Traslado neonatal: evaluación de 4 años en un departamento del interior del país / Neonatal transport services: 4-year assessment in the interior of Uruguay / Transporte neonatal: avaliação de 4 anos em um departamento do interior do Uruguai

Introducción: la creación de sistemas de traslado neonatal marcó una inflexión en cuanto a la reducción de morbimortalidad de los recién nacidos (RN). La Organización Panamericana de la Salud estima que 1% de los RN requerirá ingreso a la unidad de cuidados intensivos. El traslado ideal es intraútero, pero muchas veces esto no es posible, requiriendo un traslado neonatal. La regionalización de los sistemas de traslado, la capacitación de recursos humanos y la adquisición de materiales son elementos que han mejorado su calidad y disminuido su indicación. Objetivos: describir a los RN que requirieron traslado y valorar el impacto sobre ellos al adquirir materiales y recursos humanos capacitados. Metodología: estudio descriptivo, retrospectivo y multicéntrico, incluyendo todos los RN que requirieron traslado en el período 2016-2019. Variables analizadas: número de nacimientos, número de traslados, edad gestacional (EG), edad al momento del traslado, peso al nacer, tiempo de estabilización, oxigenoterapia y métodos, medicación recibida, medio de transporte y recursos humanos. Resultados y discusión: se realizaron 101 traslados neonatales, 1,5% del total de nacimientos. Variación anual: 2% de los RN en el año 2016, 1,6% en el 2017, 1,4% en el 2018, 1.1% en el 2019. Sector público: 63,3%. La media de EG fue de 33 semanas (25-40), modo 31 semanas. Pretérminos extremos 4,17%, pretérminos severos 37,5%, pretérminos moderados 17,7%, pretérminos tardíos 15,6% y de término 25%. La media de peso al nacer fue de 2.102 gramos (710-4.160), modo 1.440 gramos. La media de días al momento del traslado fue de 2,1 (3 horas-26 días). Indicaciones de traslado: prematurez 39,6%, otros SDR 22,9%, patología quirúrgica 13,5%, shock séptico 10,4%, asfixia/convulsiones 8,3% y cardiopatías 3%. Tratamiento durante la estabilización: oxigenoterapia 87,1%. Intubación orotraqueal y asistencia ventilatoria mecánica 71%, CPAP 9,7%, catéter nasal 6,4%. Requirieron surfactante 58,5%, antibióticos 77,4%, inotrópicos 26,6%, prostaglandinas 3,3%, aminofilina 3,3%. La media de tiempo de estabilización fue de 10,5 horas (3-36 horas). Destino: 64,3% Montevideo, 30,6% Tacuarembó, 3% Salto, 1% Canelones y 1% Minas. Medio de transporte: terrestre 95% y aéreo 5%. Fallecidos 1%. Recursos humanos disponibles: en 2016 un neonatólogo y seis pediatras. En 2019 tres neonatólogos, dos posgrados en neonatología, un pediatra intensivista, nueve pediatras (que se capacitaron en la estabilización del RN) y un supervisor docente y referente. Concomitante creación de unidades neonatales de estabilización con capacitación continua del personal de enfermería. Conclusiones: la principal causa de traslado fue la prematurez severa. Con la adquisición de recursos materiales adecuados y humanos capacitados se logró un descenso de casi 50% de los traslados. La regionalización ha ido en aumento pero se debe enfatizar, sobre todo en los RN menores a 1.000 gramos.

Introduction: the creation of neonatal transport systems showed a landmark regarding reduced morbidity and mortality of newborns (NB). The Pan-American Health Organization estimates that 1% of NBs require admission to an Intensive Care Unit. The ideal transport system would be intrauterine; however, many times this is not possible and neonatal transport services are needed. The regionalization of transport services, the training of human resources and the acquisition of materials have improved and therefore the need for transport services has decreased. Objectives: to describe the situation of newborns who required transport services and assess the impact on these services when acquiring materials and skilled human resources. Methodology: descriptive, retrospective and multicenter study, including all newborns who required transport services in 2016-2019. Variables analyzed: number of births, number of transfers, gestational age (GA), age at the time of transfer, birth weight, stabilization time, oxygen therapy and methods, medication received, means of transport and human resources. Results and discussion: 101 neonatal transfers were carried out, 1.5% of all births. Annual variation: 2% of newborns in 2016, 1.6% in 2017, 1.4% in 2018, 1.1% in 2019. Public sector: 63.3%. The mean GA was 33 weeks (25-40), mode 31 weeks. Extreme pre-terms 4.17%, severe pre-terms 37.5%, moderate pre-terms 17.7%, late pre-terms 15.6% and term newborns 25%. The mean birth weight was 2102 grams (710-4160), mode 1440 grams. The mean number of days at the time of transfer was 2.1 (3 hours-26 days). Transport main indications: prematurity 39.6%, other RDS 22.9%, surgical pathology 13.5%, septic shock 10.4%, asphyxia/seizures 8.3%, and heart disease 3%. Treatment during stabilization: Oxygen therapy: 87.1%. Orotracheal intubation and mechanical ventilation assistance 71%, CPAP 9.7%, nasal catheter 6.4%. 58.5% required surfactant, 77.4% antibiotics, 26.6% inotropes, 3.3% prostaglandins, 3.3% aminophylline. The mean stabilization time was 10.5 hours (3-36 hours). Destination: 64.3% Montevideo, 30.6% Tacuarembó, 3% Salto, 1% Canelones and 1% Minas. Means of transport: land 95% and air 5%. Deceased 1%. Available human resources: in 2016, 1 neonatologist and 6 pediatricians. In 2019, 3 neonatologists, 2 post graduated doctors in neonatology, 1 intensivist pediatrician, 9 pediatricians (who were trained in NB stabilization) and an academic supervisor and referent. Simultaneous neonatal stabilization units with continuous training of the nursing staff were created. Conclusions: the main cause of neonatal transport was severe prematurity. With the acquisition of adequate material and trained human resources, a decrease of almost 50% of these transfers was achieved. Regionalization has been rising even though it should be strengthened, especially in newborns weighing less than 1000 grams.

Introdução: a criação dos sistemas de transporte neonatal marcou uma virada na redução da morbimortalidade de recém-nascidos (RN). A Organização Pan-Americana da Saúde estima que 1% dos RNs necessitarão de internação em Unidade de Terapia Intensiva. O transporte ideal é intrauterino, más muitas vezes isso não é possível, sendo necessário o transporte neonatal. A regionalização do transporte neonatal, a formação de recursos humanos e a aquisição de materiais, tem melhorado a qualidade e diminuído a indicação do transporte neonatal. Objetivos: descrever a situação dos recém-nascidos que necessitaram de transporte e avaliar o impacto da aquisição de materiais e recursos humanos capacitados sobre os resultados. Metodologia: estudo descritivo, retrospectivo e multicêntrico, incluindo todos os recém-nascidos que necessitaram de transporte no período 2016-2019. Variáveis analisadas: número de partos, número de transportes, idade gestacional (IG), idade no momento do transporte, peso ao nascer, tempo de estabilização, oxigenoterapia e métodos, medicação recebida, meio de transporte e recursos humanos. Resultados e discussão: foram realizados 101 transportes neonatais, 1,5% de todos os nascimentos. Variação anual: 2% dos recém-nascidos em 2016, 1,6% em 2017, 1,4% em 2018, 1,1% em 2019. Setor público: 63,3%. A média de IG foi de 33 semanas (25-40), moda de 31 semanas. Pré-termos maduros extremos 4,17%, pré-termos graves 37,5%, pré-termos moderados 17,7%, pré-termos tardios 15,6% e recém-nascidos a termo 25%. O peso médio ao nascer foi de 2.102 gramas (710-4.160), moda 1.440 gramas. O número médio de dias no momento do traslado foi de 2,1 (3 horas-26 dias). Indicações de transporte: prematuridade 39,6%, outras SDR 22,9%, patologia cirúrgica 13,5%, choque séptico 10,4%, asfixia/convulsões 8,3% e cardiopatia 3%. Tratamento durante a estabilização: Oxigenoterapia: 87,1%. Intubação orotraqueal e assistência à ventilação mecânica 71%, CPAP 9,7%, cateter nasal 6,4%. 58,5% necessitaram de surfactante, 77,4% de antibióticos, 26,6% de inotrópicos, 3,3% de prostaglandinas, 3,3% de aminofilina. O tempo médio de estabilização foi de 10,5 horas (3-36 horas). Destino: 64,3% Montevidéu, 30,6% Tacuarembo, 3% Salto, 1% Canelones e 1% Minas. Meios de transporte: terrestre 95% e aéreo 5%. Falecidos 1%. Recursos humanos disponíveis: em 2016, 1 neonatologista e 6 pediatras. Em 2019, 3 neonatologistas, 2 pós-graduados em neonatologia,1 pediatra intensivista, 9 pediatras (treinados em estabilização de RN) e uma supervisora e referente académica. Simultaneamente se criaram unidades de estabilização neonatal com treinamento contínuo da equipe de enfermagem. Conclusões: a principal causa de transporte neonatal foi a prematuridade grave. Com a aquisição de material adequado e recursos humanos capacitados, conseguiu-se uma diminuição de quase 50% dos traslados. A regionalização vem aumentando, mas deve ser reforçada, principalmente para os casos de recém-nascidos com menos de 1.000 gramas de peso.

Caracterização das transferências inter-hospitalares de mulheres realizadas pelo atendimento móvel de urgência / Caracterización de las transferencias interhospitalarias de mujeres realizadas por la atención móvil de urgencia / Characterization of inter-hospital transfers of women performed by mobile emergency care

Objetivo: descrever a caracterização de mulheres transferidas pelo serviço de atendimento móvel de urgência localizado em cidade do interior de Pernambuco, Brasil. Método: pesquisa descritiva, quantitativa, realizada com 302 fichas de transferência de pacientes do sexo feminino ocorridas entre 2014 e 2019. O instrumento elaborado para coleta dos dados possibilitou análise descritiva posterior. Resultados: predominaram pacientes transferidas no ano de 2018 (24,5%), mês de setembro (10,9%), durante o turno da tarde (36,7%). Entre as mulheres, 47,7% eram idosas, 89,1% foram deslocadas para hospitais públicos, e 49,7% foram para a região metropolitana do estado. Referente aos agravos, as transferências foram mais numerosas nos casos clínicos (74,2%). Houve a presença de técnico de enfermagem, condutor e médico na composição da equipe de atendimento móvel. Conclusão: as transferências inter-hospitalares caracterizaram-se pela predominância de pacientes idosas, acometidas por doenças cardiovasculares, transferidas no turno vespertino para instituições hospitalares da região metropolitana.

Objetivo: describir la caracterización de mujeres transferidas por el servicio de atención móvil de urgencia ubicado en ciudad del interior de Pernambuco, Brasil. Método: investigación descriptiva, cuantitativa, realizada con 302 fichas de transferencias de pacientes del sexo femenino ocurridas entre 2014 y 2019. El instrumento elaborado para la recolección de los datos posibilitó análisis descriptivo posterior. Resultados: predominaron pacientes transferidas en el año 2018 (24,5%), mes de septiembre (10,9%), durante el turno de la tarde (36,7%). Entre las mujeres, 47,7% eran ancianas, 89,1% fueron desplazadas para hospitales públicos, y 49,7% fueron para la región metropolitana del estado. Referente a los agravios, las transferencias fueron más numerosas en los casos clínicos (74,2%). Hubo la presencia de técnico de enfermería, conductor y médico en la composición del equipo de atención móvil. Conclusión: las transferencias interhospitalarias se caracterizaron por la predominancia de pacientes ancianos, afectados por enfermedades cardiovasculares, transferidas en el turno vespertino para instituciones hospitalarias de la región metropolitana.

Objective: to describe the characterization of women transferred by the mobile emergency care service located in a city in the interior of Pernambuco, Brazil. Method: descriptive, quantitative research, conducted with 302 transfer forms of female patients occurred between 2014 and 2019. The instrument developed for data collection allowed further descriptive analysis. Results: patients were predominantly transferred in 2018 (24.5%), September (10.9%), during the afternoon shift (36.7%). Among women, 47.7% were elderly, 89.1% were displaced to public hospitals, and 49.7% went to the metropolitan region of the state. Regarding injuries, transfers were more frequent in clinical cases (74.2%). There was the presence of nursing technician, driver and doctor in the composition of the mobile care team. Conclusion: inter-hospital transfers were characterized by the predominance of elderly patients, affected by cardiovascular diseases, transferred in the afternoon shift to hospital institutions in the metropolitan region.

Registro Nacional de Quemados Chile: presentación de una plataforma online y mirada al pronóstico de pacientes no trasladados a Centro de Quemados / Presentation of an online National Registration Platform for severely burned patients in the Chilean Public Health System and a look into the prognosis of patients not transferred to the National Reference Burn Center

Resumen Introducción: En el año 2017 se incorporó un registro de notificación en línea (Registro Nacional de Quemados) al flujo de derivación de pacientes quemados en Chile. Objetivo: A partir de la información obtenida de esta plataforma, se describe la epidemiología de las quemaduras y las variables que podrían explicar los traslados fallidos a nuestra unidad de quemados. Materiales y Método: Se analizaron los casos subidos a esta plataforma entre julio de 2017 y julio de 2018. Se caracterizó la población global y comparó variables relevantes entre el grupo de pacientes no trasladados a nuestra unidad y los que fueron trasladados con éxito. Resultados: Se analizaron 319 pacientes, 66% hombres, edad promedio 51 años, IMC de 27% y 47% con enfermedades previas. El fuego fue la principal causa de quemaduras. Se observó un 31% de injuria inhaladora. 107 pacientes no se trasladaron a nuestro centro de quemados. Los pacientes trasladados puntuaron más alto en comorbilidad, índice de gravedad, superficie corporal total quemada y aseo quirúrgico en el hospital base. El grupo de pacientes no trasladados puntuó más alto en injuria inhalatoria. La mortalidad global fue 20,4%. La mortalidad fue mayor en pacientes no trasladados (33,6% versus 13,7%; p < 0,001). Conclusiones: Además de facilitar el flujo de pacientes y ahorrar recursos, un uso noble de esta plataforma es ser fuente de información epidemiológica y de implementación de políticas públicas, lo cual puede ser tomado como ejemplo por otros países en vías de desarrollo. Además, se demuestra que ser trasladado constituye un factor protector de muerte por quemaduras.

Introduction: In 2017, an online notification register, the National Burn Registry, was incorporated into the referral flow of burned patients in Chile. Aim: Through the information obtained from this platform, we describe the epidemiology of burns in Chile, and identify variables that could explain failed transfers to our burn unit. Materials and Method: Cases uploaded to this platform between July 2017 - July 2018 were analyzed. We characterize the global population and relevant variables were compared between the group of patients that failed to be transferred to the burn unit and the ones who were successfully transferred. Results: 319 patients were analyzed, 66% men, average age 51 years, BMI of 27 and 47% with previous illnesses. Fire was the main cause of burn injury. Smoke inhalation injury was observed for 31%. 107 patients failed to reach to our burn center. Transferred patients rated higher in comorbidity, severity index, total burned body surface and surgical debridement at base hospital. The group of not transferred patients rated higher in inhalation injury. Overall mortality was 20.4%. Mortality was higher in non-transferred patients (33.6% versus 13.7%; p < 0.001). Conclusions: Aside from facilitating the flow of burned patients and resources saving, a noble use of this platform has been to serve as a source of epidemiological information and implementation of public policies, which can be taken as an example by other developing countries. Also, being transferred is a protective factor for death from burn injuries.

Utilização do Modified Early Warning Score na transferência intra-hospitalar de pacientes / Use of the Modified Early Warning Score in intrahospital transfer of patients

RESUMO Objetivo: Verificar se há associação entre o Modified Early Warning Score antes da transferência da emergência para enfermaria e o óbito ou a admissão na unidade de terapia intensiva em 30 dias. Métodos: Trata-se de estudo de coorte histórica desenvolvido em hospital de alta complexidade do Sul do Brasil com pacientes transferidos da emergência para a enfermaria entre os meses de janeiro e junho de 2017. Foram coletados: variáveis sociodemográficas, comorbidades pelo índice de Charlson, motivo da internação hospitalar, pontuação do Modified Early Warning Score no momento da transferência, internação na unidade de terapia intensiva, atendimento pelo Time de Resposta Rápida, mortalidade em 30 dias e mortalidade hospitalar. Resultados: Foram incluídos 278 pacientes no estudo. Em relação ao Modified Early Warning Score, os pacientes com óbito em 30 dias apresentaram escore significativamente maior do que os pacientes sobreviventes nesse período (2,0 [1,0 - 3,0] versus 1,0 [1,0 - 2,0], respectivamente; p = 0,006). As áreas sob a curva Característica de Operação do Receptor para óbito em 30 dias e para admissão na UTI foram 0,67 (0,55 - 0,80; p = 0,012) e 0,72 (0,59 - 0,84; p = 0,02), respectivamente, com ponto de corte do Modified Early Warning Score ≥ 2. Na regressão de Cox, o Modified Early Warning Score apresentou associação independente com mortalidade em 30 dias, após ajuste multivariável (hazard ratio 2,91; intervalo de confiança de 95% 1,04 - 8,13). Conclusão: O Modified Early Warning Score antes da transferência intra-hospitalar da emergência para enfermaria está associado com admissão na unidade de terapia intensiva e óbito em 30 dias. Calcular o Modified Early Warning Score pode ser um indicador importante para acompanhamento desses pacientes, permitindo ações específicas da equipe receptora.

Abstract Objective: To verify whether there is an association between the Modified Early Warning Score before the transfer from the emergency room to the ward and death or admission to the intensive care unit within 30 days. Methods: This is a historical cohort study conducted in a high-complexity hospital in southern Brazil with patients who were transferred from the emergency room to the ward between January and June 2017. The following data were collected: sociodemographic variables; comorbidities, as determined by the Charlson index; reason for hospitalization; Modified Early Warning Score at the time of transfer; admission to the intensive care unit; care by the Rapid Response Team; mortality within 30 days; and hospital mortality. Results: A total of 278 patients were included in the study. Regarding the Modified Early Warning Score, patients who died within 30 days had a significantly higher score than surviving patients during this period (2.0 [1.0 - 3.0] versus 1.0 [1.0 - 2.0], respectively; p = 0.006). The areas under the receiver operating characteristic curve for death within 30 days and for ICU admission were 0.67 (0.55 - 0.80; p = 0.012) and 0.72 (0.59 - 0.84; p = 0.02), respectively, with a Modified Early Warning Score cutoff of ≥ 2. In the Cox regression, the Modified Early Warning Score was independently associated with mortality within 30 days after multivariate adjustment (hazard ratio 2.91; 95% confidence interval 1.04 - 8.13). Conclusion: The Modified Early Warning Score before intrahospital transfer from the emergency room to the ward is associated with admission to the intensive care unit and death within 30 days. The Modified Early Warning Score can be an important indicator for monitoring these patients and can prompt the receiving team to take specific actions.

Parto domiciliar planejado no Brasil: uma revisão sistemática nacional / Planned home birth in Brazil: a systematic review

Resumo O parto domiciliar planejado (PDP) tem crescido cada vez mais no Brasil, especialmente nos grandes centros urbanos, frente à crescente insatisfação das mulheres com o sistema obstétrico hospitalar vigente. Estudos internacionais demonstram a segurança do PDP, porém a produção nacional ainda é limitada nesta área. Desta maneira, este estudo objetivou revisar a produção bibliográfica nacional acerca de parto domiciliar entre os anos de 2008 e 2018, a fim de compilar dados relacionados ao PDP no Brasil. Após levantamento, 18 estudos foram incluídos na revisão, sendo subdivididos nas seguintes categorias: "Desfechos maternos e neonatais dos PDP", "Sentimentos, motivação e perfis associados à escolha pelo PDP", "Percepção dos profissionais que atendem PDP" e "Abordagem teórica do PDP". Concluiu-se que o PDP tem crescido entre parcelas privilegiadas da população, representando importante prática de exercício da autonomia da mulher em contraponto ao modelo obstétrico vigente, apresentando-se como alternativa segura de local de parto, com alto grau de satisfação para as mulheres e famílias. Este modelo de assistência, entretanto, apresenta-se como opção limitada, uma vez que o PDP não é oferecido pelo Sistema Único de Saúde, ainda inacessível para a maioria das mulheres no país.

Abstract Planned home birth (PHB) has grown in Brazil, especially in large urban centers, in the face of women's dissatisfaction with the current obstetric system. International studies have demonstrated the security of PHB, but national production about this area is still limited. Thus, this study aimed to review the national bibliographic production about PHB between 2008 and 2018, in order to compile data related to PHB in Brazil. After survey, 18 studies were included in the review, and then subdivided into the following categories: "Maternal and neonatal outcomes of PHB", "Feelings, motivation and personal characteristics of women that choose PHB", "Perception of professionals that practice PHB" and "Theoretical approach to PHB". It was concluded that the PHB has grown between privileged portions of Brazilian population, representing the important practice of women's autonomy, presenting itself as a safe alternative place of birth, with a high degree of satisfaction of women and families. However, this model of assistance presents itself as a limited option, since the PHB is not offered by the Health System, still unaccessible to most of women in the country.

Comparative Analysis between Transferred and Self-Referred STEMI Patients Undergoing Primary Angioplasty / Análise Comparativa entre Pacientes com IAMCSST Transferidos e Pacientes de Demanda Espontânea Submetidos à Angioplastia Primária

Abstract Background: Studies have shown the benefits of rapid reperfusion therapy in acute myocardial infarction. However, there are still delays during transport of patients to primary angioplasty. Objective: To evaluate whether there is a difference in total ischemic time between patients transferred from other hospitals compared to self-referred patients in our institution. Methods: Historical cohort study including patients with acute myocardial infarction treated between April 2014 and September 2015. Patients were divided into transferred patients (group A) and self-referred patients (group B). Clinical characteristics of the patients were obtained from our electronic database and the transfer time was estimated based on the time the e-mail requesting patient's transference was received by the emergency department. Results: The sample included 621 patients, 215 in group A and 406 in group B. Population characteristics were similar in both groups. Time from symptom onset to arrival at the emergency department was significantly longer in group A (385 minutes vs. 307 minutes for group B, p < 0.001) with a transfer delay of 147 minutes. There was a significant relationship between the travel distance and increased transport time (R = 0.55, p < 0.001). However, no difference in mortality was found between the groups. Conclusion: In patients transferred from other cities for treatment of infarction, transfer time was longer than that recommended, especially in longer travel distances.

Resumo Fundamento: Estudos mostram o benefício da terapia de reperfusão rápida no infarto agudo do miocárdio. No entanto, ainda ocorrem atrasos durante o transporte de pacientes para angioplastia primária. Objetivo: Definir se existe uma diferença no tempo total de isquemia entre pacientes transferidos de outro hospital comparados aos que procuram o serviço espontaneamente. Método: Estudo de coorte histórico, incluindo pacientes atendidos com infarto entre abril de 2014 e setembro de 2015. Os pacientes foram divididos em pacientes transferidos (grupo A) e por demanda espontânea (grupo B). As características clínicas dos pacientes foram retiradas do banco de dados de infarto e o tempo de transferência foi estimado tendo como base o correio eletrônico de acordo com o horário de contato. O nível de significância adotado foi um p < 0,05%. Resultados: A amostra incluiu 621 pacientes, 215 no grupo A e 406 no grupo B. As características populacionais foram semelhantes nos dois grupos. O delta T foi significativamente maior no grupo de pacientes transferidos (385 minutos vs. 307 minutos para o grupo B, p < 0,001) com um atraso decorrente do transporte de 147 minutos. Houve relação significativa da distância de transferência e aumento do tempo de transporte (R = 0,55; p < 0,001). Entretanto, não houve diferença na mortalidade entre os grupos. Conclusão: Pacientes transferidos de outras cidades para tratamento de infarto tem Delta T de transferência acima do recomendado, com tempo ainda mais longo quanto maior a distância a ser percorrida.

Emergency Department Crowding Disparity: a Nationwide Cross-Sectional Study

In this study, we evaluated national differences in emergency department (ED) crowding to identify factors significantly associated with crowding in institutes and communities across Korea. This was a cross-sectional nationwide observational study using data abstracted from the National Emergency Department Information System (NEDIS). We calculated mean occupancy rates to quantify ED crowding status and divided EDs into three groups according to their occupancy rates (cutoffs: 0.5 and 1.0). Factors potentially related to ED crowding were collected from the NEDIS. We performed a multivariate regression analysis to identify variables significantly associated with ED crowding. A total of 120 EDs were included in the final analysis. Of these, 73 were categorized as 'low crowded' (LC, occupancy rate < 0.50), 37 as 'middle crowded' (MC, 0.50 ≤ occupancy rate < 1.00), 10 EDs as 'high crowded' (HC, 1.00 ≤ occupancy rate). The mean ED occupancy rate varied widely, from 0.06 to 2.33. The median value was 0.39 with interquartile ranges (IQRs) from 0.20 to 0.71. Multivariate analysis revealed that after adjustment, ED crowding was significantly associated with the number of visits, percentage of patients referred, number of nurses, and ED disposition. This nationwide study observed significant variety in ED crowding. Several input, throughput, and output factors were associated with crowding.

Emergency Department Crowding Disparity: a Nationwide Cross-Sectional Study

In this study, we evaluated national differences in emergency department (ED) crowding to identify factors significantly associated with crowding in institutes and communities across Korea. This was a cross-sectional nationwide observational study using data abstracted from the National Emergency Department Information System (NEDIS). We calculated mean occupancy rates to quantify ED crowding status and divided EDs into three groups according to their occupancy rates (cutoffs: 0.5 and 1.0). Factors potentially related to ED crowding were collected from the NEDIS. We performed a multivariate regression analysis to identify variables significantly associated with ED crowding. A total of 120 EDs were included in the final analysis. Of these, 73 were categorized as 'low crowded' (LC, occupancy rate < 0.50), 37 as 'middle crowded' (MC, 0.50 ≤ occupancy rate < 1.00), 10 EDs as 'high crowded' (HC, 1.00 ≤ occupancy rate). The mean ED occupancy rate varied widely, from 0.06 to 2.33. The median value was 0.39 with interquartile ranges (IQRs) from 0.20 to 0.71. Multivariate analysis revealed that after adjustment, ED crowding was significantly associated with the number of visits, percentage of patients referred, number of nurses, and ED disposition. This nationwide study observed significant variety in ED crowding. Several input, throughput, and output factors were associated with crowding.

Impact of long-stay beds on the performance of a tertiary hospital in emergencies / Impacto de leitos de longa permanência no desempenho de hospital terciário em emergências

ABSTRACT OBJECTIVE To assess the impact of implementing long-stay beds for patients of low complexity and high dependency in small hospitals on the performance of an emergency referral tertiary hospital. METHODS For this longitudinal study, we identified hospitals in three municipalities of a regional department of health covered by tertiary care that supplied 10 long-stay beds each. Patients were transferred to hospitals in those municipalities based on a specific protocol. The outcome of transferred patients was obtained by daily monitoring. Confounding factors were adjusted by Cox logistic and semiparametric regression. RESULTS Between September 1, 2013 and September 30, 2014, 97 patients were transferred, 72.1% male, with a mean age of 60.5 years (SD = 1.9), for which 108 transfers were performed. Of these patients, 41.7% died, 33.3% were discharged, 15.7% returned to tertiary care, and only 9.3% tertiary remained hospitalized until the end of the analysis period. We estimated the Charlson comorbidity index - 0 (n = 28 [25.9%]), 1 (n = 31 [56.5%]) and ≥ 2 (n = 19 [17.5%]) - the only variable that increased the chance of death or return to the tertiary hospital (Odds Ratio = 2.4; 95%CI 1.3;4.4). The length of stay in long-stay beds was 4,253 patient days, which would represent 607 patients at the tertiary hospital, considering the average hospital stay of seven days. The tertiary hospital increased the number of patients treated in 50.0% for Intensive Care, 66.0% for Neurology and 9.3% in total. Patients stayed in long-stay beds mainly in the first 30 (50.0%) and 60 (75.0%) days. CONCLUSIONS Implementing long-stay beds increased the number of patients treated in tertiary care, both in general and in system bottleneck areas such as Neurology and Intensive Care. The Charlson index of comorbidity is associated with the chance of patient death or return to tertiary care, even when adjusted for possible confounding factors.

RESUMO OBJETIVO Avaliar o impacto da implantação de leitos de longa permanência para pacientes de baixa complexidade e alta dependência em hospitais de pequeno porte sobre o desempenho de hospital terciário de referência em emergência. MÉTODOS Para este estudo longitudinal, foram identificados hospitais em três municípios no departamento regional de saúde coberto pela instância terciária e que forneciam 10 leitos de longa permanência cada. Os pacientes foram transferidos para os hospitais desses municípios com base em protocolo específico. Obteve-se o desfecho dos pacientes transferidos por acompanhamento diário. Fatores de confusão foram ajustados por regressão logística e semiparamétrica de Cox. RESULTADOS Entre 1 de setembro de 2013 e 30 de setembro de 2014, foram transferidos 97 pacientes, sendo 72,1% homens, com idade média de 60,5 anos (DP = 1,9), para os quais foram realizadas 108 transferências. Desses pacientes, 41,7% evoluíram ao óbito, 33,3% receberam alta, 15,7% retornaram à instância terciária, e apenas 9,3% permaneceram internados até o final do período analisado. Foi calculado o índice de comorbidade de Charlson - 0 (n = 28 [25,9%]), 1 (n = 31 [56,5%]) e ≥ 2 (n = 19 [17,5%]) - a única variável que aumentou a chance de óbito ou retorno ao hospital terciário (Razão de Chances = 2,4; IC95% 1,3;4,4). O tempo de permanência nos leitos de longa permanência foi de 4.253 pacientes-dia, que representariam 607 vagas no hospital terciário, considerando-se a média de internação de sete dias. O hospital terciário aumentou o número de vagas em 50,0% para terapia intensiva, 66,0% para neurologia e 9,3% para as vagas totais. A permanência dos pacientes nos leitos de longa permanência limitou-se em grande parte aos primeiros 30 (50,0%) e 60 (75,0%) dias. CONCLUSÕES A implantação de leitos de longa permanência teve impacto no aumento de vagas novas oferecidas pela instância terciária tanto gerais como para áreas de estrangulamento do sistema, como a Neurologia e Terapia Intensiva. O índice de comorbidade de Charlson está associado à chance de o paciente evoluir ao óbito ou retornar para a instância terciária, mesmo quando ajustado por possíveis fatores de confusão.

The Relationship between Clinical Outcome in Subarachnoidal Hemorrhage Patients with Emergency Medical Service Usage and Interhospital Transfer

Prompt diagnosis and appropriate transport of patients with subarachnoid hemorrhage (SAH) is critical. We aimed to study differences in clinical outcomes by emergency medical services (EMS) usage and interhospital transfer in patients with SAH. We analyzed the CAVAS (CArdioVAscular disease Surveillance) database which is an emergency department-based, national cohort of cardiovascular disease in Korea. Eligible patients were adults with non-traumatic SAH diagnosed between January 2007 and December 2012. We excluded those whose EMS use and intershopital transfer data was unknown. The primary and secondary outcomes were mortality and neurologic status at discharge respectively. We compared the outcomes between each group using multivariable logistic regressions, adjusting for sex, age, underlying disease, visit time and social history. Of 5,461 patients with SAH, a total of 2,645 were enrolled. Among those, 258 used EMS and were transferred from another hospital, 686 used EMS only, 1,244 were transferred only, and 457 did not use EMS nor were transferred. In the regression analysis, mortality was higher in patients who used EMS and were transferred (OR 1.40, 95% CI 1.02-1.92), but neurologic disability was not meaningfully different by EMS usage and interhospital transfer. In Korea, SAH patients' mortality is higher in the case of EMS use or receiving interhospital transfer.

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.

Seguridad en el traslado intrahospitalario de pacientes críticos en pediatría / Safety of interhospital transfers of critical care patients in pediatrics

La unidad de cuidados intensivos (UCI) es el ámbito más seguro para la atención de pacientes críticamente enfermos. Sin embargo, hay situaciones en las que el paciente debe ser trasladado a algún otro lugar del hospital, pudiendo incrementar el riesgo para eventos adversos. El objetivo es describir la implementación de un programa de capacitación y realizar un relevamiento de los traslados de pacientes de UCI. Estudio descriptivo y prospectivo. Se incluyeron todos los pacientes trasladados desde las UCI 44-45-72 y 65 durante el periodo de Julio 2012 a Junio 2013. Se diseñó una lista de chequeo, con datos de cada paciente, material para el traslado y registro de efectos adversos. Se agruparon por gravedad en Grupo I: Sin requerimientos de inotrópicos y sin asistencia respiratoria mecánica (ARM) y Grupo II: Requerimientos de ARM y/o inotrópicos (A Estables, B Inestable). Se realizó capacitación del personal encargado de los traslados para completar las listas de chequeo y recomendaciones sobre traslado seguro. Se documentaron 104 traslados y se distribuyeron en Grupo IA 32%, 2A 61% y 2B 11%. Se pesquisó un total de 61 (58.65%) eventos adversos. Se registraron eventos adversos en 58.65% de los traslados y solo 47.11% de los traslados fueron realizados en condiciones adecuadas (AU)

The intensive care unit (ICU) is the safest environment for the care of critically ill patients. Nevertheless, in certain settings the patients have to be transferred to other sectors of the hospital, which may increase the risk of adverse events. With the aim to describe the implementation of a training program and to assess the transfer of ICU patients a descriptive and prospective study was conducted. All patients transferred from ICUs 44-45,72, and 65 over the period July 2012 to June 2013 were included. A checklist was developed with patient data, materials included in the transfer, and recording of adverse events. Patients were categorized according to severity into Group I: No need for inotropics and mechanical ventilation (MV) and Group II: Need for MV and/or inotropics (A Stable, B Unstable). Personnel in charge of the transfers were trained in the filling out of the checklists and recommendations for safe transfers. One hundred and four transfers were registered; 32% of the patients were in Group IA, 61% in Group 2A, and 11% in 2B. A total of 61 (58.65%) adverse events were observed. Adverse events were registered in 58.65% of the transfers and only 47.11% of the transfers were performed under adequate conditions (AU)

Partos domiciliares planejados assistidos por enfermeiras obstétricas: transferências maternas e neonatais / Planned home births assisted by nurse midwives: maternal and neonatal transfers / Partos domiciliarios planificados atendidos por enfermeras obstétricas: traslados maternales y neonatales

O presente trabalho trata-se de estudo exploratório-descritivo que teve como objetivo descrever a taxa e as causas de transferência intraparto para o hospital de mulheres assistidas no domicílio por enfermeiras obstétricas e os desfechos desses nascimentos. A amostra foi composta por onze mulheres e seus recém-nascidos, de janeiro de 2005 a dezembro de 2009. Os dados foram coleta-dos em prontuários e cadernetas de saúde e analisados por estatística descritiva. A taxa de transferência foi de 11%, a maioria de nulíparas (63,6%), e todas foram transferidas durante o primeiro período clínico do parto. Os motivos mais frequentes de transferência foram parada de dilatação cervical e progressão da apresentação fetal, e desproporção cefalopélvica. Os escores de Apgar no 1º e 5º minutos foram >7 em 81,8% dos casos e não houve internação em unidade de terapia intensiva neonatal. Neste estudo constatou-se que o parto domiciliar planejado assistido por enfermeiras obstétricas, com protocolo assistencial, apresentou bons resultados maternos e neonatais, mesmo quando a transferência para o hospital foi necessária.

The objective of this explorative and descriptive study was to describe the rates and reasons for intrapartum transfers from home to hospital among women assisted by nurse midwives, and the outcomes of those deliveries. The sample consisted of eleven women giving birth and their newborns, from January 2005 to December 2009. Data was collected from the maternal and neonatal records and was analyzed using descriptive statistics. The transfer rate was 11%, most of the women were nulliparous (63.6%), and all of them were transferred during the first stage of labor. The most common reasons for transfer were arrested cervical dilation, arrested progress of the fetal head and cephalopelvic disproportion. Apgar scores were >7 for 81.8% of the newborns; and there were no admissions to the neonatal intensive care unit. The results show that planned home births assisted by nurse midwives following a clinical protocol, had good outcomes even when a transfer to the hospital was needed.

Estudio exploratorio descriptivo que objetivó describir la tasa y causas de traslados hospitalarios intraparto a mujeres atendidas en domicilio por enfermeras obstétricas y los desenlaces de tales nacimientos. Muestra compuesta por once mujeres y sus recién nacidos, de enero 2005 a diciembre 2009; datos recolectados a partir de historia clínicas y carpetas de salud, analizadas por estadística descriptiva. La tasa de traslado fue 11,0%, mayoritariamente de nulíparas (63,3%), todas ellas trasladadas durante el primer período clínico del parto. Los motivos más frecuentes obedecieron a interrupción de dilatación cervical, progresión de presentación fetal y desproporción cefalopélvica. Los puntajes de Apgar en minutos 1 y 5 fueron >7 en 81,8% de los casos, no produciéndose internación en unidad de terapia intensiva neonatal. Según el estudio, el parto domiciliario planificado atendido por enfermeras obstétricas según protocolo de atención, exhibió buenos resultados maternales y neonatales, inclusive cuando fue necesario efectuar traslados hospitalarios.

[Neuroradiological pattern of peripartum cerebro vascular disease medicating transfer to determine care unit]

Pregnancy and puerperium are considered a period of a high risk of stroke responsible in a part of the morbidity and mortality in women. Imaging is the pivotal tool to diagnostics and care. To investigate the clinical and imaging features cerebrovascular complications during pregnancy and in post partum period. We report a retrospective analysis of forty four patients [November 2002 - October 2010] admitted in the intensive car department of the national institute of neurology for cerebro-vascular complications during pregnancy and in post partum period. Cerebro-vascular imaging modalities included cerebral computed tomography [CCT] with and without contrast in 94% of cases, magnetic resonance imaging [MRI] in 30.6% of cases completed by venous angiography MRI in 27.2% of cases and angiography MRI of Willis polygon in 11.3% of cases and by cerebral angiography in 13.6% of cases. Posterior reversible encephalopathy syndrome [PRES] is diagnosed in 61.4% of cases followed by meningo-cerebral haemorrhage [MCH] in 29.5% and finally cerebral venous thrombosis [CVT] and arterial ischemia in 4.5% of cases each one. The cerebro-vascular complications are revelled in 86.3% of the cases during the postpartum and were associated with the eclampsia or preeclampsia in 90.9% of the cases [n=40]. CCT showed typical lesions of PRES in 23 patients. It confirms the presence of hematoma in the 13 patients with MCH and find hypodense lesion in one case with ischemic stroke. CCT show direct [delta sign] and indirect signs of CVT. MRI confirms the diagnostic of PRES, when done [11 of 12 cases] and show cortical sub cortical hyper signal on T2 and FLAIR and hypo signal on T1 sequences. MRI was normal in one case. It shows hemorrhagic lesion in the 2 cases of MCH, thrombosis in the cases of CVT and ischemic lesion in the cases of ischemic stroke. CCT and MRI done within 48 hours from admission were decisive for early diagnostic and for fast and adequate care. Early recognition of stroke in peri partum by cerebral imaging is of paramount importance for prompt diagnosis and treatment to improve maternal morbidity and mortality

Remoções maternas da Casa do Parto de Sapopemba para hospital de referência / Transferring mothers from a free-standing birth center to a reference hospital / Remociones maternas de la Casa del Parto de Sapopemba para hospital de referencia

Estudo descritivo com objetivo de caracterizar as remoções maternas da Casa do Parto de Sapopemba, em São Paulo, para hospitais de referência, entre setembro de 1998 e julho de 2008. A população do estudo compôs-se de 229 casos. Os dados foram obtidos dos prontuários e dos livros de registro de remoções. Foi realizada análise descritiva. A taxa de remoção materna foi de 5,8 por cento (5,5 por cento intraparto e 0,3 por cento pós-parto). A maioria das mulheres removidas para o hospital era nulípara (78,6 por cento). O motivo mais frequente para remoção intraparto foi anormalidade da pélvis materna ou do feto (22,6 por cento) e para a remoção pós-parto, anormalidade da dequitação (50 por cento). Destacaram-se a nuliparidade, dilatação cervical na admissão, membranas ovulares rotas e idade gestacional superior a 40 semanas como variáveis importantes para o estudo de fatores de risco para remoção materna.

The objective of this descriptive study was to characterize the transfers of mothers from the Sapopemba Birth Center to reference hospitals in São Paulo, from September 1998 to July 2008. The studied population was 229 cases of mother transfers. Data were obtained from medical records and record books of the transferred women. Descriptive analysis was performed. The transfer rate was 5.8 percent (5.5 percent in the intrapartum period and 0.3 percent in the postpartum period). Most women who were transferred to the hospital were nulliparous (78.6 percent). The most common reason for intrapartum transfers was fetal or pelvis abnormalities (22.6 percent), and abnormal placental detachment (50 percent) for women in the postpartum period. Some conditions such as nulliparity, cervical dilation at admission, rupture of the membranes and gestational age over 40 weeks were highlighted as important variables for studying the risk factors for mothers being transferred.

Estudio descriptivo que objetivó caracterizar las remociones maternas de la Casa del Parto de Sapopemba-SP para hospitales de referencia entre setiembre 1998 y julio 2008. La población del estudio se compuso de 229 casos de remoción materna. Los datos se obtuvieron de las historias clínicas y libros de registro de remociones. Se realizó análisis descriptivo. La tasa de remoción materna fue del 5,8 por ciento (5,5 por ciento intraparto y 0,3 por ciento postparto). La mayoría de las mujeres derivadas para hospitales era nulípara (78,6). El motivo más frecuente de derivación intraparto fue anormalidad de pelvis materna o del feto (22,6 por ciento), y para cada remoción postparto, anormalidad de expulsión placentaria (50 por ciento). Tuvieron destaque la nuliparidad, dilatación cervical en la admisión, membranas ovulares rotas y edad gestacional superior a 40 semanas como variables importantes para el estudio de factores de riesgo en la remoción materna.

Postconceptional age at the treatment of retinopathy of prematurity in inborn and referred preterm infants from the same institution / Idade pós-concepção no tratamento da retinopatia da prematuridade em pré-termos nascidos e em transferidos para o tratamento em uma mesma instituição

PURPOSE: The outcomes of the treatment of retinopathy of prematurity (ROP) seem to be better in inborn patients than in those patients who were referred for ROP treatment. This study aims to investigate the timing of treatment and the outcomes in inborn patients and in patients referred for treatment to the Hospital de Clínicas de Porto Alegre, Brazil. METHODS: An institutional prospective cohort study was conducted from 2002 to 2010 and included in group 1 all inborn preterm neonates treated for retinopathy of prematurity and in group 2 all babies referred for treatment to the same institution. All of the included patients presented birth weight (BW) <1,500 g and/or gestational age (GA) <32 weeks. Main outcomes were postconceptional age at the treatment and one year follow-up outcomes in both groups. The considered variables were: BW, GA, stage and location of retinopathy of prematurity at treatment. RESULTS: Group 1 comprised 24 inborn patients. Mean BW and GA at birth were 918 ± 232 g and 28.2 ± 2.1 weeks, respectively, and median post-conceptional postconceptional age at treatment was 37 weeks. Group 2 comprised 14 infants transferred for treatment. Mean BW and GA at birth were 885 ± 188 g and 28.2 ± 2.4 weeks, respectively, and median postconceptional age at treatment was 39 weeks. Mean BW and GA were similar in both groups (P=0.654 and P=0.949, respectively), but the difference among the postconceptional age was significant (P=0.029). CONCLUSIONS: Inborn patients were treated for retinopathy of prematurity during the 37th week of postconceptional age while transferred patients were treated, usually, after the 39th week postconceptional age. The worst outcomes observed among referred patients could be partially explained by the delayed time for treatment.

OBJETIVOS: Os resultados do tratamento da retinopatia da prematuridade (ROP) parecem ser melhores em pacientes nascidos na mesma instituição onde o tratamento foi praticado do que naqueles pacientes transferidos para o tratamento em centros de referência. Este estudo tem como objetivos investigar o momento do tratamento e seus resultados em pacientes nascidos e em pacientes transferidos para o tratamento em uma mesma instituição. MÉTODOS: Estudo de coorte institucional e prospectivo conduzido de 2002 a 2010 e incluiu no grupo 1 todos os prematuros tratados para a retinopatia da prematuridade nascidos na instituição e no grupo 2 todos os prematuros tratados para a retinopatia da prematuridade transferidos para o tratamento. Todos os pacientes incluídos tinham peso de nascimento (PN) <1.500 gramas e/ou idade gestacional (IG) <32 semanas. As principais consideradas foram a idade pós-concepção (IPC) por ocasião do tratamento e os resultados do tratamento ao final do 1º ano de vida dos pacientes nos 2 grupos. As variáveis consideradas foram: peso de nascimento, idade gestacional, estadiamento e localização da retinopatia da prematuridade por ocasião do tratamento. RESULTADOS: O grupo 1 incluiu 24 prematuros nascidos na instituição. As médias do PN e da IG foram 918 ± 232 gramas e 28,2 ± 2,1 semanas, respectivamente. A mediana da idade pós-concepção ao tratamento foi de 37 semanas. O grupo 2 incluiu 14 pacientes transferidos para o tratamento. As médias do PN e da IG foram 885 ± 188 gramas e 28,2 ± 2,4 semanas, respectivamente. A mediana da idade pós-concepção ao tratamento foi de 39 semanas. As médias dp PN e da IG eram similares nos dois grupos (P=0,654 e P=0,949, respectivamente), mas a diferença entre a idade pós-concepção ao tratamento foi significativa entre os 2 grupos (P=0,029). CONCLUSÕES: Os pacientes nascidos na instituição foram tratados para a retinopatia da prematuridade durante a 37ª semana de idade pós-concepção enquanto os pacientes transferidos foram tratados após a 39ª semanas de idade pós-concepção em média. Os piores resultados do tratamento assim como do seguimento de um ano observados entre os pacientes do grupo 2 podem ser explicados, em parte, pelo tempo maior decorrido para o tratamento da retinopatia da prematuridade.

Alternativas de tratamento para pacientes pediátricos em ventilação mecânica crônica / Care alternatives for pediatric chronic mechanical ventilation

OBJETIVO: Determinar o impacto da transferência de uma população pediátrica para unidades de dependentes de ventilação mecânica (UDVMs) ou para ventilação mecânica domiciliar (VMD) na disponibilidade de leitos na unidade de terapia intensiva (UTI) pediátrica. MÉTODOS: Estudo longitudinal retrospectivo de crianças hospitalizadas que necessitavam de VM prolongada na UDVM do Hospital Auxiliar de Suzano, um hospital público secundário do estado de São Paulo. Calculamos o número de dias que os pacientes passaram na UDVM e em VMD e analisamos sua sobrevida com o estimador Kaplan-Meier. RESULTADOS: Quarenta e um pacientes foram admitidos na UDVM em 7,3 anos. A mediana do tempo de internação na unidade foi de 239 dias (amplitude interquartil = 102-479). Desses pacientes, 22 vieram da UTI pediátrica, onde a transferência disponibilizou 8.643 leitos-dia (uma média de 14 novos pacientes por mês). A VMD de oito pacientes disponibilizou 4.022 leitos-dia no hospital em 4 anos (uma média de 12 novos pacientes por mês na UTI). A taxa de sobrevida dos pacientes em casa não foi significativamente diferente daquela verificada nos pacientes hospitalizados. CONCLUSÕES: Uma unidade hospitalar para dependentes de ventilação mecânica e a VMD podem melhorar a disponibilidade de leitos em UTIs. A taxa de sobrevida dos pacientes que recebem VMD não apresentou diferenças significativas em relação à dos pacientes que permanecem hospitalizados.

OBJECTIVE: To determine the impact of transferring a pediatric population to mechanical ventilator dependency units (MVDUs) or to home mechanical ventilation (HMV) on bed availability in the pediatric intensive care unit (ICU). METHODS: This is a longitudinal, retrospective study of hospitalized children who required prolonged mechanical ventilation at the MVDU located at the Hospital Auxiliar de Suzano, a secondary public hospital in São Paulo, Brazil. We calculated the number of days patients spent at MVDU and on HMV, and analyzed their survival rates with Kaplan-Meier estimator. RESULTS: Forty-one patients were admitted to the MVDU in 7.3 years. Median length of stay in this unit was 239 days (interquartile range = 102-479). Of these patients, 22 came from the ICU, where their transfer made available 8,643 bed-days (a mean of 14 new patients per month). HMV of eight patients made 4,022 bed-days available in the hospital in 4 years (a mean of 12 new patients per month in the ICU). Survival rates of patients at home were not significantly different from those observed in hospitalized patients. CONCLUSIONS: A hospital unit for mechanical ventilator-dependent patients and HMV can improve bed availability in ICUs. Survival rates of patients who receive HMV are not significantly different from those of patients who remain hospitalized.

Prolonged neonatal interhospital transport on road: Relevance for developing countries.

Objective. To compare prolonged inter hospital long distance transports on road undertaken by a qualified transport team vs those done by the same team from shorter distances and time. Methods. Retrospective descriptive comparative study of the neonatal transports done during a period of 48 mo. All neonates transferred on road to a tertiary level pediatric hospital from various maternity and pediatric centers. The biochemical characteristics, adverse effects during transport and 24 hr survival after the transport in both the groups were compared. Results. The babies were comparable in their gestational age and ventilatory requirements (46% vs 39%). The biochemical and metabolic characteristics and 24 hr mortality rates for babies who were transported for longer times and distances were comparable (p value =0.75) to those transported for shorter times. Conclusion. Long distance neonatal transport on road is feasible and with a qualified team results can be comparable to those transported from shorter distances.

Transfer of head-injured patients in Jamaica: is there a problem? / Transferencia de pacientes con heridas de cabeza en Jamaica: ¿hay problema?

Head-injured patients are often transferred to the University Hospital of the West Indies (UHWI) for tertiary care. There is no standardized, agreed protocol governing their transfer. During the three-year period January 1998 to December 2000, 144 head injured patients were transferred to the UHWI from other institutions. They were 70male, had a mean age of 34 years and spent a mean of 13 days in hospital. Eighteen per cent were admitted to the Intensive Care Unit, where they spent a mean of nine days. On arrival, mean pulse rate was 92 +/- 22 beats/minute, mean systolic blood pressure was 130 +/- 27 mmHg and mean diastolic was 76 +/- 19mmHg. Twenty-eight per cent of patients had a pulse rate above 100/min on arrival and 13.8had systolic blood pressure below 60 mmHg. The Glasgow Coma Scale score was unrecorded at the referring institution in 70of cases and by the receiving officers at the UHWI in 23of cases. Intubation was done on only half of those who were eligible. Junior staff members initiated and carried out transfers whenever this was documented. The types of vehicles and monitoring equipment used could not be determined in most instances. Fifty-eight per cent of patients had minor head injuries, 12, severe injury and 33, associated injuries requiring a variety of surgical procedures by multiple specialties. Most patients (80.6) were discharged home but 11.8died in hospital. Transfer of head-injured patients, many with multiple injuries is not being performed in a manner consistent with modern medical practice. There is urgent need for implementation of a standardized protocol for the transfer of such patients in Jamaica.

Los pacientes con heridas en la cabeza son a menudo transferidos al Hospital Universitario de West Indies (UHWI) para su cuidado terciario. No existe ningún protocolo acordado en relación con las normas que deben regir la transferencia. En el trienio de enero de 1998 a diciembre 2000, 144 pacientes con heridas de cabeza, fueron transferidos al HUWI desde otras instituciones. El 70% de ellos eran varones de 34 años de edad promedio, y el período de permanencia en el hospital fue 13 días como promedio. El 18% fue ingresado en la Unidad de Cuidados Intensivos, donde permaneció un promedio de 9 días. Al llegar al hospital, su pulso medio era de 92 ± 22 pulsaciones/minuto, la presión arterial sistólica media era de 130 ± 27 mmHg, y la media diastólica de 76 ± 19 mmHg. El 28% de los pacientes tenía un ritmo de pulsaciones por encima de 100/min al momento del ingreso, y un 13.8% tenía la presión arterial sistólica por debajo de 60 mmHg. No había constancia de la aplicación de la Escala de Coma de Glasgow en las instituciones que remitieron a los pacientes en el 70% de los casos, ni por parte de los funcionarios médicos que recibieron a los pacientes en el HUWI en el 23% de los casos. La entubación se realizó solamente en la mitad de los pacientes elegibles. El personal subalterno inició y llevó a cabo las transferencias en todos los casos docu-mentados. En la mayor parte de los casos no fue posible determinar los tipos de vehículos ni el equipo de monitoreo utilizados. El 58% por ciento de los pacientes presentaba heridas menores de la cabeza, el 12% tuvo heridas graves, y un 33% acudió con heridas asociadas que requerían diversos procedimientos quirúrgicos de múltiples especialidades. La mayoría de los pacientes (80.6%) regresó de alta a sus casas, pero el 11.8% murió en el hospital. La transferencia de pacien-tes con heridas en la cabeza – muchos de ellos con lesiones múltiples – no se está realizando de manera consistente con la práctica médica moderna...

Realidad de un policlínico de coloproctología / Reality of a coloproctology clinic

Se estudian en forma prospectiva 100 pacientes consecutivos atendidos en el policlínico de Coloproctología del Hospital de Talca. Se comparan los diagnósticos del médico que envió al enfermo con los diagnósticos definitivos. Además se analizó la acuciosidad del examen proctológico practicado, la demora en el traslado y si ésta influyó en el resultado final del enfermo. El 49 por ciento procedía de consultorio municipal, rural u otro hospital, un 46 por ciento de otros servicios de nuestro hospital; el 50 por ciento de los pacientes fueron derivados por médicos generales. A sólo el 25 por ciento se le practicó un examen proctológico que incluyó inspección y tacto rectal, al 29 por ciento no se le practicó ningún examen. La coincidencia diagnóstica fue del 49 por ciento, con 19 pacientes enviados tardíamente, en 8 de los cuales el resultado final fue influenciado por este retraso. Se concluye que es necesario mejorar la entrega de conocimientos de la especialidad en el pregrado, postgrado y establecer criterios de derivación para ser aplicados en los centros de salud que dependen del policlínico especializados