Reduction of hospital length of stay through the implementation of SAFER patient flow bundle and Red2Green days tool: a pre-post study.

BACKGROUND: In 2018, the National Health System released the 'Guide to reducing long hospital stays' to stimulate improvement and decrease length of stay (LOS) in England hospitals. The SAFER patient flow bundle and Red2Green tool were described as strategies to be implemented in inpatient wards to reduce discharge delays. OBJECTIVE: To verify if implementing the SAFER patient flow bundle and Red2Green days tool is associated with LOS reduction in the internal medicine unit (IMU) wards of a university hospital in Brazil. METHODS: In this pre post study, we compared the LOS of patients discharged from the IMU wards in 2019, during the implementation of the SAFER bundle and Red2Green tool, to the LOS of patients discharged in the same period in 2018. The Diagnosis-Related Group Brazil algorithm compared groups according to complexity and resource requirements. In-hospital mortality, readmission rates, the number of hospital acquired conditions and the number and causes of inappropriate hospital days were also evaluated. RESULTS: Two hundred and eight internal medicine patients were discharged in 2018, and 252 were discharged in 2019. The median hospital LOS was significantly lower during the intervention period (14.2 days (IQR, 8-23) vs 19 days (IQR, 12-32); p<0.001). In-hospital mortality, 30-day mortality, readmission in 30 days and the number of hospital acquired conditions were the same between groups. Of the 3350 patient days analysed, 1482 (44.2%) were classified as green and 1868 (55.8%) as red. The lack of senior review was the most frequent cause of a red day (42.4%). CONCLUSION: The SAFER patient flow bundle and Red2Green days tool implementation were associated with a significant decrease in hospital LOS in a university hospital IMU ward. There is a considerable improvement opportunity for hospital LOS reduction by changing the multidisciplinary team's attitude during patient hospitalisation using these strategies.

Combined diagnostic methods identify a remarkable proportion of asymptomatic Leishmania (Leishmania) chagasi carriers who present modulated cytokine profiles.

Peripheral blood samples of 138 co-habitants from 25 families with recently diagnosed cases of visceral leishmaniasis in the Metropolitan Region of Belo Horizonte, Minas Gerais, Brazil, were analyzed by indirect fluorescent antibody test (IFAT), rK39 and Leishmania chagasi Enzyme Linked Immunosorbent Assay (ELISA), intradermal skin-test and Polymerase Chain Reaction (PCR) over a 12-month period. The cumulative positivity was significantly higher by PCR (29.7%) than by IFAT, rK39 ELISA, L. chagasi ELISA and intradermal skin-test (5.1%, 6.5%, 14.5% and 2.9%, respectively). In addition, the cytokine profile was measured in 16 of the 138 volunteers, of whom eight were asymptomatic carriers and eight were non-infected co-habitants. The innate immunity cells from asymptomatic carriers displayed, upon in vitro antigenic stimulation, a modulated increase in cytokine synthesis that was distinct from that observed in non-infected volunteers. This study suggests that the identification of a large proportion of asymptomatic carriers is facilitated when more than one diagnostic method is applied and that a mixed pattern of immune response is correlated with clinical status of asymptomatic individuals. These observations suggest also that asymptomatic infection by L. chagasi is a frequent event and that control programs could benefit by including this indicator in their interventions.

Comparative evaluation of direct agglutination test, rK39 and soluble antigen ELISA and IFAT for the diagnosis of visceral leishmaniasis.

Five serological tests for the diagnosis of visceral leishmaniasis (VL) were compared: a direct agglutination test (DAT) based on freeze-dried antigen (DAT-fd); a locally produced DAT (DAT-LPC); an IgG ELISA against rK39 (ELISA-rK39); an IgG ELISA for Leishmania chagasi (ELISA-L. chagasi); and an IgG IFAT against L. chagasi. Serum samples from 88 patients with VL, 20 non-infected individuals and 85 patients with others infectious diseases were evaluated. The sensitivity rates were: DAT-fd, 96.6%; DAT-LPC, 95.5%; ELISA-rK39, 88.6%; ELISA-L. chagasi, 89.8%; and IFAT, 92.0% (P>0.05). The specificity for the control groups varied from 53.3% to 100%. DAT-fd had the highest efficiency (97.4%), followed by DAT-LPC (91.7%) and ELISA-rK39 (90.7%). Our data suggest that DAT-fd, DAT-LPC and ELISA-rK39 are useful tests for the diagnosis of VL and could replace IFAT as the routine diagnostic test in Brazil.

Factors associated with Schistosoma mansoni infection 5 years after selective treatment in a low endemic area in Brazil.

Five years after a single dose treatment, prevalence, intensity and morbidity of schistosomiasis mansoni were evaluated in Agua Branca, a low endemic community in the South East Brazil (cure rate 94%). At community level, prevalence showed a decrease from 38.9 to 24.5% and the intensity of infection dropped from 119.5 to 38.9 eggs per g of faeces (epg). However, after the exclusion of immigrants, newborn children and individuals that had left the area after the first evaluation, the prevalence among the treated and followed population was not significantly affected. Multivariate analysis showed that the 10-29 age group and water contact for agricultural purposes were independently associated with the presence of infection on post treatment evaluation [OR 3.9 and 5.09, respectively]. A previous treatment among subjects older than 15 years was inversely associated [OR 0.58]. The authors wish to draw attention to the fact that mobility may lead to a serious bias in evaluating the impact of the control programme.