of an Independent Capacity Protocol on Emergency Department Length of Stay: A before and after Study

PURPOSE: In this study, we determined the long-term effects of the Independent Capacity Protocol (ICP), in which the emergency department (ED) is temporarily used to stabilize patients, followed by transfer of patients to other facilities when necessary, on crowding metrics. MATERIALS AND METHODS: A before and after study design was used to determine the effects of the ICP on patient outcomes in an academic, urban, tertiary care hospital. The ICP was introduced on July 1, 2007 and the before period included patients presenting to the ED from January 1, 2005 to June 31, 2007. The after period began three months after implementing the ICP from October 1, 2007 to December 31, 2010. The main outcomes were the ED length of stay (LOS) and the total hospital LOS of admitted patients. The mean number of monthly ED visits and the rate of inter-facility transfers between emergency departments were also determined. A piecewise regression analysis, according to observation time intervals, was used to determine the effect of the ICP on the outcomes. RESULTS: During the study period the number of ED visits significantly increased. The intercept for overall ED LOS after intervention from the before-period decreased from 8.51 to 7.98 hours [difference 0.52, 95% confidence interval (CI): 0.04 to 1.01] (p=0.03), and the slope decreased from -0.0110 to -0.0179 hour/week (difference 0.0069, 95% CI: 0.0012 to 0.0125) (p=0.02). CONCLUSION: Implementation of the ICP was associated with a sustainable reduction in ED LOS and time to admission over a six-year period.

Neoliberalismo en salud: La tortura de trabajadoras y trabajadores del Instituto Materno Infantil de Bogotá / Neoliberalism in health: the torture of the health care workers of the Bogota s Instituto Materno Infantil (child and maternity hospital)

Objetivos Relacionar históricamente las transformaciones más significativas del Instituto Materno Infantil (IMI) en su proceso de crisis, cierre y liquidación con las experiencias de sus trabajadores/as. Encontrar elementos vivenciales y teóricos que interconecten el proceso de privatización de la salud con las experiencias de resistencia y dolor/sufrimiento de trabajadores/as. Métodos Etnografía inscrita en corrientes críticas y apoyada en trabajo de campo constante y colectivo, investigación histórica (fuentes primarias y secundarias) y entrevistas semiestructuradas con cinco mujeres que trabajaron por más de quince años en el IMI. Resultados Una línea del tiempo con cuatro periodos principales: Los años de gloria (hasta 1990), Llega el neoliberalismo (1990-2000), La crisis y las resistencias (2001-2005) y Liquidación (2006-). La narrativa de las mujeres entrevistadas devela múltiples agresiones que se intensificaron desde el 2006 generando dolor/ sufrimiento, relatos que ilustran violaciones a sus derechos humanos y laborales. Discusión Proponemos analizar las conexiones entre los diferentes tipos de violencia y el dolor/sufrimiento bajo la categoría tortura, entendida como acciones violentas que causan dolor físico-emocional, las cuales son ejecutadas por actores de poder sobre otros que desafían alterarlo. Enfatizamos en las burocracias, el confinamiento, los agentes torturadores y los resquebrajamientos a la unidad mente/cuerpo para argumentar que esta relación neoliberalismo y tortura pretende eliminar los últimos trabajadores/as de la salud del país con garantías laborales para avanzar en la acumulación de capital que genera la creciente sobreexplotación del trabajo y la mercantilización de la salud.

Objectives To link, from a historical point of view, the most significant transformations of the Instituto Materno Infantil (IMI) [the oldest child and maternity hospital of the country] during its process of crisis, closure and liquidation with the experiences of the hospital workers. To find experience-based and theoretical elements that can interconnect the process of health care privatization of the country with the workers' experiences of resistance and pain/suffering. Methods Critically-oriented ethnography based on continuous collective field work, historical research (primary and secondary sources) and semi-structured interviews with 5 women who worked at the IMI for more than 15 years.Results: A time line of 4 main periods: Los años de gloria [The golden years] (up to 1990); Llega el neoliberalismo [Neoliberalism arrives] (1990-2000); La crisis y las resistencias [Crisis and resistances] (2001-2005); and Liquidación [Liquidation (2006-20??)]. The narratives of the interviewed women unveil multiple aggressions that have intensified since 2006, have caused pain and suffering and are examples of violations of human and labour rights. Discussion We suggest to analyze the links between the different kinds of violence and pain and suffering as torture. This category is defined as the set of violent actions that cause physical and emotional pain, which are performed by actors in positions of power over other people who challenge that power and are part of modern States' ideological principles around a defined moral social order. For the IMI workers' case, the ideological principle that is being challenged is health care neoliberalism. From the analyses of bureaucracy, confinement, torturing agents, and the breaking-off of the body-mind unit we conclude that this relationship between neoliberalism and torture aims to eliminate the last health care workers of the country who had job stability and full-benefits through public labour contracts. Their elimination furthers the accumulation of capital generated by increasing over-exploitation of labour and commodification of health care.

A Unidade de Terapia Intensiva Neonatal possibilitando novas práticas no cuidado ao recém-nascido / La Unidad de Terapia Intensiva Neonatal posibilitando nuevas prácticas en el cuidado al recién nacido / The Neonatal Intensive Care Units giving new practices to newborns care

Pesquisa qualitativa, com abordagem sócio-histórica. O objetivo é compreender como se instituíram as práticas de cuidado ao recém-nascido na Unidade de Terapia Intensiva Neonatal (UTIN) em Florianópolis, na década de 1980. O contexto do estudo foi o Hospital Infantil Joana de Gusmão. Os sujeitos foram profissionais de saúde que participaram da implantação da UTIN. Para análise dos dados utilizamos o método genealógico proposto por Foucault. Identificamos quatro agrupamentos discursivos: Muita criança saiu ganhando com isso; A gente aprendeu a cuidar do recém-nascido, cuidando; Faltava um olhar mais científico para a assistência; Cuidado sensível, humanizado e individualizado. A implantação de uma unidade específica para o cuidado do recém-nascido resultou numa redução da morbi-mortalidade neonatal e na aquisição do conhecimento científico. Os discursos dos profissionais de saúde revelam que, desde os primórdios da UTIN, já havia uma preocupação com o cuidado sensível, humanizado e individualizado ao recém-nascido.

Investigación cualitativa, con abordaje socio-histórica, objetivo comprender como se instituyeron las prácticas de cuidado al recién nacido en la Unidad de Terapia Intensiva Neonatal (UTIN) en Florianópolis, Brasil, en la década de 1980. El contexto del estudio fue el Hospital Infantil Joana de Gusmão. Los sujetos fueron profesionales de salud que participaron de la implantación de la UTIN. Para análisis de los datos fue utilizado el método genealógico propuesto por Foucault. Identificamos 4 formaciones discursivas: Muchas niños salieron ganando con eso; Aprendimos a cuidar del recién nacido, cuidando; Faltaba un mirar más científico para la asistencia; Cuidado sensible, humanizado e individualizado. La implantación de una unidad para cuidado del recién nacido resultó en reducción de la morbimortalidad neonatal y adquisición del conocimiento científico. Los discursos de los profesionales de salud revelan que desde los primordios de la UTIN, existía preocupación con el cuidado sensible, humanizado e individualizado al recién nacido.

A qualitative research with a socio-historical approach. The aim is to understand how the established practices of the newborn Intensive Care Units Neonatal (ICUN) in Florianopolis, Brazil, in the 1980's. The study's context was the Child's Hospital Joana de Gusmão. The interviewed for this research were health professionals that had a role in the ICUN implantation. Data analysis was performed using the genealogical method proposed by Foucault. Four discursive groups were identified: Many children won with that; It was learned how to care of newborns; A more scientific view to assistance was lacking; Sensitive, humanized and individualized care. The establishment of a specific unit directed to the newborns resulted in a reduction in the neonatal mortality and scientific knowledge acquisition. The health professionals' speeches reveal that since the beginning of the ICUN, a concern with the sensible, humanized and individualized care with the newborn was present.

Surveillance of nosocomial infections in a Mexican community hospital: how are we doing? / Vigilancia epidemiológica de infecciones nosocomiales en un hospital comunitario de México: ¿Cómo vamos?

OBJECTIVE. To compare the nosocomial infection (NI) rate obtained from a retrospective review of clinical charts with that from the routine nosocomial infection surveillance system in a community hospital. MATERIAL AND METHODS. Retrospective review of a randomized sample of clinical charts.Results were compared to standard surveillance using crude and adjusted analyses. RESULTS. A total of 440 discharges were reviewed, there were 27 episodes of NIs among 22 patients. Cumulated incidence was 6.13 NI per 100 discharges. Diarrhea, pneumonia and peritonitis were the most common infections. Predictors of NI by Cox regression analysis included pleural catheter (HR 16.38), entry through the emergency ward, hospitalization in the intensive care unit (HR 7.19), and placement of orotracheal tube (HR 5.54). CONCLUSIONS. Frequency of NIs in this community hospital was high and underestimated. We identified urgent needs in the areas of training and monitoring.

OBJETIVO. Comparar la tasa de infecciones nosocomiales (IN) resultante de la revisión retrospectiva de expedientes clínicos con los resultados del sistema rutinario de vigilancia de IN de un hospital general. MATERIAL Y MÉTODOS. Revisión retrospectiva de una muestra seleccionada aleatoriamente de expedientes clínicos. Comparación con los resultados obtenidos por el sistema rutinario de vigilancia de IN. Análisis bivariado y multivariado de datos retrospectivos. RESULTADOS. De 440 egresos hubo 27 episodios de IN en 22 pacientes. La incidencia acumulada fue de 6.13 IN por 100 egresos. Las infecciones más frecuentes fueron diarrea, neumonía y peritonitis. Los predictores de IN fueron catéter pleural (HR 16.38), ingreso por urgencias y estancia en cuidados intensivos (HR 7.19), y colocación de tubo orotraqueal (HR 5.54). CONCLUSIONES. La frecuencia de IN fue elevada y subestimada por el sistema rutinario. Identificamos necesidades urgentes de monitoreo y entrenamiento en áreas específicas.

Hospital care: assessment of users' satisfaction during hospital stay / Atención hospitalaria: evaluación de la satisfacción de los pacientes durante su período de internación / Assistência hospitalar: avaliação da satisfação dos usuários durante seu período de internação

Health care teams have followed the National Health System's (SUS) principles to ensure quality improvement in healthcare, and patient satisfaction is one of the instruments used to evaluate quality. This study aimed to evaluate patient satisfaction regarding the assistance to their needs during hospitalization, in a general hospital of a city in the interior of São Paulo. Data were collected through participant observation and use of focal group techniques in this qualitative research. A theme guide was used and a total of 20 subjects participated in the study. Data were analyzed through content analysis and interpreted through triangulation. Study results demonstrate that patients were satisfied with the care rendered. However, the researcher concluded that the institution's work organization is not directed to the attainment of quality.

El equipo de salud ha tomado como base los principios del SUS para asegurar la calidad de la atención. La satisfacción de los pacientes ha sido utilizada como uno de los instrumentos de evaluación. Este estudio busca evaluar la satisfacción de los pacientes con la atención de sus necesidades durante la internación, en un hospital general del interior de Sao Paulo. Se adoptó como metodología la investigación cualitativa y, como técnica de recolecta de datos, la observación participante y el grupo focal. Se utilizó un guía de temas y participaron en la investigación doce sujetos. El análisis de los datos se basó en el análisis de contenido. Para la interpretación se utilizó la técnica de triangulación. Los resultados demostraron que los pacientes se sintieron satisfechos con la atención. No obstante, la investigadora concluyó que la forma de organización del trabajo de la institución no evidencia una preocupación por la calidad de la atención.

A equipe de saúde tem se baseado nos princípios do SUS para assegurar a melhoria do atendimento dos serviços de saúde e a satisfação dos usuários e tem sido utilizada como um dos instrumentos de avaliação da qualidade. Este estudo objetivou avaliar a satisfação dos usuários com o atendimento de suas necessidades durante a internação, num hospital geral do interior do Estado de São Paulo. Adotou-se, como metodologia, a pesquisa qualitativa e, como técnica de coleta de dados, a observação participante e o grupo focal. Foi utilizado um guia de temas e participaram da pesquisa doze sujeitos. Realizou-se a análise de conteúdo dos dados e, para a interpretação, utilizou-se a técnica de triangulação. Os resultados demonstraram que os usuários ficaram satisfeitos com o atendimento. Entretanto, a pesquisadora concluiu que a organização do trabalho da instituição não tem como meta o alcance da qualidade.

Effectiveness of baby friendly hospital initiative on the promotion of exclusive breast feeding among the Dhaka city dwellers in Bangladesh.

To assess the effectiveness of baby friendly hospital initiative on exclusive breast feeding status; this longitudinal study designed to compare the incidence of exclusive breast feeding at 30, 60, 90, 120 and 150 days post partum for mothers who delivered at baby friendly hospital and mothers who delivered at a nearby non-baby friendly hospital. 105 mothers from baby friendly hospital and 104 mothers from non-baby friendly hospital were recruited and followed up for determining duration of exclusive breast-feeding. The median survival time of exclusive breast-feeding was 73.85 days among mothers of baby friendly hospital and 30 days among mothers of non-baby friendly hospital, with a difference of 43.85 days. Life table cumulative surviving proportion for exclusive breast-feeding shows that 82 percent mothers of baby friendly hospital continue at 30 days, compared with 50 percent mothers off non-baby friendly hospital. At 150 days, 16 percent mothers of baby friendly hospital continue exclusive breast-feeding compared with 6 percent mothers of non-baby friendly hospital. Finally 8 percent mothers of baby friendly hospital continue exclusive breast feeding between two hospital was found highly significant (P < 0.001). Duration of exclusive breast-feeding is longer among the mothers who have been delivered in a baby friendly hospital than those mothers who have been delivered in a non-baby friendly hospital.