Submitted by Filipe dos Santos (fsantos@pucsp.br) on 2017-10-19T12:01:03Z No. of bitstreams: 1 Luíza Moreira Grisolia.pdf: 1595190 bytes, checksum: 83615c11d340ba8f1c0ab988352c1623 (MD5) / Made available in DSpace on 2017-10-19T12:01:03Z (GMT). No. of bitstreams: 1 Luíza Moreira Grisolia.pdf: 1595190 bytes, checksum: 83615c11d340ba8f1c0ab988352c1623 (MD5) Previous issue date: 2017-10-02 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / The present study proposes to analyze the health forum as a device for the creation of healthcare networks, in conjunction with the idea of production of the commons, hereby understood, alike with Espinosa, as everything that results from the gathering of people who establish multiple and equivalent mannerisms and whose effect is the increase of potential in each one. The health forums are organizational arrangements that bring together health professionals from different departments to debate and negotiate strategies for building Brazil’s publicly funded healthcare system (SUS), as well as critical analysis of health practices within itself and joint networks. By setting itself up as a border place in public policy, the aforementioned instrument, bears the potential to promote democratic ways of doing / thinking about health. The research was conducted from observant participation in a health forum in the Northern Zone of São Paulo, Brazil, with the sole purpose of analyzing how the sociability experimentation, the production of the commons and the collective construction of creative strategies operate inside the device. The main theme of the discussion forum is the Psychosocial Attention Network, which aims to create links between the basic healthcare devices, mental health, hospitals, amongst other areas beyond the healthcare network. All the collected material (themes, dialogues, affections) has been kept in a field diary, highlighting the concrete ways of establishing relationships in this collective space. The said material has been analyzed from the institutional review perspective, in the form of themes and critical events. It has been later presented in the form of construe scenes, emphasizing the affections and power relations which surround the attendants. Based on the theoretical recovery of network concepts and the production of the commons, and with the assistance of authors such as Espinosa, Negri and Teixeira, we speculate the place of the health forum in the framing of SUS. We also indicate the forum as a boundary between the inside and the outside, the public and the private, a place of displacement of senses, in which it is possible to identify community areas which provide creative solutions for the healthcare creation / O presente estudo propõe analisar o fórum de saúde como um dispositivo de construção das redes de saúde, em diálogo com a noção de produção do comum, aqui entendida, com Espinosa, como tudo aquilo que se produz no encontro entre pessoas que estabelecem formas múltiplas e mútuas de afetação e cujo efeito é o aumento de potência de cada um. Os fóruns de saúde são arranjos organizativos que reúnem profissionais de saúde de diferentes serviços para o debate e negociação de estratégias de construção do Sistema Único de Saúde (SUS), de análise crítica das práticas de saúde e de articulação de redes. Tal dispositivo, por se configurar como um lugar de fronteira na política pública, carrega a potência de produzir modos democráticos de fazer/pensar saúde. A pesquisa foi realizada a partir da participação observante em um fórum de saúde da Zona Norte do município de São Paulo, com o objetivo de analisar como opera no espaço do Fórum a experimentação de sociabilidade, a produção do comum e a construção coletiva de estratégias criativas. A temática do fórum é a Rede de Atenção Psicossocial, que visa a articulação de redes entre equipamentos da atenção básica, saúde mental, hospitais e outros setores para além da saúde. O material colhido (temas, diálogos, afetos) foi registrado em diário de campo, destacando os modos concretos de relação que se estabelecem neste espaço coletivo. O material foi analisado na perspectiva da análise institucional, na forma de eixos temáticos e de eventos críticos. Posteriormente, foi apresentado na forma de cenas analisadoras, evidenciando as afetações e relações de poder que circulam entre os participantes. A partir da retomada teórica dos conceitos de rede e de produção do comum, com aportes de autores como Espinosa, Negri e Teixeira, refletimos sobre o lugar do fórum de saúde na construção do SUS. Apontamos para o fórum como lugar de fronteira entre o dentro e o fora, entre o público e o privado, lugar de deslocamento de sentidos, nos quais é possível identificar zonas de comunidade que propiciam soluções criativas para a construção do cuidado em saúde

Increasing number of ageing population and people who need continuous health monitoring and rising the costs of health care have triggered the concept of the novel wireless technology-driven human body monitoring. Human body monitoring can be performed using a network of small and intelligent wireless medical sensors which may be attached to the body surface or implanted into the tissues. It enables carers to predict, diagnose, and react to adverse events earlier than ever. The concept of Wireless Body Area Network (WBAN) was introduced to fully exploit the benefits of wireless technologies in telemedicine and m-health. The main focus of this research is the design and performance evaluation of strategies and architectures that would allow seamless and efficient interconnection of patient’s body area network and the stationary (e.g., hospital room or ward) wireless networks. I first introduce the architecture of a healthcare system which bridges WBANs and Wireless Local Area Networks (WLANs). I adopt IEEE 802.15.6 standard for the patient’s body network because it is specifically designed for WBANs. Since IEEE 802.15.6 has strict Quality of Service (QoS) and priorities to transfer the medical data to the medical server a QoS-enabled WLAN for the next hop is needed to preserve the end-to-end QoS. IEEE 802.11e standard is selected for the WLAN in the hospital room or ward because it provides prioritization for the stations in the network. I investigate in detail the requirements posed by different healthcare parameters and to analyze the performance of various alternative interconnection strategies, using the rigorous mathematical apparatus of Queuing Theory and Probabilistic Analysis; these results are independently validated through discrete event simulation models. This thesis has three main parts; performance evaluation and MAC parameters settings of IEEE 802.11e Enhanced Distributed Channel Access (EDCA), performance evaluation and tuning the MAC parameters of IEEE 802.15.6, and designing a seamless and efficient interconnection strategy which bridges IEEE 802.11e EDCA and IEEE 802.15.6 standards for a healthcare system.

Increasing number of ageing population and people who need continuous health monitoring and rising the costs of health care have triggered the concept of the novel wireless technology-driven human body monitoring. Human body monitoring can be performed using a network of small and intelligent wireless medical sensors which may be attached to the body surface or implanted into the tissues. It enables carers to predict, diagnose, and react to adverse events earlier than ever. The concept of Wireless Body Area Network (WBAN) was introduced to fully exploit the benefits of wireless technologies in telemedicine and m-health. The main focus of this research is the design and performance evaluation of strategies and architectures that would allow seamless and efficient interconnection of patient’s body area network and the stationary (e.g., hospital room or ward) wireless networks. I first introduce the architecture of a healthcare system which bridges WBANs and Wireless Local Area Networks (WLANs). I adopt IEEE 802.15.6 standard for the patient’s body network because it is specifically designed for WBANs. Since IEEE 802.15.6 has strict Quality of Service (QoS) and priorities to transfer the medical data to the medical server a QoS-enabled WLAN for the next hop is needed to preserve the end-to-end QoS. IEEE 802.11e standard is selected for the WLAN in the hospital room or ward because it provides prioritization for the stations in the network. I investigate in detail the requirements posed by different healthcare parameters and to analyze the performance of various alternative interconnection strategies, using the rigorous mathematical apparatus of Queuing Theory and Probabilistic Analysis; these results are independently validated through discrete event simulation models. This thesis has three main parts; performance evaluation and MAC parameters settings of IEEE 802.11e Enhanced Distributed Channel Access (EDCA), performance evaluation and tuning the MAC parameters of IEEE 802.15.6, and designing a seamless and efficient interconnection strategy which bridges IEEE 802.11e EDCA and IEEE 802.15.6 standards for a healthcare system.

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Introduction. Clinical Pharmacy Services (CPS) have been growing worldwide and have positively impacted health outcomes. However, studies that go deep into the steps of CPS implementation in the healthcare networks of the Brazilian healthcare system (SUS) are incipient. Objective. To analyze the implementation and propose strategies for integrating CPS into healthcare networks. Methods. A study was carried out in the Recife city, in three steps, from July 2015 to October 2017. The first step corresponded to a quasi-experimental study (before and after), carried out through the problematization with the Maguerez Arc in order to implement CPS. The second step gathered two qualitative studies, conducted through focus groups and semi-structured interviews, in order to identify barriers, facilitators and strategies that influenced the implementation. The third step included a methodological development study, conducted through semi-structured interviews and a nominal group, to propose and prioritize CPS integration strategies for SUS. Participants in the study were pharmacists, health managers and decision-makers involved in implementation, patients and panel experts. This study was approved by the Research Ethics Committee. Results. We carried out in the first step: i) initial evaluations (before): identified incipient CPS, deficiencies in the structure and work process of pharmacists; ii) planning: 16 brainstorming meetings and a strategic plan; iii) intervention: 22 political-administrative meetings were held with managers and health staff, 768 hours of theoretical-practical training with Mentoring for pharmacists; iv) preliminary evaluation (after): structure indicators presented a statistically significant difference, differently from the work process, and 1,465 pharmaceutical appointments were performed with 842 patients. It was possible to identify changes in the clinical status of the most prevalent diseases among the patients attended by three pharmaceutical appointments. In the second step, two focus groups were held with pharmacists and five interviews with health managers, which identified 43 barriers and 39 facilitators related to the healthcare networks, pharmacists, health team, implementation process and/or patients. In addition, 21 strategies related to pharmacists were identified as necessary for the implementation of CPS. In the third step, interviews were conducted with five managers and seven decision-makers who identified 21 barriers and 20 facilitators. From these results, specialists who composed the nominal group proposed 41 CPS integration strategies and prioritized the following: formalizing CPS; agreeing on care flows and referral protocols; evaluating and publicizing CPS results/benefits; planning and defining CPS; sensitizing the health managers. Conclusion. The analysis of the process identified factors that may have influenced the implementation of CPS, planning of the interventions and their application to reality, as well as in the prioritization of the strategies of integration of these services to SUS. Thus, the results obtained in this thesis can serve as a guide to help pharmacists, managers and decision-makers to plan, implement and integrate CPS in SUS. / Introdução. Serviços Clínicos Farmacêuticos (SCF) tem se expandido mundialmente e tem impactado positivamente nos resultados em saúde. Entretanto, estudos que se aprofundem nas etapas de implementação de SCF nas redes de atenção à saúde do sistema de saúde brasileiro (SUS) são incipientes. Objetivo. Analisar a implementação e propor estratégias para integração de SCF às redes de atenção à saúde. Métodos. Foi realizado estudo na cidade do Recife-PE, em três etapas, de julho/2015 a outubro/2017. A primeira etapa correspondeu a um estudo quasi-experimental (antes e depois), realizado por meio da metodologia da problematização com Arco de Maguerez, a fim de implementar SCF. A segunda etapa compreendeu dois estudos qualitativos, realizados por meio de grupos focais e entrevistas semiestruturadas, com a finalidade de identificar barreiras, facilitadores e estratégias que influenciaram na implementação dos SCF. A terceira etapa compreendeu estudo de desenvolvimento metodológico, realizado por meio de entrevistas semiestruturadas e grupo nominal, para propor e priorizar estratégias de integração de SCF ao SUS. Os participantes do estudo foram farmacêuticos, gestores e decision-makers envolvidos na implementação dos SCF, pacientes e painel de especialistas. Este estudo foi aprovado pelo Comitê de Ética em Pesquisa. Resultados. Na primeira etapa foram realizados: i) diagnóstico situacional (antes): identificou SCF incipientes, carências na estrutura e no processo de trabalho dos farmacêuticos; ii) planejamento: foram realizadas 16 reuniões de brainstorming com diferentes atores e um cronograma de atividades; iii) intervenção: foram realizadas 22 reuniões político-administrativas com gestores e equipe de saúde, 768 horas de treinamento teórico-prático com Mentoring para os farmacêuticos; iv) avaliação preliminar (depois): indicadores de estrutura apresentaram diferença estatística significativa, diferentemente dos indicadores de processo, e foram realizadas 1.465 consultas farmacêuticas com 842 pacientes, impactando em mudanças na situação clínica das doenças mais prevalentes entre pacientes atendidos por três consultas. Na segunda etapa foram realizados dois grupos focais com farmacêuticos e cinco entrevistas com gestores, o que identificou 43 barreiras e 39 facilitadores relacionados à rede de saúde, farmacêuticos, equipe de saúde, processo de implementação e/ou pacientes. Ademais, 21 estratégias relacionadas aos farmacêuticos foram identificadas como necessárias à implementação de SCF. Na terceira etapa foram realizadas entrevistas com cinco gestores e sete decision-makers que identificaram 21 barreiras e 20 facilitadores. A partir destes resultados, especialistas que compuseram o grupo nominal propuseram 41 estratégias para integração de SCF e priorizaram as seguintes: institucionalizar os SCF; pactuar fluxos assistenciais e protocolos de encaminhamentos; avaliar e divulgar os resultados/benefícios dos SCF; planejar e definir SCF; sensibilizar a gestão. Conclusão. A análise do processo identificou fatores que podem ter influenciado na implementação de SCF, planejamento das intervenções e sua aplicação à realidade, bem como na priorização das estratégias de integração desses serviços ao SUS. Assim, os resultados obtidos nesta tese poderão servir como eixos norteadores para que farmacêuticos, gestores e decision-makers planejem, implementem e integrem SCF no SUS. / Aracaju

The spread of healthcare-associated infections (HAIs) and multi-drug resistance in healthcare networks is a major public health issue. Evaluating the role of inter-facility patient transfers that form the structure of these networks may provide insights on novel infection control measures. Identifying novel infection control strategies is especially important for multi-drug resistant pathogens such as Carbapenemase-producing Enterobacteriaceae (CPE) due to limited treatment options. The increasing use of inter-individual contact and inter-facility transfer network data in mathematical modelling of HAI spread has helped these models become more realistic; however, they remain limited to a few settings and pathogens. The main objectives of this thesis were two-fold: 1) to better understand the structure of the healthcare networks of France and their impact on HAI spread dynamics; and 2) to assess the role of transfers on the spread of CPE in France during the 2012 to 2015 period. The French healthcare networks are characterized by centralized patient flows towards hubs hospitals and a two-tier community clustering structure. We also found that networks of patients with HAIs form the same underlying structure as that of the general patient population. The number of CPE episodes have increased over time in France and projections estimate that the number of monthly episodes could continue to increase with seasonal peaks in October. The general patient network was used to show that, since 2012, patient transfers have played an increasingly important role over time in the spread of CPE in France. Multiple spreading events of CPE linked to patient transfers were also observed. Despite subtle differences in the flows of patients with an HAI and the general patient population, the general patient network may best inform novel infection control measures for pathogen spread. The structure of healthcare networks may help serve as a basis for novel infection control strategies to tackle HAIs in general but also CPE in particular. Key healthcare hubs in large metropoles and key patient flows connecting hospital communities at the local and regional level should be considered in the development of coordinated regional strategies to control pathogen spread in healthcare systems. / La propagation des infections nosocomiales (IN), notamment liées aux bactéries multi-résistantes, au sein du réseau des hôpitaux, est un grand enjeu de santé publique. L’évaluation du rôle joué par les transferts inter-établissements des patients sur cette propagation pourrait permettre l’élaboration de nouvelles mesures de contrôle. L’identification de nouvelles mesures de contrôle est particulièrement importante pour les bactéries résistantes aux antibiotiques comme les entérobactéries productrices de carbapenemase (EPC) pour lesquelles les possibilités de traitement sont très limitées. L’utilisation des données de réseaux de contact inter-individus et de transferts inter-établissement dans la modélisation mathématique ont rendu ces modèles plus proches de la réalité. Toutefois, ces derniers restent limités à quelques milieux hospitaliers et quelques pathogènes. La thèse a eu pour objectifs de 1) mieux comprendre la structure des réseaux hospitaliers français et leur impact sur la propagation des IN ; et 2) évaluer le rôle des transferts sur la propagation des EPC.Les réseaux hospitaliers français sont caractérisés par des flux de patients vers des hubs et par deux niveaux de communautés des hôpitaux. La structure du réseau de transfert des patients présentant une IN n’est pas différente de celle du réseau général de transfert des patients. Au cours des dernières années, le nombre d’épisode d’EPC a augmenté en France et les prédictions prévoient une poursuite de cette augmentation, avec des pics de saisonnalité en octobre. Ce travail a également montré que, depuis 2012, les transferts de patients jouent avec les années un rôle de plus en plus important sur la diffusion des EPC en France. Des évènements de propagation multiple liée aux transferts sont également de plus en plus souvent observés.En conséquence, la structure du réseau des hôpitaux pourrait servir de base pour la proposition des nouvelles stratégies de contrôles des IN en général, et des EPC en particulier. Les hôpitaux très connectés des grandes métropoles et les flux des patients entre les communautés locale et régionale doivent être considérés pour le développement de mesures de contrôle coordonnées entre établissements de santé.