京都大学 / 新制・課程博士 / 博士(医学) / 甲第24968号 / 医博第5022号 / 新制||医||1069(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 中山 健夫, 教授 佐藤 俊哉, 教授 江木 盛時 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

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A segurança do paciente grave é uma meta da qualidade do atendimento em Unidade de Terapia Intensiva (UTI), daí a necessidade de se investigar os fatores relacionados à ocorrência de eventos adversos nesse contexto. Trata-se este estudo de uma pesquisa quantitativa, retrospectiva, analítico-transversal que teve como objetivo analisar os fatores associados aos incidentes e/ou eventos adversos (INC/EA) no preparo e administração de medicamentos, nos cuidados com tubo endotraqueal/traqueostomia, sondas, drenos, cateteres e queda em UTI segundo as características demográficas e clínicas do paciente e recursos estruturais da Unidade. Os dados foram coletados por meio dos registros de INC/EA dos prontuários dos pacientes que tiveram notificado algum tipo de INC/EA no período de 2003 e 2006, inclusive, em cinco UTI de cinco hospitais do Município de São Paulo. No tratamento estatístico, foi utilizada a análise de regressão logística multivariada para a identificação dos fatores independentes de INC/EA e condições de saída da Unidade. Para a identificação dos fatores independentes do tempo de permanência nas UTI, utilizou-se a análise de regressão linear múltipla. As variáveis que entraram nos modelos foram aquelas que apresentaram na regressão logística univariada um valor de teste Wald<0,20; em todas as análises realizadas foi utilizado o nível de significância de 5%. Do total de 21.230 admissões nas UTI, 377 (1,78%) pacientes sofreram algum tipo de INC/EA. Foram notificadas 461 ocorrências, a maioria relacionada ao preparo e administração de medicamentos (196-42,51%), seguidas aos cateteres periféricos e arteriais (105-22,77%) e às sondas nasogástricas (73-15,83%). Quanto aos fatores associados aos INC/EA e recursos materiais/equipamentos e ambiente físico das unidades, o baixo número de ocorrências (16-2,82%) inviabilizou a análise dessas variáveis. Da mesma forma, nenhum hospital dispunha das escalas diárias de enfermagem com dados retrospectivos sobre os recursos humanos existentes no período do estudo. Verificou-se que o número de dias de permanência dos artefatos terapêuticos foi um dos principais fatores independentes associados aos INC/EA quer no preparo e administração de medicamentos (número de dias de TE/Traq.), quer nos cuidados com cateter periférico, sonda nasogástrica e cateter central (número de dias de artefatos terapêuticos), seguidos da gravidade e da não sobrevivência dos pacientes. Referente ao tempo de permanência na UTI, os fatores associados foram número de dias de sondas, drenos e cateteres, número de itens da prescrição medicamentosa, não sobrevivência e INC/EA com cateteres periféricos e medicamentos. Finalizando, constatou-se que pacientes não sobreviventes tiveram maior número de dias com TE/Traq., eram mais graves e apresentaram, aproximadamente, cinco vezes mais chance de sofrer um INC/EA com TE/Traq.. Considerando que o enfoque da segurança do paciente é de responsabilidade compartilhada de todos os profissionais, da área de saúde ou não, julga-se que os resultados dessa investigação contribuam para a melhoria da assistência ao paciente crítico, por abrir perspectivas para o estabelecimento de protocolos de prevenção dessas ocorrências / The safety of serious patients is a goal of the quality of service in Intensive Care Units (ICUs), therefore, the need to investigate the factors related to the occurrence of adverse events in this context. This study reports a quantitative, retrospective, analytic-transversal research that aimed to analyze the factors associated with the incidents and/or adverse events (INC/AE) in the preparation and administration of medication, in the care of endotracheal/tracheostomy tubes, probes, drains, catheters and fall in ICUs according to the demographic and clinical characteristics of patients and structural resources of the Units. Data was collected from the registry of INC/AE made in the charts of patients that were notified with some type of INC/AE in five ICUs of five hospitals of the City of Sao Paulo from 2003 to 2006. The statistical treatment consisted of an analysis of multivariate logistic regression to identify the independent factors of INC/AE and exit conditions of the Units. The author also ran the multiple linear regression analysis to identify the independent factors of the length of stay in the ICUs. Variables that presented a Wald test rate <0,20 in the univariate logistic regression entered in the models. All analysis adopted a 5% significance level. From 21.230 total admissions in the ICUs, 377 (1,78%) patients suffered some type of INC/AE. A total of 461 occurrences were notified. Most of these occurrences were related to the preparation and administration of medication (196-42,51%), followed by the peripheral catheters and A- lines (105-22,77%), and the nasograstic tubes (73-15,83%). The low number of occurrences (16-2,82%) of factors associated with INC/AE, material/equipment resources and physical settings of the units made the analysis of these variables unfeasible. The same way, no hospital made available daily nursing schedules that contained retrospective data about the existing human resources at the time of the study. The author verified that the number of days of use of therapeutic artifacts was one of the main independent factors associated with INC/AE. These related to the preparation and administration of medication (number of days of TE/Traq.), as well as to the care of peripheral catheters, nasograstic tubes and central catheters (number of days of therapeutic artifacts), followed by seriousness and non-survival of the patients. The factors associated with the length of stay in the ICU were number of days with probes, drains and catheters, number of items of the prescribed medication, non-survival and INC/AE with peripheral catheters and medication. At last, the author established that non-survival patients spent a greater number of days with TE/Traq. They were also more serious and were about five times more likely to suffer INC/AE with TE/Traq. Considering that the focus of a patient safety is shared responsibility of all professionals, from the health field or not, the author considers that the results of this investigation contribute to the improvement of the assistance to critical patients, as it opens perspectives for the establishment of protocols for the prevention of such occurrences

A segurança do paciente grave é uma meta da qualidade do atendimento em Unidade de Terapia Intensiva (UTI), daí a necessidade de se investigar os fatores relacionados à ocorrência de eventos adversos nesse contexto. Trata-se este estudo de uma pesquisa quantitativa, retrospectiva, analítico-transversal que teve como objetivo analisar os fatores associados aos incidentes e/ou eventos adversos (INC/EA) no preparo e administração de medicamentos, nos cuidados com tubo endotraqueal/traqueostomia, sondas, drenos, cateteres e queda em UTI segundo as características demográficas e clínicas do paciente e recursos estruturais da Unidade. Os dados foram coletados por meio dos registros de INC/EA dos prontuários dos pacientes que tiveram notificado algum tipo de INC/EA no período de 2003 e 2006, inclusive, em cinco UTI de cinco hospitais do Município de São Paulo. No tratamento estatístico, foi utilizada a análise de regressão logística multivariada para a identificação dos fatores independentes de INC/EA e condições de saída da Unidade. Para a identificação dos fatores independentes do tempo de permanência nas UTI, utilizou-se a análise de regressão linear múltipla. As variáveis que entraram nos modelos foram aquelas que apresentaram na regressão logística univariada um valor de teste Wald<0,20; em todas as análises realizadas foi utilizado o nível de significância de 5%. Do total de 21.230 admissões nas UTI, 377 (1,78%) pacientes sofreram algum tipo de INC/EA. Foram notificadas 461 ocorrências, a maioria relacionada ao preparo e administração de medicamentos (196-42,51%), seguidas aos cateteres periféricos e arteriais (105-22,77%) e às sondas nasogástricas (73-15,83%). Quanto aos fatores associados aos INC/EA e recursos materiais/equipamentos e ambiente físico das unidades, o baixo número de ocorrências (16-2,82%) inviabilizou a análise dessas variáveis. Da mesma forma, nenhum hospital dispunha das escalas diárias de enfermagem com dados retrospectivos sobre os recursos humanos existentes no período do estudo. Verificou-se que o número de dias de permanência dos artefatos terapêuticos foi um dos principais fatores independentes associados aos INC/EA quer no preparo e administração de medicamentos (número de dias de TE/Traq.), quer nos cuidados com cateter periférico, sonda nasogástrica e cateter central (número de dias de artefatos terapêuticos), seguidos da gravidade e da não sobrevivência dos pacientes. Referente ao tempo de permanência na UTI, os fatores associados foram número de dias de sondas, drenos e cateteres, número de itens da prescrição medicamentosa, não sobrevivência e INC/EA com cateteres periféricos e medicamentos. Finalizando, constatou-se que pacientes não sobreviventes tiveram maior número de dias com TE/Traq., eram mais graves e apresentaram, aproximadamente, cinco vezes mais chance de sofrer um INC/EA com TE/Traq.. Considerando que o enfoque da segurança do paciente é de responsabilidade compartilhada de todos os profissionais, da área de saúde ou não, julga-se que os resultados dessa investigação contribuam para a melhoria da assistência ao paciente crítico, por abrir perspectivas para o estabelecimento de protocolos de prevenção dessas ocorrências / The safety of serious patients is a goal of the quality of service in Intensive Care Units (ICUs), therefore, the need to investigate the factors related to the occurrence of adverse events in this context. This study reports a quantitative, retrospective, analytic-transversal research that aimed to analyze the factors associated with the incidents and/or adverse events (INC/AE) in the preparation and administration of medication, in the care of endotracheal/tracheostomy tubes, probes, drains, catheters and fall in ICUs according to the demographic and clinical characteristics of patients and structural resources of the Units. Data was collected from the registry of INC/AE made in the charts of patients that were notified with some type of INC/AE in five ICUs of five hospitals of the City of Sao Paulo from 2003 to 2006. The statistical treatment consisted of an analysis of multivariate logistic regression to identify the independent factors of INC/AE and exit conditions of the Units. The author also ran the multiple linear regression analysis to identify the independent factors of the length of stay in the ICUs. Variables that presented a Wald test rate <0,20 in the univariate logistic regression entered in the models. All analysis adopted a 5% significance level. From 21.230 total admissions in the ICUs, 377 (1,78%) patients suffered some type of INC/AE. A total of 461 occurrences were notified. Most of these occurrences were related to the preparation and administration of medication (196-42,51%), followed by the peripheral catheters and A- lines (105-22,77%), and the nasograstic tubes (73-15,83%). The low number of occurrences (16-2,82%) of factors associated with INC/AE, material/equipment resources and physical settings of the units made the analysis of these variables unfeasible. The same way, no hospital made available daily nursing schedules that contained retrospective data about the existing human resources at the time of the study. The author verified that the number of days of use of therapeutic artifacts was one of the main independent factors associated with INC/AE. These related to the preparation and administration of medication (number of days of TE/Traq.), as well as to the care of peripheral catheters, nasograstic tubes and central catheters (number of days of therapeutic artifacts), followed by seriousness and non-survival of the patients. The factors associated with the length of stay in the ICU were number of days with probes, drains and catheters, number of items of the prescribed medication, non-survival and INC/AE with peripheral catheters and medication. At last, the author established that non-survival patients spent a greater number of days with TE/Traq. They were also more serious and were about five times more likely to suffer INC/AE with TE/Traq. Considering that the focus of a patient safety is shared responsibility of all professionals, from the health field or not, the author considers that the results of this investigation contribute to the improvement of the assistance to critical patients, as it opens perspectives for the establishment of protocols for the prevention of such occurrences

Text in English / The purpose of this study was to develop strategies to overcome the challenges in the management of large intensive care units (ICUs). Qualitative, research was conducted to explore and describe the challenges and needs experienced by the ICU managers and critical care nurses in the management of large ICUs. Data was collected through interviews. The study was conducted in two phases, that is, Phases I and II which involved compilation of evidence in preparation for development of the strategies and development of the strategies respectively. Two groups of critical care nurses participated in the steps of data collection in Phase I of the study. The unit managers participated in Phase I step 1 which was individual interviews and the critical care nurses not in the management role participated in Phase I, step 2 which was focus group interviews. Data was analysed using the descriptive analysis method of Tesch (1990). The study has highlighted the challenges and needs in the management of large ICUs, through seven themes that emerged from the findings. Ten strategies were developed to overcome the challenges and address the identified needs. The strategies have been presented as a contribution to literature. / Health Studies / D. Litt. et Phil. (Health Studies)

by Chow Wai-hung. / Thesis (M.B.A.)--Chinese University of Hong Kong, 1995. / Includes bibliographical references (leaves 56-57). / ABSTRACT --- p.ii / TABLE OF CONTENTS --- p.iv / LIST OF FIGURES --- p.vi / LIST OF TABLES --- p.vii / ACKNOWLEDGMENT --- p.viii / Chapter / Chapter I. --- INTRODUCTION --- p.1 / Intensive Care Services --- p.1 / Clinician as an Information Processor --- p.2 / Executive Information System (EIS) for Intensive Care Services --- p.7 / Scope of the Study --- p.7 / The Organization of the Remaining Report --- p.8 / Chapter II. --- LITERATURE REVIEW --- p.9 / Sickness Scoring Systems --- p.9 / Executive Information Systems (EIS) --- p.15 / Information Requirements Determination for EIS --- p.17 / Future Direction of EIS in Intensive Care --- p.20 / Chapter III. --- RESEARCH METHODOLOGY --- p.22 / Survey by Mailed Questionnaire --- p.23 / Personal Interview --- p.24 / Subjects Selection --- p.26 / Analysis --- p.27 / Chapter IV. --- RESULTS AND FINDINGS --- p.28 / Part 1 - Questionnaires --- p.29 / Part 2 - Interviews --- p.31 / Chapter V. --- ANALYSIS AND DISCUSSION --- p.44 / Analysis of Results and Findings --- p.44 / Evaluation on Information Requirements Determination for an EIS --- p.50 / Chapter VI. --- CONCLUSION --- p.52 / Chapter VII. --- FUTURE DIRECTION OF DECISION SUPPORT IN CRITICAL CARE --- p.54 / REFERENCES --- p.56 / INTERVIEWS --- p.59 / APPENDIX --- p.60 / Chapter 1. --- A Sample of Hospital Information System Requirement Survey Questionnaire --- p.61 / Chapter 2. --- Samples of Visual Display --- p.67 / Chapter 3. --- A Sample of Format of a Structured Report --- p.70

by Leung Ho-Yin. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1997. / Includes bibliographical references (leaves 82-89). / Abstract --- p.ii / Table of Contents --- p.iv / LIST of Figures --- p.viii / List of Tables --- p.ix / Acknowledgments --- p.xi / Chapter / Chapter 1. --- Introduction --- p.1 / Chapter 1.1 --- Intensive Care Unit --- p.2 / Chapter 1.1.1 --- Expensive Costs of Intensive Care --- p.2 / Chapter 1.1.2 --- Tremendous Demands with Limited Resources --- p.3 / Chapter 1.1.3 --- Conflicting Roles of ICU Physicians --- p.3 / Chapter 1.1.4 --- Disorganized Patient Information --- p.4 / Chapter 1.2 --- ICU Management Problems --- p.5 / Chapter 1.3 --- Executive Information Systems (EIS) for ICU Physician --- p.6 / Chapter 1.4 --- Determine Information Requirements of the EIS --- p.7 / Chapter 1.5 --- Scope of the Study --- p.8 / Chapter 1.6 --- Organization of the Report --- p.8 / Chapter 2. --- Literature Review --- p.9 / Chapter 2.1 --- Intensive Care Unit --- p.9 / Chapter 2.1.1 --- Costs of ICU --- p.10 / Chapter 2.2 --- ICU Physicians are Executives --- p.10 / Chapter 2.3 --- Computers in ICU --- p.11 / Chapter 2.3.1 --- Record Keeping --- p.11 / Chapter 2.3.2 --- Data Management --- p.12 / Chapter 2.3.3 --- Decision Making --- p.13 / Chapter 2.4 --- Problems Facing ICU Physicians --- p.14 / Chapter 2.4.1 --- Conflicting Role --- p.14 / Chapter 2.4.2 --- Information Overload --- p.14 / Chapter 2.4.3 --- Poor Information Quality --- p.15 / Chapter 2.4.4 --- Technophobia --- p.16 / Chapter 2.5 --- Executive Information Systems --- p.16 / Chapter 2.5.1 --- Definition --- p.16 / Chapter 2.5.2 --- Characteristics of EIS --- p.17 / Chapter 2.5.3 --- EIS in Healthcare Industry --- p.20 / Chapter 2.6 --- Determining Information Requirements --- p.20 / Chapter 2.6.1 --- Strategies and Methods to Determine Information Requirements --- p.21 / Chapter 2.6.2 --- Critical Success Factors Analysis --- p.25 / Chapter 2.6.2.1 --- Definition of CSFs --- p.26 / Chapter 2.6.2.2 --- Different Executives Have Different CSFs and Different Information Needs --- p.26 / Chapter 2.6.2.3 --- Hierarchical Nature of CSFs --- p.26 / Chapter 2.6.2.4 --- Steps in the CSFs Approach --- p.28 / Chapter 2.6.2.5 --- "Critical Information, Assumptions, and Decisions" --- p.29 / Chapter 3. --- Research Methodology --- p.31 / Chapter 3.1 --- Literature Review --- p.31 / Chapter 3.2 --- Design a Methodology for Information Requirements Determination --- p.32 / Chapter 3.3 --- ICU Admission Case Study --- p.34 / Chapter 3.4 --- Analysis and Validation --- p.35 / Chapter 3.5 --- COPD Survey: The Importance of Medical History --- p.36 / Chapter 3.5.1 --- Chronic Obstructive Pulmonary Disease --- p.36 / Chapter 3.5.2 --- The Survey --- p.38 / Chapter 4. --- A Three-Stage Methodology --- p.41 / Chapter 4.1 --- Stage 1 - Understanding ICU Operations --- p.42 / Chapter 4.2 --- Stage 2 - Determine CSFs within the ICU --- p.43 / Chapter 4.2.1 --- CSFs Analysis Steps in the Study --- p.44 / Chapter 4.2.2 --- Step 1: Determine CSFs of ICUs --- p.44 / Chapter 4.2.3 --- Step 2: Determine CSFs of the ICU Physicians --- p.45 / Chapter 4.2.4 --- Step 3: Determine CSFs of the ICU Admission --- p.45 / Chapter 4.3 --- Stage 3 譯 Determine Information Requirements --- p.45 / Chapter 4.4 --- Importance of Medical History: A COPD Survey --- p.46 / Chapter 4.4.1 --- COPD Questionnaire --- p.46 / Chapter 5. --- Findings --- p.48 / Chapter 5.1 --- Findings in Stage 1 --- p.48 / Chapter 5.1.1 --- Decision Making in ICU --- p.49 / Chapter 5.2 --- Findings in Stage 2 - CSFs --- p.54 / Chapter 5.2.1 --- CSFs of the ICU --- p.54 / Chapter 5.2.2 --- CSFs of the ICU Physicians --- p.56 / Chapter 5.2.3 --- CSFs of the ICU Admission --- p.56 / Chapter 5.3 --- Findings in Stage 3 --- p.58 / Chapter 5.3.1 --- Types of Information Requirement --- p.58 / Chapter 5.3.2 --- Detailed Contents of the Information Requirements --- p.59 / Chapter 6. --- Analysis --- p.65 / Chapter 6.1 --- A Three-Stage Methodology for Information Requirements Determination --- p.65 / Chapter 6.1.1 --- Comparison of the Three-Stage Methodology with CSFs Analysis --- p.66 / Chapter 6.1.2 --- A Case Study Using the Three-Stage Methodology --- p.67 / Chapter 6.2 --- Roles of Information Types in Admission Decision --- p.68 / Chapter 6.2.1 --- Admitting Patients from Different Sources --- p.69 / Chapter 6.2.2 --- Admitting Patients with Different Diseases --- p.70 / Chapter 6.3 --- The Importance of Medical History --- p.71 / Chapter 7 --- Conclusions --- p.78 / Bibliography --- p.82 / Interviews --- p.90 / Appendices --- p.91

Thesis (M.S.)--University of Texas Health Science Center at Houston, School of Public Health, 2008. / Source: Masters Abstracts International, Volume: 46-04, page: 2056. Adviser: Maureen Sanderson. Includes bibliographical references.

Text in English / The purpose of this study was to develop strategies to overcome the challenges in the management of large intensive care units (ICUs). Qualitative, research was conducted to explore and describe the challenges and needs experienced by the ICU managers and critical care nurses in the management of large ICUs. Data was collected through interviews. The study was conducted in two phases, that is, Phases I and II which involved compilation of evidence in preparation for development of the strategies and development of the strategies respectively. Two groups of critical care nurses participated in the steps of data collection in Phase I of the study. The unit managers participated in Phase I step 1 which was individual interviews and the critical care nurses not in the management role participated in Phase I, step 2 which was focus group interviews. Data was analysed using the descriptive analysis method of Tesch (1990). The study has highlighted the challenges and needs in the management of large ICUs, through seven themes that emerged from the findings. Ten strategies were developed to overcome the challenges and address the identified needs. The strategies have been presented as a contribution to literature. / Health Studies / D. Litt. et Phil. (Health Studies)

Submitted in fulfilment of the Master's Degree in Clinical Technology, Durban University of Technology, 2010. / Introduction: The aim of this study was to establish the most reliable standard method for monitoring endotracheal tube cuff pressure in an intensive care unit. Methodology: The study was conducted at King Edward VIII Hospital ICU on adult patients undergoing prolonged intubation of more than 24 hours. Consent was obtained from the patient’s next of kin. The patient’s Pcuff for this study was recorded in two ways simultaneously for a period of 12 hours during the day. The principal investigator recorded the Pcuff thrice during the study period using the Posey cufflator®. Continuous recording was done using a pressure transducer connected to the Nihon Kohden BSM®. Factors causing changes in Pcuff were also documented. Results: Thirty-five critically ill adult patients were enrolled into the study. Nineteen (54.3%) of the subjects were male. Seventeen out of 35 subjects were studied for the entire 720 minute period. The mean time of study of the group was 667 minutes with the lowest period being 135 minutes for one patient. The group mean ± Standard deviation (SD) was 26.6 8.7 with a 95% confidence index of 9.2 – 44.0 and the median value was 25 for continuous readings. For the entire group, 13% of the time was spent in the low pressure range (< 20 cmH2O), while 23% was spent in the high pressure (> 30 cmH2O). A mean of 64% of the time was spent in the normal pressure range. Overall, the most frequently encountered events that caused pressure changes were body movement, coughing, head movement and suctioning accounting for 26.2%, 20.1%, 19.2% and 9.4% respectively. For intermittent readings, the mean ± SD of all patients for T0 was 25.3 ± 6.9; for T6 25.9 ± 8.7 and for T12 24.8 ± 3.8. The overall mean ± SD for all readings was 25.6 ± 7.1. For the entire group, 12% of the time was spent in the low pressure range (< 20 cmH2O), while 5% was spent in the high pressure (> 30 cmH2O). A mean of 83% of the time was spent in the normal pressure range. The correlation between intermittent pressure and the continuous reading at the same time was r = 0.87. iii Discussion: Continuous monitoring of Pcuff indicated that the endotracheal cuff pressure varies extensively during mechanical ventilation in critically ill patients, such variation being noted both between patients and within an individual patient. In an attempt to compare intermittent and continuous monitoring of endotracheal cuff pressures, a good correlation between the two measurements was demonstrated. However, the variations in pressures noted for an individual patient would not have been detected if endotracheal cuff pressures were monitored intermittently. Hence, with continuous monitoring the pressure changes may be detected early. Conclusion: Continuous monitoring of cuff pressure during mechanical ventilation in intensive care units is thus recommended for all patients. If intermittent monitoring is performed, it should be more frequently than eight-hourly. It is recommended that a pressure range of 20-30 cmH2O still be used as the normal range. The role of self adjusting pressure devices, although needing further exploration, holds much promise. / DUT Postgraduate Development Services.