[Argentine Consensus in effective management of anticoagulation clinics for the use of vitamin k antagonists]. / Consenso Argentino en gestión efectiva de clínicas de anticoagulación para el uso de antagonistas de la vitamina k.

Treating an anticoagulated patient with vitamin K antagonists (VKA) remains a challenge, especially in areas where dicoumarins are still the first drug of choice due to the cost of other oral anticoagulants. Anticoagulation clinics have proven to be the most efficient and safe way to avoid thrombotic and hemorrhagic complications and to keep patients in optimal treatment range. However, they require adequate infrastructure and trained personnel to work properly. In this Argentine consensus we propose a series of guidelines for the effective management of the anticoagulation clinics. The goal is to achieve the excellence in both the clinical healthcare and the hemostasis laboratory for the anticoagulated patient. The criteria developed in the document were agreed upon by a large group of expert specialists in hematology and biochemistry from all over the country. The criteria presented here must always be considered when indicating VKA although they had to be adapted to the unequal reality of each center. Taking these premises into consideration will allow us to optimize the management of the anticoagulated patient with VKA and thus minimize thrombotic and hemorrhagic intercurrences, in order to honor our promise not to harm the patient.

El tratamiento de un paciente anticoagulado con antagonistas de la vitamina K (AVK) sigue siendo un desafío, especialmente en regiones donde, por el costo, los dicumarínicos son todavía la alternativa más buscada a la hora de elegir un anticoagulante oral. Las clínicas de anticoagulación han demostrado ser la forma más eficiente y segura de evitar complicaciones trombóticas y hemorrágicas y de mantener al paciente en rango óptimo de tratamiento. Sin embargo, requieren de una adecuada infraestructura y personal capacitado para que funcionen eficientemente. En este consenso argentino se propone una serie de parámetros para la gestión efectiva de una clínica de anticoagulación. El objetivo es lograr una elevada calidad desde el punto de vista clínico-asistencial a través de un laboratorio de hemostasia de excelencia. Los criterios desarrollados en el documento fueron consensuados por un amplio grupo de expertos especialistas en hematología y en bioquímica de todo el país. Estos criterios deben adaptarse a la irregular disponibilidad de recursos de cada centro, pero siempre se los debe tener en cuenta a la hora de indicar el tratamiento anticoagulante con estas drogas. Tener en consideración estas premisas nos permitirá optimizar la atención del enfermo anticoagulado con AVK y de esta forma minimizar las intercurrencias trombóticas y hemorrágicas a las que está expuesto, para así honrar nuestra promesa de no dañar al paciente.

Consenso argentino en gestión efectiva de clínicas de anticoagulación para uso de antagonistas de la vitamina K / Argentine consensus in effective management of anticoagulation clinics for the use of vitamin K antagonists

Resumen El tratamiento de un paciente anticoagulado con antagonistas de la vitamina K (AVK) sigue siendo un desafío, especialmente en regiones donde, por el costo, los dicumarínicos son todavía la alternativa más buscada a la hora de elegir un anticoagulante oral. Las clínicas de anticoagulación han demostrado ser la forma más eficiente y segura de evitar complicaciones trombóticas y hemorrágicas y de mantener al paciente en rango óptimo de tratamiento. Sin embargo, requieren de una adecuada infraestructura y personal capacitado para que funcionen eficientemente. En este consenso argentino se propone una serie de parámetros para la gestión efectiva de una clínica de anticoagulación. El objetivo es lograr una elevada calidad desde el punto de vista clínico-asistencial a través de un laboratorio de hemostasia de excelencia. Los criterios desarrollados en el documento fueron consensuados por un amplio grupo de expertos especialistas en hematología y en bioquímica de todo el país. Estos criterios deben adaptarse a la irregular disponibilidad de recursos de cada centro, pero siempre se los debe tener en cuenta a la hora de indicar el tratamiento anticoagulante con estas drogas. Tener en consideración estas premisas nos permitirá optimizar la atención del enfermo anticoagulado con AVK y de esta forma minimizar las intercurrencias trombóticas y hemorrágicas a las que está expuesto, para así honrar nuestra promesa de no dañar al paciente.

Abstract Treating an anticoagulated patient with vitamin K antagonists (VKA) remains a challenge, especially in areas where dicoumarins are still the first drug of choice due to the cost of other oral anticoagulants. Anticoagulation clinics have proven to be the most efficient and safe way to avoid thrombotic and hemorrhagic complications and to keep patients in optimal treatment range. However, they require adequate infrastructure and trained personnel to work properly. In this Argentine consensus we propose a series of guidelines for the effective management of the anticoagulation clinics. The goal is to achieve the excellence in both the clinical healthcare and the hemostasis laboratory for the anticoagulated patient. The criteria developed in the document were agreed upon by a large group of expert specialists in hematology and biochemistry from all over the country. The criteria presented here must always be considered when indicating VKA although they had to be adapted to the unequal reality of each center. Taking these premises into consideration will allow us to optimize the management of the anticoagulated patient with VKA and thus minimize thrombotic and hemorrhagic intercurrences, in order to honor our promise not to harm the patient.

Documentation of the nursing process in public health institutions. / Documentação do processo de enfermagem em instituições públicas de saúde.

OBJECTIVE: To identify the prevalence of nursing process documentation in hospitals and outpatient clinics administered by the São Paulo State Department of Health. METHOD: A descriptive study conducted through interviews with nurses responsible for 416 sectors of 40 institutions on the documentation of four phases of the Nursing Process (data collection, diagnosis, prescription and evaluation) and nursing annotations. RESULTS: Of the 416 sectors studied, 89.9% documented at least one phase; 56.0% documented the four phases; 4.3% only documented nursing annotations; 5.8% did not document any phase, nor did the nursing notes. The types of sectors which were less documented were: ambulatory, diagnostic support, surgical center and obstetric center; while the ones which were most documented included: intensive care units, emergency rooms and hospitalization units. The data collection and diagnosis were the least documented phases, both in 78.8% of the sectors. CONCLUSION: Most of the studied sectors document the Nursing Process and do nursing annotations, but there are sectors where documentation does not meet formal requirements. The viability of documentation of all the Nursing Process phases in certain types of sectors needs to be better studied.

Socioeconomic profile and degree of satisfaction of patients attending Gastroenterology Outpatient Clinics of a University Institution.

OBJECTIVE: To evaluate the degree of satisfaction and the socioeconomic profile of patients attending Gastroenterology Outpatient Clinics at a University institution linked to the Brazilian Unified Health System. METHOD: A researcher-administered questionnaire was applied during a structured interview in outpatient clinics. RESULTS: Two hundred and forty (240) patients were included in the study (mean age of 53 years, 55% women). About 30% of the patients had incomplete elementary education, 25% had complete secondary education, and 53% were active workers. Approximately 87% attending the outpatient clinics were from the B2, C1 and C2 socioeconomic classes with an estimated family income of USD$275.00 to USD$825.00/month. Ninety-two percent (92%) of patients were satisfied with the care received; the items associated with a lower degree of satisfaction were facilities/comfort, cleanliness, and waiting time for consultation. No relationship was observed between socioeconomic profile and degree of satisfaction. CONCLUSION: Satisfaction surveys are important to identify opportunities for improving healthcare services, and it is incumbent upon managers, health professionals and even users to promote compliance with laws and decrees that seek to improve healthcare.

State Law Approaches to Facility Regulation of Abortion and Other Office Interventions.

OBJECTIVES: To compare the prevalence and characteristics of facility laws governing abortion provision specifically (targeted regulation of abortion providers [TRAP] laws); office-based surgeries, procedures, sedation or anesthesia (office interventions) generally (OBS laws); and other procedures specifically. METHODS: We conducted cross-sectional legal assessments of state facility laws for office interventions in effect as of August 1, 2016. We coded characteristics for each law and compared characteristics across categories of laws. RESULTS: TRAP laws (n = 55; in 34 states) were more prevalent than OBS laws (n = 25; in 25 states) or laws targeting other procedures (n = 1; in 1 state). TRAP laws often regulated facilities that would not be regulated under OBS laws (e.g., all TRAP laws, but only 2 OBS laws, applied regardless of sedation or anesthesia used). TRAP laws imposed more numerous and more stringent requirements than OBS laws. CONCLUSIONS: Many states regulate abortion-providing facilities differently, and more stringently, than facilities providing other office interventions. The Supreme Court's 2016 decision in Whole Woman's Health v Hellerstedt casts doubt on the legitimacy of that differential treatment.

Do mobile clinics provide high-quality antenatal care? A comparison of care delivery, knowledge outcomes and perception of quality of care between fixed and mobile clinics in central Haiti.

BACKGROUND: Antenatal care (ANC) is an important health service for women in developing countries, with numerous proven benefits. Global coverage of ANC has steadily increased over the past 30 years, in part due to increased community-based outreach. However, commensurate improvements in health outcomes such as reductions in the prevalence of maternal anemia and infants born small-for-gestational age have not been achieved, even with increased coverage, indicating that quality of care may be inadequate. Mobile clinics are one community-based strategy used to further improve coverage of ANC, but their quality of care delivery has rarely been evaluated. METHODS: To determine the quality of care of ANC in central Haiti, we compared adherence to national guidelines between fixed and mobile clinics by performing direct observations of antenatal care consultations and exit interviews with recipients of care using a multi-stage random sampling procedure. Outcome variables were eight components of care, and women's knowledge and perception of care quality. RESULTS: There were significant differences in the predicted proportion or probability of recommended services for four of eight care components, including intake, laboratory examinations, infection control, and supplies, iron folic acid supplements and Tetanus Toxoid vaccine provided to women. These care components were more likely performed in fixed clinics, except for distribution of supplies, iron-folic acid supplements, and Tetanus Toxoid vaccine, more likely provided in mobile clinics. There were no differences between clinic type for the proportion of total physical exam procedures performed, health and communication messages delivered, provider communication or documentation. Women's knowledge about educational topics was poor, but women perceived extremely high quality of care in both clinic models. CONCLUSIONS: Although adherence to guidelines differed by clinic type for half of the care components, both clinics had a low percentage of overall services delivered. Efforts to improve provider performance and quality are therefore needed in both models. Mobile clinics must deliver high-quality ANC to improve health and nutrition outcomes.

Evaluation of Primary Health Care Units in the Rio De Janeiro City According to the Results of PMAQ 2012.

To assess the quality of the primary health care network, the Ministry of Health created the Program for Improving Access and Quality in Primary Care (PMAQ), a national evaluation of family health teams. Thus, this study aims to present the geolocation of PMAQ 2012 quality indicators in the city of Rio de Janeiro. The PMAQ data show that, in the city of Rio de Janeiro, 65% of the teams achieved the performances "good" or "excellent," 34.7% "regular," and 0.3% "unsatisfactory." The results show a clear PMAQ polarization between teams units classified as optimal and regular in program areas 5 and 3, respectively.

Low Compliance of Urgent Care Centers in the United States With Recommendations for Office-Based Disaster Preparedness.

OBJECTIVES: The aim of the study was to determine the compliance of urgent care centers in the United States with published recommendations for office-based disaster preparedness. METHODS: An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory. RESULTS: One hundred twenty-two questionnaires of the 872 distributed were available for analysis (14% usable response rate). Twenty-seven percent of centers have an established disaster plan for events that involve their establishment and surrounding community; 49% practice the plan at least once a year, 19% less frequent than once a year, and 32% never practice. Forty-seven percent of centers are familiar with designated emergency shelters and community evacuation plans. Seventeen percent of centers function as part of a surveillance system to provide early detection of any biologic/chemical/nuclear agents. Twenty-two percent of centers take part in local community and hospital disaster planning, exercises, and drills through emergency medical services and public health systems. Five percent of centers aid schools, child care centers, camps, and other child congregate facilities in disaster planning. Twenty-eight percent of centers have an assembled emergency/disaster kit, containing such items as water, first aid supplies, radios, flashlights, batteries, heavy-duty gloves, food, and sanitation supplies. CONCLUSIONS: Areas for improvement in urgent care center disaster preparedness were identified, such as developing an office disaster plan that is practiced at least yearly, becoming familiar with designated emergency shelters and community evacuation plans, providing surveillance to detect potential acts of terrorism, assisting community organizations (hospitals, schools, child care centers, etc) in disaster planning, and assembling office emergency/disaster kits.

Pediatric Care Provided at Urgent Care Centers in the United States: Compliance With Recommendations for Emergency Preparedness.

OBJECTIVES: To describe the compliance of urgent care centers in the United States with pediatric care recommendations for emergency preparedness as set forth by the American Academy of Pediatrics. METHODS: An electronic questionnaire was distributed to urgent care center administrators as identified by the American Academy of Urgent Care Medicine directory. RESULTS: A total of 122 questionnaires of the 872 distributed were available for analysis (14% usable response rate). The most common diagnoses reported for pediatric patients included otitis media (72%), upper respiratory illness (69%), strep pharyngitis (61%), bronchiolitis (30%), and extremity sprain/strain (28%). Seventy-one percent of centers have contacted community emergency medical services (EMS) to transport a critically ill or injured child to their local emergency department in the past year. Sixty-two percent of centers reported having an established written protocol with community EMS and 54% with their local emergency department or hospital. Centers reported the availability of the following essential medications and equipment: oxygen source (75%), nebulized/inhaled ß-agonist (95%), intravenous epinephrine (88%), oxygen masks/nasal cannula (89%), bag-valve-mask resuscitator (81%), suctioning device (60%), and automated external defibrillator (80%). Centers reported the presence of the following written emergency plans: respiratory distress (40%), seizures (67%), dehydration/shock (69%), head injury (59%), neck injury (67%), significant fracture (69%), and blunt chest or abdominal injury (81%). Forty-seven percent of centers conduct formal reviews of emergent or difficult cases in a quality improvement format. CONCLUSIONS: Areas for improvement in urgent care center preparedness were identified, such as increasing the availability of essential medications and equipment, establishing transfer and transport agreements with local hospitals and community EMS, and ensuring a structured quality improvement program.

Same Physician, Different Location, Different Patient Satisfaction Scores.

STUDY OBJECTIVE: We assess whether patient satisfaction scores differ for individual emergency physicians according to the clinical setting in which patients are treated. METHODS: We obtained Press Ganey satisfaction survey results from June 2013 to August 2014 for patients treated in either an urban hospital emergency department (ED) or 2 affiliated suburban urgent care centers. The same physicians work in all 3 facilities. Physicians with available survey results from at least 10 patients in both settings were included. Survey scores range from 1 (very poor) to 5 (very good). Survey questions directly assessed physicians' courtesy, ability to keep patients informed about their treatment, concern for patient comfort, listening ability, and the overall care at the facility. We calculated differences in mean urgent care and ED scores for individual physicians, along with the mean of these differences. Our primary outcome was the mean difference between urgent care and ED score with respect to physician courtesy. RESULTS: Seventeen physicians met inclusion criteria. For all 17 physicians, the point estimate for the mean urgent care courtesy score was higher than the point estimate for the mean ED courtesy score. The mean difference in courtesy scores between urgent care and the ED was 0.35 (95% confidence interval 0.22 to 0.49). ED scores were also consistently lower than urgent care scores for keeping patients informed about their treatment, concern for patient comfort, listening ability, and overall care rating. CONCLUSION: Although these results are limited by small sample size, we found that physicians consistently received lower satisfaction ratings from ED patients than from urgent care patients. This challenges the validity of using satisfaction scores to compare providers in different practice settings.

Postnatal and postabortion care during adolescence in the National Health System in Rio de Janeiro, Brazil.

OBJECTIVE: To study postnatal and postabortion outpatient care for adolescents in relation to the guidelines of the Brazilian Ministry of Health. METHODS: The present cross-sectional study was conducted between 2011 and 2012 via interviews with coordinators from 147 of 148 (99.3%) National Health System facilities providing sexual and reproductive healthcare for adolescents in the city of Rio de Janeiro, Brazil. The χ(2) test or Fisher exact test was used to compare ratios, and t test to compare means, with a significance level of 5% (P<0.05). RESULTS: Postnatal care was provided by 141 (95.9%) facilities; however, only 95 (67.4%) facilities complied with the guidelines of the Ministry of Health by providing two consultations: one in the first week and one between the 30th and 42nd day postpartum. In 32 (22.7%) facilities, a consultation was not scheduled in the first week; and in 25 (17.7%), a consultation between the 30th and 42nd day postpartum was not scheduled. Furthermore, only 11 (7.8%) facilities provided care in the age bracket recommended by WHO and the Brazilian Ministry of Health. CONCLUSION: The provision of puerperal care in the Brazilian National Health System is currently far from the recommendations in government guidelines.

Quality of travel health advice in a French travel medicine and vaccine center: a prospective observational study.

BACKGROUND: The number of international trips undertaken by French citizens is rising and we wished to assess the appropriateness of advices given to travelers in a vaccine and travel medicine center in France. METHODS: We conducted a 3-month prospective study in one center in Paris where prescriptions and advice to travelers are given by trained physicians in travel medicine who have access to a computerized decision support system (Edisan). A questionnaire was used to record trip characteristics, patients' demographics, and prescriptions. Main outcome measure was the adequacy of prescriptions for malaria prophylaxis, yellow fever, and hepatitis A vaccines to French guidelines. RESULTS: A total of 730 subjects were enrolled in this study, with a median age of 28 years. Travel destinations were sub-Saharan Africa (58%), Asia (21%), and South America (18%). Among the 608 patients (83%) traveling to malaria-endemic areas, malaria prophylaxis was in accordance with guidelines in 578/608 patients (95.1%, 95% CI: 93-96.5), and doxycycline was the regimen of choice (48%). Inappropriate malaria prophylaxis was given to eight patients, one of whom developed plasmodium falciparum malaria. All 413 patients (100%, 95% CI: 99-100) traveling to yellow fever-endemic areas who needed vaccination were correctly vaccinated. However, three patients received yellow fever vaccination without indication. Also, 442 of 454 patients (97.4%, 95% CI: 95.4-98.5) eligible to receive hepatitis A vaccination were immunized. CONCLUSION: Appropriate advice for malaria prophylaxis, yellow fever, and hepatitis A vaccinations was provided in a travel medicine and vaccine center where trained physicians used a computerized decision support system. Even in this setting, however, errors can occur and professional practices should be regularly assessed to improve health care.

Women's experiences with legal abortion in Mexico City: a qualitative study.

In April 2007, elective first-trimester abortion was legalized in Mexico City. As of June 2011, more than 60,000 women from Mexico City and other Mexican states have obtained legal abortions in the city's public hospitals and health centers, with private facilities providing additional abortion services. This study examines women's experiences of abortion services in one public and two private clinic settings in 2008. Twenty-five in-depth interviews were conducted: 15 with women who obtained abortions in a public health center and 10 who obtained the procedure at either of two private clinics. Participants were highly satisfied with services at both public and private sites, although some had to go to more than one site before receiving services. None expressed doubts about their decision to have an abortion, and they felt unanimously that they were treated with respect. Furthermore, participants were pleased with the counseling they received and most accepted a contraceptive method after the procedure.

Imaging facilities for basic medical units: a case in the state of Guerrero, Mexico.

This work presents the methodology to design a small imaging unit in a small regional hospital that takes into account the real imaging needs in the region regardless of current administrative guidelines. The situation of the imaging facilities in Mexico's states is studied and compared with other countries, and a project plan is designed for the specific state (Guerrero) where the clinic is to be located. The proposal includes the acquisition of a basic suite of modalities that include an ultrasound system, a mammography unit, and a conventional X-ray system in addition to a CT system that is not available anywhere within the state. The system should be primarily digital and should incorporate a simple picture archiving and communications system that can be the basis of a future telemedicine unit. The conclusion of this study also proposes changes in the segmented and pyramidal structure of the Mexican health system in order to provide higher quality care at the lower level, to reduce bottlenecks, and to provide higher quality health care near the patient's home.

[An evaluation of the characteristics, processes and outcomes of hemodialysis units in Mexico]. / Las unidades de hemodiálisis en México: una evaluación de sus características, procesos y resultados.

OBJECTIVE: To evaluate the characteristics, processes, outcomes and structure of a sample of hemodialysis units (HU) in Mexico. MATERIAL AND METHODS: Cross-sectional study in 83 public and private HU from the 32 states in Mexico. The HU were stratified, according to a score, in five categories: very good, good, regular, poor and very poor. RESULTS: 48% of the HU were classified as poor and very poor, and they granted medical attention to 58% of the patients. The average number of sessions per patient in the last six months assessed was 1.2 per week. 46.5% of the sessions with determination of Kt/V reported values inferior to the recommended value (Kt/ V≥1.2). 75% of the units scored less than 70% in infrastructure. CONCLUSIONS: Half of the HU did not fulfill the process and result criteria defined by the Consejo de Salubridad de la Secretaría de Salud.

Las unidades de hemodiálisis en México: una evaluación de sus características, procesos y resultados / An evaluation of the characteristics, processes and outcomes of hemodialysis units in Mexico

OBJETIVO. Evaluar las características, procesos y resultados, así como, la estructura de una muestra de unidades de hemodiálisis (UH) en México. Material y métodos. Estudio transversal en 83 UH públicas y privadas del país. Las UH fueron estratificadas, de acuerdo con el puntaje obtenido, en cinco categorías: muy buena, buena, regular, mala y muy mala. Resultados. El 48 por ciento de las UH se clasificaron en las categorías mala y muy mala y atendieron 58 por ciento de los pacientes. El promedio de sesiones/paciente en los seis meses evaluados fue de 1.2 por semana. El 46.5 por ciento de las sesiones con determinación de Kt/V reportaron valores inferiores al valor recomendado (Kt/V≥1.2). En infraestructura, tres cuartas partes de las unidades obtuvieron puntajes menores a 70 por ciento. Conclusiones. La mitad de las unidades de hemodiálisis no cumplieron los criterios de proceso y resultado establecidos por el Consejo de Salubridad de la Secretaría de Salud.

OBJECTIVE. To evaluate the characteristics, processes, outcomes and structure of a sample of hemodialysis units (HU) in Mexico. MATERIAL AND METHODS. Cross-sectional study in 83 public and private HU from the 32 states in Mexico. The HU were stratified, according to a score, in five categories: very good, good, regular, poor and very poor. RESULTS. 48 percent of the HU were classified as poor and very poor, and they granted medical attention to 58 percent of the patients. The average number of sessions per patient in the last six months assessed was 1.2 per week. 46.5 percent of the sessions with determination of Kt/V reported values inferior to the recommended value (Kt/ V≥1.2). 75 percent of the units scored less than 70 percent in infrastructure. CONCLUSIONS. Half of the HU did not fulfill the process and result criteria defined by the Consejo de Salubridad de la Secretaría de Salud.

Blood pressure measurement in different outpatient clinics.

The objective of this study is to investigate how blood pressure is measured in different outpatient clinics. This is a retrospective study performed with 1,000 patients, randomly selected among patients followed in different outpatient clinics in Fortaleza, Brazil. Among the 1,000 patients, 962 had available records. The older the patient, the greater the possibility of having had blood pressure measured. In subsequent visits, blood pressure was measured more often than in the first visits. Blood pressure was measured more often among patients with chronic disease. The specialty with the highest proportion of blood pressure measurement was cardiology (85%). At the surgery, dermatology and traumatology clinics, blood pressure was measured in less than 5% of visits, and at the ophthalmology, sexually transmitted diseases, psychiatry, proctology and otolaryngology clinics, blood pressure was not measured in any visit. Cardiology, endocrinology, nephrology, geriatrics and internal medicine were the specialties where blood pressure was more frequently measured. It is important to measure blood pressure in any medical specialty in order to give early diagnosis of hypertension and provide adequate blood pressure control.

Reproductive tourism in Argentina: clinic accreditation and its implications for consumers, health professionals and policy makers.

A subcategory of medical tourism, reproductive tourism has been the subject of much public and policy debate in recent years. Specific concerns include: the exploitation of individuals and communities, access to needed health care services, fair allocation of limited resources, and the quality and safety of services provided by private clinics. To date, the focus of attention has been on the thriving medical and reproductive tourism sectors in Asia and Eastern Europe; there has been much less consideration given to more recent 'players' in Latin America, notably fertility clinics in Chile, Brazil, Mexico and Argentina. In this paper, we examine the context-specific ethical and policy implications of private Argentinean fertility clinics that market reproductive services via the internet. Whether or not one agrees that reproductive services should be made available as consumer goods, the fact is that they are provided as such by private clinics around the world. We argue that basic national regulatory mechanisms are required in countries such as Argentina that are marketing fertility services to local and international publics. Specifically, regular oversight of all fertility clinics is essential to ensure that consumer information is accurate and that marketed services are safe and effective. It is in the best interests of consumers, health professionals and policy makers that the reproductive tourism industry adopts safe and responsible medical practices.