Diese Studie soll klären, ob und inwieweit zurückliegende Schwangerschaftsverluste und -abbrüche für eine stationäre Psychotherapie relevant sind. Aufbauend auf zwei Vorstudien wurden in die retrospektive, querschnittliche Hauptstudie 440 Patientinnen einer psychosomatischen Klinik und 585 Frauen aus der Allgemeinbevölkerung (AB) einbezogen. Die geburtshilfliche Anamnese und alle psychologischen Parameter wurden mittels standardisierter Fragebögen erhoben und deskriptiv sowie parametrisch ausgewertet. Sowohl in der AB als auch in der stationären Psychosomatik wiesen 26% der Teilnehmerinnen eine geburtshilfliche Vorbelastung(geb VB) auf, welche im Mittel 20 Jahre zurückliegt. 11% der betroffenen Frauen aus der AB und 31% der Betroffenen in der stationären Psychosomatik nehmen eine anhaltende psychische Belastung durch die geb VB wahr. Trotz der subjektiv anhaltenden psychischen Belastung bei 31% der betroffenen Patientinnen unterscheiden sich diese hinsichtlich ihres aktuellen psychischen Befindens nicht von Patientinnen ohne geb VB. Unterschiede bestehen hingegen zwischen betroffenen stationär psychosomatischen Patientinnen und ebenfalls betroffenen Frauen aus der AB: Bei Patientinnen in der stationären Psychosomatik sind dysfunktionale Verarbeitungsmuster und Trauerreaktionen stärker ausgeprägt. Regressionsanalysen an der Gruppe der Patientinnen mit geb VB in der stationären Psychosomatik zeigen, dass eine Attribution zurückliegender Schwangerschaftsverluste auf „Merkmale der eigenen Person“ mit einem schlechteren Allgemeinbefinden einhergeht. Auch das Ausmaß posttraumatischer Symptome lässt sich teilweise durch Attributionsmuster und Verarbeitungsstrategien erklären. Obwohl aufgrund des Studiendesigns keine kausalen Schlüsse gezogen werden können, liefern die Ergebnisse wichtige Hinweise auf Häufigkeiten von geb VB bei Patientinnen in der stationären Psychosomatik, auf mögliche psychische Beeinträchtigungen und entsprechende Ansatzpunkte in der Psychotherapie. / The aim of this study is to explore whether and to what extent earlier pregnancy losses and abortions are relevant for inpatient psychotherapy. Based on two preliminary studies, data of 440 inpatients of a psychosomatic hospital and 585 women from the general population were included in the retrospective, cross-sectional main study. Both the obstetric history as well as psychological parameters were collected using standardized questionnaires and evaluated by descriptive and parametric statistic methods. In both groups (general population and psychosomatic inpatients) 26% of the participants reported a negative obstetric history, dating back an average of 20 years. Of these women, 11% from the general population and 31% of psychosomatic inpatients perceive an ongoing psychological strain because of their negative obstetric experience. Despite the subjective persistent psychological strain in 31% of the affected inpatients, they do not differ from inpatients without negative obstetric history in terms of their current mental condition. However, there are differences between psychosomatic inpatients with a negative obstetric history and affected women from the general population: Dysfunctional coping patterns and grief reactions are more pronounced with women in inpatient psychosomatic treatment. Regression analyses regarding psychosomatic inpatients with a negative obstetric history show that attributing past pregnancy losses to “personal characteristics” results in poorer general health. The extent of post-traumatic symptoms can also be explained partly by attributional patterns and coping styles. Although due to the study''s design, no causal conclusions can be drawn, the results provide important information on the incidence of negative obstetric history of inpatients in psychosomatic treatment, on possible psychological impairments and on suitable approaches in psychotherapy.

Introdução. Embora existam diferentes estratégias para a prestação de cuidados paliativos ao paciente com câncer, pouco se conhece sobre a efetividade desses modelos. Objetivos. Comparar os efeitos da equipe de cuidado paliativo integrada ao cuidado tradicional com o cuidado tradicional sozinho no controle de sintomas em paciente com câncer avançado hospitalizado. Método. Estudo longitudinal composto por dois grupos não randomizados. 73 pacientes foram admitidos para a equipe de cuidado paliativo integrada ao cuidado tradicional (Grupo ECP) e comparados a 75 atendidos no modelo de cuidado tradicional (Grupo CT). Os sintomas foram avaliados pela Escala de Avaliação de Sintomas de Edmonton (ESAS), a satisfação por escala numérica verbal (0-10), a funcionalidade pela Escala de Desempenho Funcional Físico Karnofsky (KPS) e a adequação analgésica pelo Índice de Manejo da Dor (IMD). Os pacientes foram avaliados na admissão, após 24 e 48 horas. O desfecho primário foi a melhora clinica significativa de 2 pontos na intensidade da dor e da náusea em 48 horas, comparados com a admissão. Os dados demográficos, os sintomas e sua redução foram comparados entre os Grupos pelo Teste Exato de Fisher ou Mann Whitney. O Teste de Wilcoxon analisou alterações dos sintomas intragrupos. A regressão múltipla de Poisson controlou fatores de confusão para a melhora do sintoma. O nível de significância adotado foi de 5%. Resultados. A prevalência de sintomas foi alta em ambos os grupos: no Grupo ECP a variação foi de 43.8% (depressão) a 87.7% (sensação de bem estar), e no Grupo CT, de 24% (dispneia) a 85.5% (dor). A magnitude dos sintomas, pelo escore da mediana, foi importante em ambos os Grupos: na admissão, no Grupo ECP, variou entre 5.5 (sensação de bem estar) a 8.0 (ansiedade, apetite, constipação e tristeza), e no Grupo CT, variou de 6.0 (sensação de bem estar e dispneia) a 9.0 (perda do apetite). A mediana de sobrecarga de sintomas, avaliada pelo ESAS, foi de 50.0 em ambos os grupos. Na análise de 24 horas (intragrupo), no Grupo ECP cinco sintomas (dor, náusea, perda do apetite, dispneia, prejuízo do sono) e sobrecarga de sintomas foram reduzidos (p<0.05), enquanto no Grupo Grupo CT três sintomas (dor, náusea e prejuízo do sono) foram reduzidos (p<0.05). Na análise de 48 horas (intragrupo), dez sintomas e sobrecarga de sintomas no Grupo ECP foram reduzidos (p<0.05), enquanto quatro sintomas melhoraram no Grupo CT (p<0.05). A regressão múltipla mostrou que a dor (RR= 2.2 [IC95%1.27-3.81]) e bem estar (RR=4.6 [IC95% 1.34-15.88]) reduziram 2 pontos e foi favorável somente no Grupo ECP. Verificou-se melhor adequação da analgesia no Grupo ECP comparado ao CT (p<0.05). A satisfação do doente foi elevada e similar em ambos os grupos. Conclusão. Os doentes de ambos os grupos mostraram grande sobrecarga de sintomas e somente o sintoma dor foi adequadamente controlado pelo Grupo ECP. Os resultados encontrados demandam análise de fatores da estratégia de tratamento que possam melhorar a efetividade das ações, como avaliação sistematizada dos sintomas em curtos períodos e estratégias que permitam ajuste rápido da terapêutica quando necessário. / Introduction. Although there are many different strategies for provision of palliative care to patients with cancer, little is known about the effectiveness of these modalities. Objective.To compare the effects of a palliative care team integrated with traditional care to traditional care alone on symptom control in inpatients with advanced cancer. Method. Longitudinal study composed of two non-randomized groups. Seventy-three patients were admitted to the palliative care team integrated to traditional care (PCT Group) and compared to 75 patients treated in the traditional care model (TC Group). Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS), satisfaction with treatment by the verbal numeric scale (0-10), performance status by the Karnofsky Performance Status Scale (KPS) and analgesic adequacy by the Pain Management Index (PMI). Patients were assessed upon admission, and after 24 and 48 hours. The primary outcomes were significant clinical improvements of 2 points in pain intensity and nausea in 48 hours, compared to admission. The demographic data, symptoms, and reduction in symptoms were compared between the groups by using Fisher\'s or Mann Whitneys Exact Tests. The Wilcoxon test examined the intragroup alteration of symptoms. The Poisson multiple regression controlled for confounding factors of improvement in symptoms. A p-value of 0.05 indicated statistical significance for all analyses. Results. The prevalence of symptoms at admission was high in both groups. In the PCT Group, it ranged from 43.8% (depression) to 87.7% (loss of well-being) and, in the TC Group, it ranged from 24% (dyspnoea) to 85.5% (pain). The magnitude of median score of symptoms was substantial in both groups: at admission for the PCT group, it ranged from 5.5 (sense of well-being) to 8.0 (anxiety, appetite, constipation, sadness), while for the TC Group, it ranged from 6.0 (sense of well-being and dyspnoea) to 9.0 (loss of appetite). The median score of the symptom burden assessed by ESAS was 50.0 in both groups. In 24 hours (intragroup), the PCT Group had significant reductions in intensity of five symptoms (pain, nausea, loss of appetite, dyspnoea, and sleep disturbance) and symptom burden, while the TC Group had significant reductions in intensity of three symptoms (pain, nausea, and sleep disturbance). In 48 hours (intragroup), the PCT Group had significant reductions in intensity of ten symptoms and symptom burden and while the TC Group had significant improve in intensity of four symptoms. Multiple regression analysis showed that pain (RR = 2.2 [95% CI 1.27-3.81]) and loss of well-being (RR = 4.6 [95% CI 1.34-15.88]) were reduced by two points and it was significantly more favourable only in the PCT Group. The PMI revealed better adequacy of analgesia in the PCT Group. Satisfaction was high and similar in both groups. Conclusion. Patients with advanced cancer in both groups showed a pronounced burden of symptoms and only pain was properly controlled in the PCT Group. The results indicate that factors that can improve treatment strategy should be implemented to improve the effectiveness of clinical assistance. Examples of factors that can improve treatment are frequent and systematic assessment of symptoms in short periods, and strategies that allow for timely adjustment of therapy when necessary.

Gruppentherapie ist in der stationären Allgemeinpsychiatrie weit verbreitet, ihre Wirksamkeit im Rahmen der allgemeinpsychiatrischen Pflicht- und Regelversorgung ist hingegen wenig untersucht. Die vorliegende Arbeit geht in einer naturalistischen Studie der Frage nach, ob psychoanalytisch-interaktionelle Gruppentherapie, eine psychoanalytische Behandlungsmethode, die speziell für die Arbeit mit schwerer beeinträchtigten Patienten entwickelt wurde, in einem solchen Setting wirksam ist. Hierzu wurden zwischen 2007 und 2009 42 Patienten bezüglich ihrer Symptomverbesserung untersucht, die in der Klinik für Psychiatrie und Psychotherapie der Katholischen Krankenhaus GmbH Hagen stationär mit psychoanalytisch-interaktioneller Gruppentherapie, ergänzt durch Elemente der Dialektisch-Behavioralen Therapie, behandelt wurden. Als Kontrollgruppe dienten 40 Patienten, die auf einer psychotherapeutischen Station des Asklepios Fachklinikums Tiefenbrunn mit Dialektisch-Behavioraler Therapie allein behandelt wurden. Die Ergebnisse zeigten signifikante Verbesserungen in beiden Patientengruppen bezüglich Symptombelastung, Lebenszufriedenheit und Beeinträchtigungsschwere von mittlerer bis hoher Effektstärke. Nur in der Hagener Gruppe zeigte sich auch eine signifikante Verbesserung interpersoneller Probleme. Die Hagener Patienten wiesen im Zwischengruppenvergleich signifikant bessere Ergebnisse in Bezug auf Beeinträchtigungsschwere und interpersonelle Probleme auf. Die Ergebnisse können ein Hinweis darauf sein, dass psychoanalytisch-interaktionelle Gruppentherapie in einer allgemeinpsychiatrischen Klinik wirksam ist und eine spezifische Beeinflussung interpersoneller Schwierigkeiten bewirkt. Methodische Einschränkungen werden diskutiert.

This work focuses on finding state of preparedness of hospitals with acute inpatient care in the Pardubice region in the case of a direct threat to the Pardubice Regional Hospital, Inc. (hereinafter "PRH") by chemical, biological, radiological or nuclear agents (hereinafter referred to as "CBRN"). The thesis is based on a comparison between the trauma plans that have been established as an indicator of a preparedness of hospitals in case of mass disaster and the legal standard, i.e. Decree No. 101 of 2012 Sb. dealing with the details of the content of trauma plan of the one-day or inpatient medical care and process for its preparation and negotiation, as amended (hereinafter the "Decree 101 of 2012"). The theoretical work describes the applicable laws governing the conditions for the provision of health care, trauma plan content and procedures of the Emergency Service (ES) components in preparation for dealing with emergencies. The next part discusses the characteristics of CBRN agents. Furthermore, the work focuses on defining terrorism and CBRN terrorism. The chapter also includes a brief historical summary of the use of CBRN agents and their threats. The following section describes the Security System of the Czech Republic and its elements. It is crucial to mention its existence in relation to the prevention of emergencies and crisis situations and elimination of their consequences. This part also introduces a selection of documents, which have a direct relationship to the security policy of the country and to this thesis. It may be noted that most of these documents have been prepared, inter alia, on the basis of current CBRN threats. The penultimate section characterizes individual hospitals with acute inpatient care in the Pardubice region and includes also a risk analysis of this region. The analysis is based on the Emergency Plan of Pardubice region. I believe that the knowledge of the possible threats pointed out in the risk analysis is important in a preparation for an emergency response in the relation to an emergency medical care. Analysis of risks and threats, based on the Decree 101 of 2012, is also a part of the trauma hospital plans. The last part of the thesis describes the different types of trauma plans and certain procedures in the process of an activation of these plans. Even though, the theme of the work is focused more on trauma plans of hospitals, in cooperation with ambulance services and regional authorities in addressing the consequences of emergencies, I find it important to pay attention to a trauma plan for emergency medical services, and also the one, which is part of the emergency plan of the region. Based on the practical experience it was decided the readiness of hospitals with acute inpatient care in the Pardubice region in case of a threat PRH is sufficient. Subsequently, a relative comparison of interdependence trauma plans was performed in selected hospitals to evaluate their index of readiness by means of comparative analysis. The overall index IPi scales the state of preparedness of the hospitals. The input parameter?s values for the index evaluation were determined based on the contents of the trauma plans. The concluding chapter presents the results evaluated by the described method. This uncovered that the degree of readiness of the examined hospitals, based on the mentioned parameters, was insufficient in three cases. Only Chrudimska Hospital, Inc. achieved satisfactory results. Based on these results, the specific measures were recommended to be taken the level of preparedness of the hospitals. The findings and the results of this thesis are mainly practical. The most important benefit of this work is the suggested measures for the activation of trauma plans for hospitals with acute inpatient care in the Pardubice region.

Introdução. Embora existam diferentes estratégias para a prestação de cuidados paliativos ao paciente com câncer, pouco se conhece sobre a efetividade desses modelos. Objetivos. Comparar os efeitos da equipe de cuidado paliativo integrada ao cuidado tradicional com o cuidado tradicional sozinho no controle de sintomas em paciente com câncer avançado hospitalizado. Método. Estudo longitudinal composto por dois grupos não randomizados. 73 pacientes foram admitidos para a equipe de cuidado paliativo integrada ao cuidado tradicional (Grupo ECP) e comparados a 75 atendidos no modelo de cuidado tradicional (Grupo CT). Os sintomas foram avaliados pela Escala de Avaliação de Sintomas de Edmonton (ESAS), a satisfação por escala numérica verbal (0-10), a funcionalidade pela Escala de Desempenho Funcional Físico Karnofsky (KPS) e a adequação analgésica pelo Índice de Manejo da Dor (IMD). Os pacientes foram avaliados na admissão, após 24 e 48 horas. O desfecho primário foi a melhora clinica significativa de 2 pontos na intensidade da dor e da náusea em 48 horas, comparados com a admissão. Os dados demográficos, os sintomas e sua redução foram comparados entre os Grupos pelo Teste Exato de Fisher ou Mann Whitney. O Teste de Wilcoxon analisou alterações dos sintomas intragrupos. A regressão múltipla de Poisson controlou fatores de confusão para a melhora do sintoma. O nível de significância adotado foi de 5%. Resultados. A prevalência de sintomas foi alta em ambos os grupos: no Grupo ECP a variação foi de 43.8% (depressão) a 87.7% (sensação de bem estar), e no Grupo CT, de 24% (dispneia) a 85.5% (dor). A magnitude dos sintomas, pelo escore da mediana, foi importante em ambos os Grupos: na admissão, no Grupo ECP, variou entre 5.5 (sensação de bem estar) a 8.0 (ansiedade, apetite, constipação e tristeza), e no Grupo CT, variou de 6.0 (sensação de bem estar e dispneia) a 9.0 (perda do apetite). A mediana de sobrecarga de sintomas, avaliada pelo ESAS, foi de 50.0 em ambos os grupos. Na análise de 24 horas (intragrupo), no Grupo ECP cinco sintomas (dor, náusea, perda do apetite, dispneia, prejuízo do sono) e sobrecarga de sintomas foram reduzidos (p<0.05), enquanto no Grupo Grupo CT três sintomas (dor, náusea e prejuízo do sono) foram reduzidos (p<0.05). Na análise de 48 horas (intragrupo), dez sintomas e sobrecarga de sintomas no Grupo ECP foram reduzidos (p<0.05), enquanto quatro sintomas melhoraram no Grupo CT (p<0.05). A regressão múltipla mostrou que a dor (RR= 2.2 [IC95%1.27-3.81]) e bem estar (RR=4.6 [IC95% 1.34-15.88]) reduziram 2 pontos e foi favorável somente no Grupo ECP. Verificou-se melhor adequação da analgesia no Grupo ECP comparado ao CT (p<0.05). A satisfação do doente foi elevada e similar em ambos os grupos. Conclusão. Os doentes de ambos os grupos mostraram grande sobrecarga de sintomas e somente o sintoma dor foi adequadamente controlado pelo Grupo ECP. Os resultados encontrados demandam análise de fatores da estratégia de tratamento que possam melhorar a efetividade das ações, como avaliação sistematizada dos sintomas em curtos períodos e estratégias que permitam ajuste rápido da terapêutica quando necessário. / Introduction. Although there are many different strategies for provision of palliative care to patients with cancer, little is known about the effectiveness of these modalities. Objective.To compare the effects of a palliative care team integrated with traditional care to traditional care alone on symptom control in inpatients with advanced cancer. Method. Longitudinal study composed of two non-randomized groups. Seventy-three patients were admitted to the palliative care team integrated to traditional care (PCT Group) and compared to 75 patients treated in the traditional care model (TC Group). Symptoms were assessed by the Edmonton Symptom Assessment Scale (ESAS), satisfaction with treatment by the verbal numeric scale (0-10), performance status by the Karnofsky Performance Status Scale (KPS) and analgesic adequacy by the Pain Management Index (PMI). Patients were assessed upon admission, and after 24 and 48 hours. The primary outcomes were significant clinical improvements of 2 points in pain intensity and nausea in 48 hours, compared to admission. The demographic data, symptoms, and reduction in symptoms were compared between the groups by using Fisher\'s or Mann Whitneys Exact Tests. The Wilcoxon test examined the intragroup alteration of symptoms. The Poisson multiple regression controlled for confounding factors of improvement in symptoms. A p-value of 0.05 indicated statistical significance for all analyses. Results. The prevalence of symptoms at admission was high in both groups. In the PCT Group, it ranged from 43.8% (depression) to 87.7% (loss of well-being) and, in the TC Group, it ranged from 24% (dyspnoea) to 85.5% (pain). The magnitude of median score of symptoms was substantial in both groups: at admission for the PCT group, it ranged from 5.5 (sense of well-being) to 8.0 (anxiety, appetite, constipation, sadness), while for the TC Group, it ranged from 6.0 (sense of well-being and dyspnoea) to 9.0 (loss of appetite). The median score of the symptom burden assessed by ESAS was 50.0 in both groups. In 24 hours (intragroup), the PCT Group had significant reductions in intensity of five symptoms (pain, nausea, loss of appetite, dyspnoea, and sleep disturbance) and symptom burden, while the TC Group had significant reductions in intensity of three symptoms (pain, nausea, and sleep disturbance). In 48 hours (intragroup), the PCT Group had significant reductions in intensity of ten symptoms and symptom burden and while the TC Group had significant improve in intensity of four symptoms. Multiple regression analysis showed that pain (RR = 2.2 [95% CI 1.27-3.81]) and loss of well-being (RR = 4.6 [95% CI 1.34-15.88]) were reduced by two points and it was significantly more favourable only in the PCT Group. The PMI revealed better adequacy of analgesia in the PCT Group. Satisfaction was high and similar in both groups. Conclusion. Patients with advanced cancer in both groups showed a pronounced burden of symptoms and only pain was properly controlled in the PCT Group. The results indicate that factors that can improve treatment strategy should be implemented to improve the effectiveness of clinical assistance. Examples of factors that can improve treatment are frequent and systematic assessment of symptoms in short periods, and strategies that allow for timely adjustment of therapy when necessary.

Indicadores de qualidade hospitalar correspondem a medidas que contém informações relevantes sobre determinados atributos e dimensões que caracterizam a qualidade de diferentes instituições de saúde. Tais medidas são capazes de sinalizar eventuais deficiências ou práticas de sucesso associadas à qualidade dos serviços de saúde. O presente estudo teve por finalidade desenvolver uma ferramenta computacional de análise, voltada para o gerenciamento hospitalar, com o objetivo de se obter um instrumento que possa ser utilizado para monitorar e avaliar a qualidade dos serviços oferecidos por instituições hospitalares através da análise e gerenciamento de indicadores de qualidade hospitalar. Os indicadores alvo para avaliar a qualidade dos serviços representaram um subconjunto de indicadores de qualidade denominados Inpatient Quality Indicators (IQIs) da Agency for Healthcare Research and Quality (AHRQ). A partir da revisão bibliográfica de textos científicos na área e com base nas dimensões de processo e resultado do Modelo Donabediano, foram selecionados vinte e dois indicadores da AHRQ, que avaliam a mortalidade por determinadas afecções e procedimentos cirúrgicos, bem como a quantidade e a qualidade dos procedimentos realizados nas instituições de saúde. A ferramenta foi construída em dois módulos: um módulo responsável pela geração dos indicadores a partir de dados coletados de um banco de dados relacional; e outro destinado ao estudo e análise das séries temporais dos indicadores, permitindo o acompanhamento da evolução dos mesmos de forma histórica. Os dados utilizados para a geração dos indicadores são oriundos da base de dados do Observatório Regional de Atenção Hospitalar (ORAH), que consiste numa entidade responsável pelo processamento de dados de internação de quarenta hospitais públicos e privados, distribuídos ao longo de vinte e seis municípios da região de Ribeirão Preto, São Paulo, Brasil, que compõem a Departamento Regional de Saúde XIII (DRS-XIII). A ferramenta computacional foi concluída e validade com êxito e suas funcionalidades foram disponibilizadas para gestores de saúde e acadêmicos através do portal web de conteúdo vinculado ao ORAH. Em adição, os resultados obtidos através do uso da ferramenta foram utilizados para analisar a situação da assistência hospitalar na região de Ribeirão Preto através da comparação histórica dos indicadores entre as três microrregiões de saúde que compõem a DRS-XIII: Aquífero Guarani, Vale das Cachoeiras e Horizonte Verde. A análise destes resultados também foi essencial para verificar a capacidade da ferramenta em prover informações relevantes para a gestão hospitalar. A partir da análise dos resultados obtidos, concluímos que a ferramenta permite a definição de um panorama geral da assistência hospitalar na região de Ribeirão Preto. De acordo com os achados deste estudo, também verificamos que os indicadores de qualidade hospitalar da AHRQ cumpriram seu papel como medidas sentinela e foram capazes de identificar certos aspectos associados à realidade. Entretanto, a análise dos resultados também remeteu à necessidade de introduzir novas variáveis que permitam conhecer o real estado dos pacientes e as condições estruturais das diferentes instituições de saúde, visto que os indicadores selecionados, por si só, não fornecem aos gestores de saúde uma avaliação final da qualidade das instituições hospitalares. / Inpatient quality indicators are measures that provide relevant inforrnation on the level of quality of care delivered by hospitals and healthcare services. These measures are capable of signaling eventual problems or successful practices associated with the quality of care provided by health services. This project was aimed to create an instrument to assess the quality of care delivered by hospitals by developing a web application whose functionalities focused on monitoring a subset of inpatient quality indicators (IQIs), extracted from the Agency for Healthcare Research and Quality (AHRQ). Based on literature review and on the components of process and outcomes defined by the Donabedian model, there were selected twenty-two AHRQ\'s inpatient quality indicators that are commonly used to evaluate the mortality associated with certain conditions and procedures, as well as the quantity and quality of certain medical procedures. The software is composed by two components: one is responsible for calculating the indicators using admission data extracted from an operational database; the other one is meant for the study and analysis of time series of the indicators, which allows the monitoring of its values over the years. The indicators were ca1culated using administrative data from the Observatory for Hospital Care\'s database (ORAH, from the acronyrn in Portuguese \"Observatório Regional de Atenção Hospitalar\"). The Observatory for Hospital Care is responsible for processing admission data collected from forty hospitals located throughout Ribeirao Preto region, in the Brazilian state of Sao Paulo. The management of hospitals located in the Ribeirao Preto region is conducted by the Regional Department of Health XIII (DRS-XIII, from the acronyrn in Portuguese \"Departamento Regional de Saúde XIII). The web application\'s services were made available to health service administrators and academic personnel through the ORAH\'s website. The results provided by this computational tool were also used to analyze the situation of care delivered by the hospitals in Ribeirao Preto region, which is subdivided into three microregions: Aquifero Guarani, Horizonte Verde e Vale das Cachoeiras. The historic values of the indicators were compared between these three microregions. The analysis of these results was also important to verify whether the web application is actually able to provi de enough inforrnation to acknowledge the reality of the hospitals in Ribeirao Preto region. According to the results, we verified that the AHRQ\'s inpatient quality indicators have fulfilled their role in signalizing certain aspects related to the quality of care of the hospitals, but they do not provi de enough inforrnation to establish a defini tive quality assessment of hospital services. Therefore, we verified the need of introducing new attributes in order to understand and acknowledge the clinical condition of the hospitalized patients, as well as the structure and resources available in the hospitals.

Background: Childhood maltreatment is associated with the development and maintenance of mental disorders. The purpose of this naturalistic study was (a) to identify different patterns of childhood maltreatment, (b) to examine how these patterns are linked to the severity of mental disorders and (c) whether they are predictive of treatment outcome. Methods: 742 adult patients of a university hospital for psychotherapy and psychosomatics were assessed at intake and discharge by standardized questionnaires assessing depression (Beck Depression Inventory, BDI) and general mental distress (Symptom Check List-90-R, SCL-90-R). Traumatic childhood experience (using the Childhood Trauma Questionnaire, CTQ) and ICD-10 diagnoses were assessed at intake. Results: The patients could be allocated to three different patterns of early childhood trauma experience: mild traumatization, multiple traumatization without sexual abuse and multiple traumatization with sexual abuse. The three patterns showed highly significant differences in BDI, General Severity Index (GSI) and in the number of comorbidity at intake. For both BDI and GSI a general decrease in depression and general mental distress from intake to discharge could be shown. The three patterns differed in BDI and GSI at intake and discharge, indicating lowest values for mild traumatization and highest values for multiple traumatization with sexual abuse. Patients with multiple traumatization with sexual abuse showed the least favourable outcome. Conclusion: The results provide evidence that the severity of childhood traumatization is linked to the severity of mental disorders and also to the treatment outcome in inpatient psychotherapy. In the study, three different patterns of childhood traumatization (mild traumatization, multiple traumatization without sexual abuse, multiple traumatization with sexual abuse) showed differences in the severity of mental disorder and in the course of treatment within the same therapy setting.

Background: Depression is one of the most frequent and costly mental disorders. While there is increasing evidence for the efficacy of online self-help to improve depression or prevent relapse, there is little evidence in blended care settings, especially combined with inpatient face-to-face psychotherapy. Therefore, we evaluated whether an evidencebased online self-help program improves the efficacy of inpatient psychotherapy. Methods: A total of 229 depressed patients were randomly allocated either to an online selfhelp program (intervention group [IG]; Deprexis) or an active control group (CG; weekly online information on depression) in addition to inpatient psychodynamic psychotherapy. Both groups had access to their respective experimental intervention for 12 weeks, regardless of inpatient treatment duration. Reduction of depressive symptoms, as measured with the Beck Depression Inventory-II, was the primary outcome at the end of the intervention (T2). Results: Depressive symptoms were statistically significantly lower in the IG compared to the active CG at T2 with a moderate betweengroup effect size of d = 0.44. The same applied to anxiety ( d = 0.33), quality of life ( d = 0.34), and self-esteem ( d = 0.38) at discharge from inpatient treatment (T1). No statistically significant differences were found regarding dysfunctional attitudes ( d = 0.14) and work ability ( d = 0.08) at T1. Conclusions: This is the first evidence for blended treatment combining online self-help with inpatient psychotherapy. The study opens new and promising avenues for increasing the efficacy of inpatient psychotherapy. Future studies should determine how integration of online self-help into the therapeutic process can be developed further.

This thesis study evaluates access to care at an internal medicine unit with solely semi-private rooms at Baystate Medical Center (BMC). Patients are divided into two types: Type I patient consumes one bed; Type II patient occupies two beds or an entire semi-private room as a private space for clinical reasons, resulting in one empty but unavailable (blocked) bed per Type II patient. Because little data is available on blocked beds and Type II patients, unit-level hospital bed planning studies that consider blocked beds have been lacking. This thesis study bridges that gap by building a single-stream and a two-stream discrete micro-simulation model in Excel VBA to describe unit-level bed queue dynamics at hourly granularity in the next 48-hour time horizon, using historical arrival rates and census-dependent discharge rates, supplemented with qualitative results on complexity of patient-level discharge prediction. Results showed that while we increase additional semiprivate beds, there was notable difference between the traditional single-stream model and the two-stream model concerning improvement in bed queue size. Possible directions for future research include patient-level discharge prediction considering both clinical and nonclinical milestones, and strategic redesign of hospital unit(s) considering overflows and internal transfers.

Vårdskador skapar lidande och ger ökade kostnader för vården. Fallskador och trycksår är två vårdskador som kan drabba en patient vid vistelse i slutenvården.    Syftet med förbättringsarbetet var att minska antalet fall och andelen trycksår på lungmedicinavdelningen Skaraborgs sjukhus Skövde (SkaS). Genom att införa och implementera de förbättringsidéer som var: utbildning i hjälpmedel, Gröna korset och mentorskap var målen att antal fall i förhållande till antal vistelser skulle minska från 6 till under 4 fall per 100 vistelser och andelen trycksår, kategori 1–4 skulle ligga inom målvärdet &lt;3 %. Syftet för studien var att undersöka medarbetares erfarenheter av patientsäkerhetsarbete på avdelningen i relation till förbättringsarbetet.  Förbättringsarbetet skedde i microsystemet på en slutenvårdsavdelning och metoden utgår från Nolans förbättringsmodell. Mätningar för att följa resultatet bygger på värdekompassen. Kvalitativ metod med induktiv ansats valdes som metod för studien. Kvalitativa intervjuer med medarbetare utifrån en intervjuguide med semistrukturerade frågor har genomförts. Analysen av data har analyserats med kvalitativ innehållsanalys.  De planerade förbättringsåtgärderna infördes under olika tidpunkter och resultatet av förbättringsarbetet visar att antalet fall har legat inom målvärdet en månad. Efter förbättringsarbetets start sågs en tydlig minskning av andelen trycksår och det låg inom målvärdet sex av tio månader. De förändringar som införts har ännu inte kunnat påvisa tydliga förbättringar Resultatet visar även att det finns förbättringsmöjligheter inom informationsöverföringen mellan medarbetare och patient när det gäller fallförebyggande och trycksårsförebyggande åtgärder. Då införandet av vissa förbättringsidéer dröjt på grund av arbete med covid-19-pandemin behövs ytterligare tid för att genomföra förbättringsidéerna. Resultatet av studien påvisar bland annat att en ökad kunskap om patientsäkerhet hos medarbetarna på avdelningen har skett och att patientdelaktighet är viktigt för ökandet av patientsäkerheten. / Health injuries create suffering and increase costs for care. Fall injuries and pressure ulcers are two health injuries that can affect a patient during a stay in inpatient care.  The aim of the improvement project was to reduce the quantity of falls and the proportion of pressure ulcers at the pulmonary medicine department at Skaraborg Hospital in Skövde (SkaS). By implementing the improvement ideas that were: training in aids, the Green Cross and mentorship. The goals were that the number of falls in relation to the number of stays would reduce from 6 to under 4 falls per 100 stays and the proportion of pressure ulcers, categories 1-4 would be within the target value &lt;3%.  The purpose of the study was to study coworkers’ experiences of patient safety in the department in relation to the improvement work. The method is based on Nolan's improvement model. Qualitative method with inductive approach was the method for the study. Qualitative interviews with co-workers have been conducted. The analysis of data has been analyzed with qualitative content analysis.  The planned improvement ideas were introduced at different times and the results of the improvement has not yet shown any clear improvement. Further time is needed to implement the improvement ideas.  There are opportunities for improvement concerning information between co-workers’ and patients regarding fall and pressure ulcer prevention. The results of the study show, among other things, that an increased knowledge of patient safety among the co-workers’ in the department has taken place and that patient participation is important for increasing patient safety.