Effectiveness of a programme to reduce the burden of catheter-related bloodstream infections in a tertiary hospital.

The objective of this study was to assess the effectiveness of a catheter-related bloodstream infection (CR BSI) reduction programme and healthcare workers' compliance with recommendations. A 3-year surveillance programme of CR BSIs in all hospital settings was implemented. As part of the programme, there was a direct observation of insertion and maintenance of central venous catheters (CVCs) to determine performance. A total of 38 education courses were held over the study period and feedback reports with the results of surveillance and recommendations were delivered to healthcare workers every 6 months. A total of 6722 short-term CVCs were inserted in 4982 patients for 58 763 catheter-days. Improvements of compliance with hand hygiene was verified at the insertion (87·1-100%, P < 0·001) and maintenance (51·1-72·1%, P = 0·029) of CVCs; and the use of chlorhexidine for skin disinfection was implemented at insertion (35·7-65·4%, P < 0·001) and maintenance (33·3-45·9%, P < 0·197) of CVCs. There were 266 CR BSI incidents recorded with an annual incidence density of 5·75/1000 catheter-days in the first year, 4·38 in the second year [rate ratio (RR) 0·76, 95% confidence interval (CI) 0·57-1·01] and 3·46 in the third year (RR 0·60, 95% CI 0·44-0·81). The education programme clearly improved compliance with recommendations for CVC handling, and was effective in reducing the burden of CR BSIs.

La brucelosis humana, ayer y hoy / No disponible

La brucelosis es una zoonosis distribuida por la mayor parte del mundo. En España tuvo una incidencia importante, estimándose en 5.000 los casos anuales al final de la primera mitad del s.XX, llegando a 8.692 casos en 1984, lo que hizo que se pusieran en marcha programas de control, que contribuyeron a reducir el número de casos, hasta los 103 declarados en 2013. La enfermedad, ha tenido una importante repercusión sanitaria y socioeconómica por la afectación del hombre y de los animales. Su pronóstico en general, ha sido bueno, salvo complicaciones. El tratamiento en las primeras décadas del s. XX, era básicamente sintomático, al no disponerse de ningún remedio efectivo. Posteriormente, los arsenicales, las sales de oro y la vacuna intravenosa, entre otros, tuvieron una aportación destacable, hasta la llegada de los antibióticos, que supuso un cambio radical en la evolución de la enfermedad (AU)

Brucellosis is a zoonosis spread throughout the world. It had a rather important incidence in Spain. An estímate of of 5000 cases per year took place in Spain during the first half of the 20th. century, reaching a peak of 8,692 in 1984. This fact promoted the establishment of control mechanisms that contributed to gradually diminish the number of cases to 103 in 2013. Brucellosis has had a considerable importance both in the health and socioeconomic fields due to vulnerability in humans and animals. The disease had a good prognosis, putting aside possible complications. Treatment, in the first decades of the 20th. Century was basically symptomatic, given the lack of effective remedies. Later, arsenic components, gold salts and the intravenous vaccine, among others, had a relevant importance in treatment until the appearance of antibiotics. These had a radical influence in the natural evolution of the disease (AU)

Conocimientos sobre gripe en personal sanitario que acude a vacunarse / No disponible

INTRODUCCIÓN: El objetivo del trabajo, es conocer el nivel de conocimientos sobre la Gripe y sus determinantes en el personal sanitario (PS) que se vacuna de la gripe. Material y MÉTODOS: Estudio transversal, en el que se incluyó al PS que se vacunó de la gripe en la temporada 2011-12, y cumplimentó un cuestionario de 10 preguntas. Se consideró nivel adecuado de conocimientos cuando se contestaron correctamente cinco o más preguntas. Para cuantificar la magnitud de la asociación se calculó la Odds Ratio con sus IC al 95%. RESULTADOS: Se encuestaron 634 trabajadores sanitarios. El 75,7% tenía un nivel adecuado de conocimientos. El tener menos de 45 años OR: 3,3 (2,1-5,2), el ser facultativo o personal de enfermería, OR: 4,1 (2,3-7,3) y OR: 3,1 (1,8-5,3) respectivamente, se asociaron con disponer de un nivel adecuado de conocimientos. CONCLUSIONES: La edad y el estamento son las variables que se asocian de manera independiente con el nivel de conocimientos sobre la Gripe en el PS. Un número importante del personal sanitario, desconoce aspectos relevantes acerca de la Gripe

BACKGROUND: The objective of this work is to know the level knowledge on Influenza and its determinants on health personnel (HP). METHODS: Observational study, in which it included the PS that was vaccinated of the influenza in season 2011-12, and complimented a of 10 questions. Suitable level of knowledge, which was considered when well, answered five or more questions. For quantify the magnitude of the association was calculated Odds Ratio with its 95% CI. RESULTS: 634 HP surveyed them. 75.7% had a suitable level f knowledge. Having less than 4 years, OR: 3,3 (2,1-5,2), be physicians or nursing, OR: 4,1 (2,3-7,3) and OR: 3,1 (1,8-5,3) respectively, they were associated with having an suitable level of knowledge. Conclusions,: the age and the professional category are the variables that are associated of independent way, with the level of knowledge on Influenza in the HW. A significant number of health workers not known about important aspects of influenza

Brote nosocomial de gripe A en un hospital de tercer nivel / Nosocomial influenza outbreak in a tertiary hospital

Objetivo: Describir un brote nosocomial de gripe A. Material y métodos: Se describe el Servicio de Medicina Digestiva donde aparecieron los casos. A los pacientes ingresados (n=47), entre el 17 de febrero y el 10 de marzo de 2012, se les realizó una encuesta epidemiológica, y a partir de esta, se describen sus características clínico-epidemiológicas (motivo de ingreso, días de hospitalización hasta el inicio de los síntomas, etc.) de los casos de gripe. Se evaluó la cobertura vacunal y la presencia de sintomatología respiratoria entre el personal sanitario (n=44), y se describen las medidas de control de infecciones puestas en marcha. Resultados: Hubo 10 pacientes con sospecha de gripe (seis de ellos confirmados) y 12 profesionales sanitarios con sospecha (dos confirmados). La cobertura vacunal en el personal sanitario de la unidad era del 18,2% (8/44). Conclusión: Se ha producido una asociación temporo-espacial de casos de gripe de adquisición nosocomial, donde la baja cobertura de la vacunación antigripal y la escasa adherencia a las Precauciones Estándar por parte del personal sanitario han podido ser factores determinantes para su aparición

Objective: Describe a nosocomial flu outbreak. Material and methods: The Service of Digestive Medicine where cases appeared is here described. Patients admitted (n=47) between February 17 and March 10, 2012 an epidemiological survey was does to each of them, obtaining their clinical and epidemiological characteristics (entry reason number of hospitalization days until the beginning of the symptoms, etc.) of the influenza cases. The vacunal coverage and the presence of respiratory symptoms in the health personnel were evaluated (n- 44). Moreover, the descriptions of all the infectious diseases control measures that were initiated are also described. Results: There were 10 patients (six of them confirmed) and 12 health professionals (two of them confirmed) with flu suspicion. The vaccination coverage in the health care workers of the unit was 18, 2% (8/44). Conclusions: An association was established between those cases of nosocomial influenza and the low influenza vaccination coverage of healthcare workers, which also had poor adherence to Standard Precautions. This may have been decisive risk factors for the emergence of this nosocomial outbreak of influenza

Catheter-related bloodstream infection: burden of disease in a tertiary hospital.

BACKGROUND: Surveillance programmes have become the most effective tool for controlling catheter-related bloodstream infections (CRBSI). However, few studies have investigated programmes covering all hospital settings. AIM: To describe the results of a control and prevention programme for CRBSI based on compliance with recommendations for insertion and maintenance, using annual burden of disease in a tertiary level hospital. METHODS: A CRBSI control and prevention programme involving all hospital settings was implemented. The programme consisted of CRBSI surveillance, direct observation of insertion and maintenance of catheters to determine performance, and education for healthcare workers. FINDINGS: In total, 2043 short-term catheters were inserted in 1546 patients for 18,570 catheter-days, and 279 long-term catheters were inserted in 243 patients for 40,440 catheter-days. The annual incidence density was 5.98 (first semester 6.40, second semester 5.64) CRBSI per 1000 catheter-days for short-term catheters, and 0.57 (first semester 0.66, second semester 0.43) CRBSI per 1000 catheter-days for long-term catheters. One hundred and forty insertion procedures were observed, with an average insertion time of 13 (standard deviation 7) min. Compliance with recommendations was as follows: hand hygiene, 86.8%; use of alcoholic chlorhexidine solution for skin disinfection, 35.5%; use of mask, 93.4%; use of gloves, 98.7%; use of gown, 75.0%; use of sterile cloth, 93.8%; use of cap, 92.2%; bandage application, 62.7%; and use of aseptic technique, 89.5%. Forty-five maintenance procedures were observed, and compliance rates were as follows: hand hygiene, 42.1%; use of gloves, 78.1%; and port disinfection with alcoholic chlorhexidine solution, 32.5%. CONCLUSION: The CRBSI control and prevention programme implemented at the study hospital has decreased the rate of CRBSI, provided important information about the total burden of disease, and revealed possible ways to improve interventions in the future.

Higiene de manos en urgencias: grado de cumplimiento, determinantes y su evolucion en el tiempo / Hand hygiene in the emergency department: degree of compliance, predictors and change over time

Objetivo: Conocer el grado de cumplimiento (GC) de la higiene de manos (HM), sus factores determinantes y su evolución en el tiempo en un servicio de urgencias (SU). Método: Estudio transversal desarrollado entre 2005 y 2010 en el SU del Hospital General Universitario de Alicante. Un observador evaluó la realización de la HM según los 5 momentos de la Organización Mundial de la Salud (OMS). El estudio de asociación entre las variables explicativas (edad, sexo, disponer de solución alcohólica en formato de bolsillo, asistencia a sesiones formativas, conocer (..) (AU)

Objective: To determine the degree of compliance with hand hygiene measures, predictors, and change over time in an emergency department. Methods: Cross-sectional study between 2005 and 2010 in the emergency department of Hospital General Universitario de Alicante, Spain. An observer assessed staff compliance with the World Health Organization's 5-moments approach to hand hygiene. We also studied the association between compliance and such potential predictors as age, sex, availability of pocket-sized alcohol hand rubs, and attendance at training sessions; the Χ² test was used to compare compliance between the 2005-2007 and 2008-2010 periods. A multivariate logistic regression model was then constructed. Results: Compliance was observed in 41.1% in the 2005-2007 period and 42.3% in the 2008-2010 period. Hygiene at the moment before touching a patient improved significantly (16.3% in 2005-2007 and 29.8% in 2008-2010). The moment of best compliance was after touching patient surroundings (67.1% in 2008-2010). Factors associated with hand hygiene compliance changed over time with the exception of a stable association in both periods between hygiene at the moment before touching a patient and the availability of pocket-sized alcohol hand rubs. Conclusions: Emergency departments should seek improvements in hygiene by providing training on the importance of hand hygiene before a patient is touched, particularly before clean/aseptic procedures, and by promoting the use of pocket-sized alcohol rubs (AU)

Satisfacción de los pacientes atendidos en una consulta externa de medicina preventiva / Patient and caregiver satisfaction with rehabilitation services after stroke

ObjetivoEvaluar la satisfacción con el programa rehabilitador del ictus de pacientes y cuidadores. Identificar los factores dependientes del propio paciente y del proceso asistencial relacionados con mayor insatisfacción en nuestra área.Material y métodosEstudio transversal en 74 pacientes ingresados en Rehabilitación con el diagnóstico de ictus (el 70,3% eran varones, con edad media de 65,4±12,2, índice de Barthel al alta de 70,5±27) desde junio de 2005 hasta junio de 2006. La satisfacción con la rehabilitación seguida durante el ingreso y el soporte al alta hospitalaria se evaluaron mediante el cuestionario de satisfacción de Pound, administrado telefónicamente 13 meses de media después del alta hospitalaria. Se entrevistó a 85 cuidadores, de los que el 71% era familiar directo (cónyuge o relación filial) y el 80,9% era de sexo femenino.ResultadosEl 52,9% de los pacientes cumplimentó el cuestionario: más del 80% refirió estar completamente satisfecho con el trato y la información recibidos durante el ingreso. En cuanto al tratamiento, el 52,7% se mostró satisfecho; la cantidad de tratamiento recibido fue el aspecto peor valorado. La menor satisfacción correspondió al soporte recibido tras el alta hospitalaria, con menos del 25% de satisfechos. Un 83,1% de cuidadores cumplimentó el cuestionario: el 74,1% estaba satisfecho con la información recibida, el 63,5% con la formación sobre el tratamiento del paciente y el 42,4% con el soporte al alta. Sólo la depresión y el tiempo de evolución tras el ictus se relacionaron con mayor insatisfacción (p<0,05).ConclusionesAunque la satisfacción de pacientes y cuidadores con la información recibida es alta, se detectan elevados porcentajes de insatisfacción con la cantidad de tratamiento recibido y el soporte social al alta hospitalaria, por lo que es necesario incluir medidas sistemáticas de información, formación y soporte al alta en el programa de rehabilitación del ictus(AU)

ObjectivesTo assess patient and caregiver satisfaction with the regular rehabilitation care after stroke. To identify patient features or aspects of the rehabilitation programme related to lower rates of satisfaction in our area.Material and methodsCross-sectional study of 74 stroke in-patients admitted from June 2005 to June 2006 (70.3% men, age 65.4±12.2 years, Barthel discharge 70.5±27). A telephone Satisfaction questionnaire (Pound 1999) was administered at 13.6±3.1 months to assess satisfaction regarding in-patient care, therapy and recovery, and services after hospital discharge. Three items addressed to caregiver satisfaction were also included. A total of 84 caregivers were identified: 71% relatives (partner or children), of which 80.9% were women.ResultsThe satisfaction questionnaire was completed by 52.9% of patients. Over 80% of interviewed patients were completely satisfied with in-patient care, and 52.7% were satisfied with therapy and recovery during admission, but more patients were dissatisfied with the amount of therapy received. The lowest rate of satisfaction was related to the services after discharge, with less than 25% of patients satisfied. A total of 83.1% of caregivers completed the questionnaire, of which 74.1% were satisfied with the information provided. Stroke educational training was given to 63.5% of caregivers, and 42.4% were given support after discharge. Only the presence of depression during admission and time passed after stroke were significantly related to patient satisfaction. (p<0.05).ConclusionsDissatisfaction with some aspects of stroke rehabilitation is considerable in our care area. Despite general patient and caregiver satisfaction regarding information provided, high dissatisfaction rates are also detected related to the amount of therapy and the social support provided after hospital discharge...(AU)

Resultados de un programa de prevención de exposiciones accidentales a fluidos biológicos en personal sanitario basado en la mejora del grado de cumplimiento de las precauciones estándar / Results of a program of prevention of accidental exposure to biological fluids in healthcare workers based on the improvement of the compliance of Standard Precautions

Objetivo: Evaluar un programa de prevención de exposiciones accidentales a fluidos biológicos basado en la mejora del grado de cumplimiento (GC) de las Precauciones Estándar (PE). Material y métodos: Intervenciones: primera (realización sesiones de actualización y reparto de trípticos informativos), y segunda (reparto de trípticos). Indicadores: Nivel de Conocimientos (NC), medido con un cuestionario de cinco preguntas, se consideró inadecuado cuando se fallaban tres o más preguntas; GC de PE medido en cuatro áreas (Higiene Manos -HM-, utilización de guantes -UG-, utilización adecuada métodos barrera -UAMB- y manejo adecuado objetos cortantes -MAOC-; Incidencia de inoculaciones y de exposiciones de mucosas a fluidos corporales. Resultados. La frecuencia de cuestionarios inadecuados paso del 54,6% al 23,3%(<0.001). La frecuencia HM pasó del 53,5% al 58,2%(<0,01), la UG del 78,7% al 84,6%(0,058), el UAMB del 53,8% al 55.5%(N.S.) y el MAOC del 52,9% al 54,0%(N.S.). La Incidencia inoculaciones paso del 5,53% al 4,98%(N.S.) y las exposiciones de mucosas del 0,95% al 0,81%(N.S.). Conclusiones: El programa ha mejorado los conocimientos del personal sobre PE, y el GC de PE y ha disminuido la incidencia exposiciones accidentales a fluidos biológicos aunque no de manera estadísticamente significativa (AU)

Introduction: The aim is to evaluate a program of prevention of accidental exposure to biological fluids based on the improvement of the compliance to Standard Precautions (SP). Methods: Interventions: first (update sessions and distributing pamphlets), and second (distributing pamphlets). Indicators: Level of knowledge (LK), measured with a 5-item questionnaire, with three or more incorrect answers considered inadequate; Compliance to SP measured in four areas (Hand Hygiene Hands -HH-, utilization of gloves - GU-, suitable utilization methods barrier - SUMB - and suitable managing cutting objects - SMCO-; Incident of percutaneus injuries and of exposure of mucous to corporal fluids. Results: The frequency of inadequate questionnaires I happen from 54,6 % to 23,3 % (<0.001). The frequency HH happened from 53,5 % to 58,2 % (<0,01), the GU of 78,7 % to 84,6 % (0,058), the SUMB of 53,8 % to 55.5 % (N.S.) and the SMCO of 52,9 % to 54,0 % (N.S.). The Incident percutaneus injuries from 5,53 % to 4,98 % (N.S.) and the exposure of mucous from 0,95 % to 0,81 % (N.S.). Conclusion: The program has improved in the knowledge of the personnel on SP, and has improved SP compliance and the Incident has diminished accidental exhibitions to biological fluids though not in a statistically significant way (AU)

[Satisfaction among patients attending outpatient preventive medicine clinic]. / Satisfacción de los pacientes atendidos en una consulta externa de medicina preventiva.

INTRODUCTION: To evaluate satisfaction among patients attending the outpatient clinics of a Preventive Medicine Department and to identify any problems with the care they receive. MATERIAL AND METHODS: We performed a cross-sectional study in outpatient clinics of the Preventive Medicine Department, at Hospital General Universitario in Alicante, during January 2009. A questionnaire was given to all patients after their visit. Patients were satisfied if the final score was > or = 8. Socio-demographic variables were: age, sex, educational level, marital status and type of user (external or internal). chi(2) were used to study the association between these variables and satisfaction. RESULTS: The response rate was 84.4% (119/141), 94.1% were correctly completed (112/119), and 82.1% had a final score of > or = 8. The worst aspects were: comfort of waiting room, signs and wait time (percentage dissatisfied: 54.5%, 46.4% and 30.4%, respectively). The rest of the items obtained the following satisfaction percentages: medical treatment (97.3%), privacy of care (95.5%), information received (93.7%), easy next appointment (93.7%), visit length (92.9%), clarity of information (92.9%), to arrange the first appointment (90.2%), nursing treatment (87.5%), time to date of appointment (81.2%). Educational level was the only variable significantly associated with satisfaction. CONCLUSIONS: General satisfaction was good, although aspects like waiting time and signs could be better, if changes were made to management of appointments and the signs in the Hospital Department were increased.

Evaluación de un programa de actualización de las recomendaciones sobre la higiene de manos / Evaluation of a program for updating recommendations about hand hygiene

Introducción. La higiene de manos (HM) es la medida más importante para prevenir las infecciones nosocomiales. El objetivo es evaluar el programa de actualización de las recomendaciones sobre HM implantado. Material y métodos. Intervenciones: marzo-octubre/2005 se realizaron sesiones de actualización sobre cuándo y cómo realizar la HM y mayo/2006 se repartió un tríptico explicativo a todos los trabajadores informando del grado de cumplimiento de las recomendaciones. Indicadores: nivel conocimientos (NC) medido con un cuestionario de cinco preguntas que se pasaba antes y después de las sesiones y se consideró respuesta inadecuada cuando se fallaban tres o más preguntas; el consumo soluciones alcohólicas (CSA) en ml/estancia agrupado en semestres desde 2004-2006; el grado cumplimiento de recomendaciones (GCR) sobre la HM medida por observación directa en dos momentos (diciembre/2005-febrero/2006 y octubre-noviembre/ 2006) y la prevalencia de infecciones nosocomiales (PI) y de pacientes con infección nosocomial (PPI) a partir estudios EPINE 2004-2005-2006. Resultados. La frecuencia de respuestas inadecuadas para evaluar NC pasó de un 57,5% antes a 18,9% después (p<0,001). El CSA para HM pasó de 3 ml/estancia en 2º semestre/2004 a 17 ml/estancia en 2º semestre/2006 (p<0,001). El GCR ha pasado del 31,0% al 55,6% (p<0,001). La PI y PPI han pasado del 11,4% y el 9,6% respectivamente en el 2004 al 9,4% y 8,9% en 2006 (N.S.). Conclusión. El programa está consiguiendo de manera progresiva sus objetivos ya que los tres indicadores de proceso (NC, CSA, GC) han mejorado de manera estadísticamente significativa, y los de resultado (PI y PPI) han mejorado aunque sin significación estadística

Background. Hand Hygiene (HH) is the most important measure in the prevention of nosocomial infections. The objective was to evaluate the program for updating recommendations on HH that had been introduced. Methods. Interventions: between March-October/2005 realisation of updating sessions about when and how to realize HH and May/2006 distribution of an explicative three-part document to all healthcare workers reporting on compliance with the recommendations. Indicators: level of knowledge (LK) measured with a questionnaire of five questions that was given to those attending before and after sessions, responses were considered inadequate when three or more questions were not answered; consumption of alcoholic solutions (CAS) on ml/stay grouped into semesters from 2004-2006; compliance (CO) with recommendations on HH was measured by direct observation at two times (December/2005-February/2006 and October- November/2006); and infections prevalence (IP) and patients with infection (IPP) for EPINE studies 2004-2005-2006. Results. The frequency of inadequate answers for evaluating LK has fallen from 57,5% before to 18,9% afterwards (p <0.001). The CAS for HH has passed from 3 ml/stay in 2nd semester/2004 to 17 ml/stay 2nd semester/2006 (p <0.001). The CO with HH has risen from 31,0% to 55,6% (p <0.001). The IP and IPP have risen respectively from 11,4% and 9,6% in 2004 to 9,4% and 8,9% in 2006 (N.S.). Conclusion. The program is progressively achieving its objectives as the three process indicators (LK, CAS, CO) have improved in a statistically significant way, and the indicators of results (IP and IPP) have improved but without achieving statistical significance

Vacunas e iconografía / No disponible

Mucho antes de que el médico inglés Edward Jenner descubriera la vacuna antivariólica ya se utilizaba de forma empírica algún método mediante el cual se padecía de forma atenuada la enfermedad y se lograba la inmunización frente a la misma. Este método, sin embargo, no estaba exento de complicaciones, que en ocasiones revestían importante gravedad, lo que contribuyó a que no lograra gran aceptación. Además de la viruela, revisamos desde una perspectiva histórica la rabia, la poliomielitis, la fiebre tifoidea y paratifoidea, la difteria y el tétanos, incluyendo cierta iconografía alusiva a estas enfermedades, sus vacunas o figuras o instituciones relacionadas con las mismas (AU)

There was some kind of method used in an empiric way that helped to suffer the small pot disease in a milder way long before the English physician E. Jenner were to discover the vaccine. This method also achieved immunity against the disease. The method was not exempt to complications, however. Sometimes these complications were serious enough as to compromise the general acceptance of the method. Besides the smallpox, we do a historic revision of rage, poliomyelitis, typhoid and partyphoid fever, as well as, that of diphtheria and tetanus. We include an iconography regarding these diseases, its vaccines and persons and institutions relate to then (AU)

[Evaluation of a program for updating recommendations about hand hygiene]. / Evaluación de un programa de actualización de las recomendaciones sobre la higiene de manos.

BACKGROUND: Hand Hygiene (HH) is the most important measure in the prevention of nosocomial infections. The objective was to evaluate the program for updating recommendations on HH that had been introduced. INTERVENTIONS: between March-October/2005 realisation of updating sessions about when and how to realize HH and May/2006 distribution of an explicative three-part document to all healthcare workers reporting on compliance with the recommendations. Indicators: level of knowledge (LK) measured with a questionnaire of five questions that was given to those attending before and after sessions, responses were considered inadequate when three or more questions were not answered; consumption of alcoholic solutions (CAS) on ml/stay grouped into semesters from 2004-2006; compliance (CO) with recommendations on HH was measured by direct observation at two times (December/2005-February/2006 and October-November/2006); and infections prevalence (IP) and patients with infection (IPP) for EPINE studies 2004-2005-2006. RESULTS: The frequency of inadequate answers for evaluating LK has fallen from 57.5% before to 18.9% afterwards (p <0.001). The CAS for HH has passed from 3 ml/stay in 2nd semester/2004 to 17 ml/stay 2nd semester/2006 (p <0.001). The CO with HH has risen from 31.0% to 55.6% (p <0.001). The IP and IPP have risen respectively from 11.4% and 9.6% in 2004 to 9.4% and 8.9% in 2006 (N.S.). CONCLUSION: The program is progressively achieving its objectives as the three process indicators (LK, CAS, CO) have improved in a statistically significant way, and the indicators of results (IP and IPP) have improved but without achieving statistical significance.