O presente trabalho teve como objeto o desenvolvimento de uma proposta para avaliação da implantação da Central de Regulação Médica de Urgências (CRMU) vinculada ao Serviço de Atenção Móvel às Urgências da região do Médio Paraíba (SAMU 192 - MP). Para tal, propõe-se a criação de um modelo teóricológico que sirva como referência para elaboração de instrumentos e seleção de indicadores para avaliação da estrutura, processos e resultados da CRMU-MP, visando à melhor efetividade e eficiência desse serviço. O trabalho descreve as fases do processo de implantação e do funcionamento do SAMU-192 na região do Médio Paraíba. Aborda a sua importância para o sistema de saúde, visando minimizar quadros de demandas desnecessárias de urgência, com a diminuição dos fluxos informais de pacientes para grandes urgências hospitalares e préhospitalares da região, relatando os vários motivos relacionados à sobrecarga desses serviços na região: ineficiência da atenção básica; pronto-socorros préhospitalares e hospitalares de pequeno e médio porte sem retaguarda mínima de recursos diagnósticos e terapêuticos; fatores culturais; maior oferta das redes de alta complexidade; problemas relacionados à gestão. Questões sobre a estrutura da rede de urgências são mencionadas, evidenciando-se as deficiências do SUS: áreas físicas inadequadas e insuficientes, informalidade na contratação de recursos humanos além do despreparo dos profissionais que atuam nessa área. No cenário descrito, as ações de regulação despontam como ferramenta de defesa do cidadão, buscando garantir acesso ao meio mais adequado a suas necessidades. O desenho proposto (modelo teórico-lógico) descreve e identifica as etapas para avaliação do serviço (estrutura, processo e resultados), e também demonstra os diversos problemas encontrados na rede de atenção às urgências do Médio Paraíba. O trabalho faz uma revisão da literatura sobre os principais conceitos da regulação e da regulação médica de urgências; discorre sobre os aspectos da Política de Urgência e Emergência a partir de 2002, a inserção da região do Médio Paraíba e de sua rede de atenção às urgências neste contexto. Aborda os diversos conceitos da avaliação, com foco nos modelos teórico-lógicos e cita as estratégias metodológicas, empregando o modelo teórico-lógico como proposta para avaliar a implantação da CRMU. A última etapa trata da elaboração do modelo teórico-lógico, bem como de suas matrizes de avaliação e de seu elenco de indicadores. / The present work had the developing of a proposal the aim to evaluate the implementation of the Central de Regulação Médica de Urgências (CRMU) bound to the Serviço de Atenção Móvel às Urgências of Médio Paraíba region. (SAMU 192 - MP). For this the creation of a theorical-logical model is which serves as a reference to preparation of instruments and selection of indicators to evaluate the structure, processes and results of CRMU-MP, for a better effectiveness and efficiency of this service. The work describes the phases of the process of implementation and functioning of SAMU-192 in Médio Paraíba region. It addresses its importance to the healthy system, aiming to decrease the unnecessary demands of urgency, with the reduction of the informal flows of patients to hospital and pre-hospital big urgencies in the region, reporting the several related reasons to the encumbrance of the services in the region: inefficiency of the basic attention, small and medium prehospital and hospital emergency-rooms without the minimum rearward of diagnosis and therapeutic resources; cultural facts; a big offering of high complex networks; problems related to management. Issues about the structure the urgent networks are highlighted in the health system, evidencing the deficiencies of SUS: insufficient and inadequate physical areas, informality in hiring human resources besides the unprepared professional who work in this area. In the described scenario, the regulation actions emerge as a toll of defense of the citizen, searching the guarantee of the access to the most adequate way to their needs. The proposed drawing (theorical-logical model ) describes and identifies the steps to evaluate the service (structure, process, result ), and also demonstrates the several problems found in the network of attention of urgencies of Médio Paraíba. The work makes a revision of the literature about the principal concepts of regulation and of urgent medical regulation; talks about the aspects of the Emergency and Urgency Policy since 2002, the insertion of Médio Paraíba and its network of attention to the urgencies in this context. It addresses the several concepts of evaluating focusing the theorical-logical models and cites the strategies methodological, employing the theorical-logical model as a proposal to evaluate the implementation of CRMU. The last step treats about the elaboration of the theorical-logical model, as well as its matrices of evaluation and of its cast of indicators.

The retention of persons on an HIV programme has been a global challenge. The success of any strategy to optimize adherence to anti-retroviral therapy (ART) depends on the intensive and effective adherence counselling and strategies. It is important to research whether persons receiving anti-retroviral therapy in public hospitals in Ghana are receiving the needed service that would optimize their adherence to the anti-retroviral therapy. Therefore, this study explored and described the experiences of healthcare professionals providing care, support and guidance to persons on ART at public hospitals in Ghana, as well as the best-practice guideline that could contribute to facilitating the ART adherence of patients. This study also explored and described the experiences of persons living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) on ART, regarding their adherence to the therapy. The study was organized into three phases. In Phase One: a qualitative, exploratory, descriptive and contextual design was employed. The research population included healthcare professionals, providing services at the HIV clinic at the public hospitals in Ghana, namely the Korle-Bu Teaching Hospital; the 37 Military Hospital and the Ridge Hospital. The healthcare professionals comprised of doctors, nurses, pharmacists and trained counsellors employed in any of the three public hospitals. Persons receiving ART at any of the three public hospitals were also part of the research population. Semi-structured interviews were conducted with healthcare professionals and persons receiving ART. Data were collected from healthcare professionals in relation to their experiences regarding the provision of ART services, their understanding of evidence-based practice and best-practice guidelines, as well as data on the experiences of persons receiving ART in relation to their adherence to the therapy. The data were analysed using Creswell’s six steps of data analysis; and the coding of the data was done according to Tesch’s eight steps of coding. Trustworthiness was ensured by using Lincoln and Guba’s framework which comprised credibility, transferability, dependability, confirmability and authenticity. Ethical principles such as beneficence and non-maleficence, respect for human dignity, justice, veracity, privacy and confidentiality were considered in the study. In phase two, the literature was searched by using an integrative literature review approach and critically appraising the methodological quality of the guidelines in order to identify the best available evidence related to adherence to ART. In Phase Three, a best-practice guideline for facilitating adherence to ART was developed for public hospitals in Ghana based on the findings of the empirical research of Phase One and the integrative literature review in Phase Two. The guideline was submitted to an expert panel for review; and it was modified, according to the recommendations of the panel.

Problemas relacionados a medicamentos (PRMs) compreendem erros de medicação (EMs) e reações adversas a medicamentos (RAMs). Este estudo teve por objetivo analisar, classificar, quantificar e intervir nos PRMs ocorridos em pacientes idosos internados. Este estudo prospectivo descritivo de uma série de casos clínicos abrangeu 28 pacientes e 100 prescrições aleatórias a eles destinadas. A identificação dos PRMs se deu por métodos de farmacovigilância ativa e as intervenções farmacêuticas (IFs) foram realizadas diretamente junto à equipe médica. Medicamentos de uso potencialmente inapropriado para idosos foram utilizados por 21,4% dos pacientes; 19% das prescrições possuíam rasuras. Foram encontrados 924 PRMs, sendo 920 EMs e 4 possíveis RAMs, sendo uma delas confirmada. A maioria dos EMs foi classificada como sem prejuízo ao paciente. Foram realizadas 143 IFs em 73 prescrições de 92,9% dos pacientes, sendo a maioria (77,6%) acatada pela equipe médica. Apesar das limitações, demonstrou-se a importância do farmacêutico na investigação, prevenção e solução de PRMs. / Drug related problems (DRPs) include medication errors (MEs) and adverse drug reactions (ADRs). The objective of this study was to analyze, classify, quantify and intervene in DRPs occurred in hospitalized elderly patients. This prospective descriptive study of a case series included 28 patients and 100 random prescriptions to them addressed. The identification of DRPs was carry out by methods of active pharmacovigilance and the pharmaceutical interventions (PIs) were performed directly with the medical staff. Drugs potentially inappropriate for the elderly were used by 21.4% of the patients; 19% of the prescriptions had rasures. There were 924 DRPs, with 920 MEs and 4 possible ADRs 4, one of which confirmed. The majority of MEs was classified as \"without harm to the patient\". Were carried out 143 PIs on 73 prescriptions of 92.9% of the patients, being the majority (77.6%) fully embraced by the medical staff. Despite the limitations, it was possible to demonstrate the pharmacist importance in research, prevention and resolution of DRPs.

Orientadores: Gastão Wagner de Sousa Campos, Nelson Rodrigues dos Santos / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas / Made available in DSpace on 2018-08-15T16:39:37Z (GMT). No. of bitstreams: 1 Alves_FabioLuiz_M.pdf: 868609 bytes, checksum: ddd3782bd9e46828eab8144cc3d66090 (MD5) Previous issue date: 2009 / Resumo: A organização hospitalar e o seu modo de funcionamento tradicional podem ser vistos como um reforço ao modelo de trabalho em saúde sustentado pelo modelo biomédico. Esta pesquisa é o relato analítico da interação do pesquisador, um médico sanitarista, com o desenvolvimento de um projeto institucional em um hospital público e universitário, com características muito próprias, com papel de assistência, ensino e pesquisa. Foram estudadas as principais diretrizes em implementação com o objetivo de descrever e analisar os arranjos e suas tessituras para a gestão, o trabalho em saúde e a inserção do HC-UNICAMP no SUS regional. O trabalho de Apoio Institucional foi avaliado como processo de intervenção no desenvolvimento da pesquisa e construção das diretrizes institucionais. A metodologia utilizada foi o estudo de documentos oficiais com base em seleção, leituras e análises dos seus conteúdos das portarias normatizadoras, atas de reuniões e instrumentos estruturados. Outra fonte importante foi a produção de um diário de campo que registrou considerações, observações e acontecimentos vivenciados nos espaços coletivos com outros atores no campo de intervenção. No estudo documental utilizamos categorias de análise à partir do conceito de práxis, em que os sujeitos compreendem suas ações e práticas sociais, o que lhe ampliaria o caráter criativo a partir das possibilidades objetivas e subjetivas apreendidas da realidade. O estudo permitiu construir a matriz analisadora de síntese das principais diretrizes como caráter teleológico da modelagem para o Chefe de Atenção Clínica, Unidade Produtiva, Colegiado de Gestão, Protocolo Assistencial e Contrato de Gestão. Os resultados demonstram que o processo de mudança se deu a partir da implementação das diretrizes com a intervenção do Apoio Institucional observando transformação na organização da gestão e do trabalho em saúde / Abstract: The hospital organization and its traditional mode of operation can be seen as a model for strengthening health work supported by the biomedical model. This research is the analytical report of the interaction of the researcher, a sanitarian with the development of an institutional project in a public hospital and university, with its own characteristics, the role of care, teaching and research. We studied the main guidelines being implemented in order to describe and analyze their textured arrangements and for the management, health work and the insertion of HCUNICAMP in regional SUS. The work of Institutional Support was assessed as an intervention process in the development of research and building of institutional guidelines. The methodology used was the study of official documents on the basis of selection, reading and analysis of the contents of normalizing ordinances, minutes of meetings and structured instruments. Another important source was the production of a diary which recorded considerations, observations and events experienced in collective spaces with other actors in the field of intervention. The desk study use categories of analysis from the concept of praxis, in which individuals understand their actions and social practices, which will broaden the creative genius from the opportunities seized objective and subjective reality. The study allowed us to construct a matrix analyzer summary of the main guidelines as teleological character modeling Chief Clinical Care Unit, Production, Collegiate Management, Protocol Assistance and Contract Management. The results show that the process of change took place after the implementation of the guidelines with the assistance of the Institutional Support observed transformation in the organization management and health work / Mestrado / Saude Coletiva / Mestre em Saude Coletiva

O SAMU brasileiro utiliza o modelo francês e opera com uma Central Única de Regulação Médica regionalizada, hierarquizada e descentralizada na composição das equipes de socorro e unidades móveis como USBs (Unidade de Suporte Básico) e USAs (Unidade de Suporte Avançado) que variam de acordo com o tipo de gravidade do caso. Na cidade de Ribeirão Preto, o serviço do SAMU, implantado em 1996, era municipal até 2012, porém seguindo as resoluções e portarias do Ministério da Saúde houve a necessidade da transição do SAMU Municipal para o SAMU Regional, com um único número (192) para os 26 municípios do Departamento Regional de Saúde de Ribeirão Preto (DRS XIII) sendo composto/constituído por 38 (trinta e oito) USBs sendo 01 USB para cada base descentralizada, 13 USB para Ribeirão Preto, 01 (uma) equipe de motolância e mais 03 (três) USAs (unidades de suporte avançado de vida) para cada base nos municípios polos microrregionais (Ribeirão Preto, Sertãozinho e Batatais). Com base nessas informações, este estudo visou caracterizar a estrutura e funcionamento do SAMU Municipal e sua Central de Regulação de Urgência e a transição para a regionalização nos seus aspectos estruturais, recursos humanos, tecnológicos e principalmente a viabilidade financeira, considerando o repasse tripartite (estado - união e município) insuficientes. Para a viabilidade financeira foi instituído o Consórcio CIS-AVH (consórcio intermunicipal de saúde - Aquífero guarani, Vale das cachoeiras e Horizonte verde). Os Consórcios Intermunicipais de Saúde (CISs) são importantíssimos instrumentos de cooperação e gestão entre municípios integrados, com 9interesses comuns definidos através do Plano Anual de Trabalho descritos pelos gestores municipais, conselhos e entidades públicas que estabelecem as prioridades e necessidades de determinado local e região. O objetivo foi criar soluções para problemas comuns, racionalizando a ação governamental a partir da realização conjunta de atividades de promoção, proteção e recuperação da saúde. Observa-se o fortalecimento da co-gestão compartilhada em saúde, em especial para os municípios de menor porte, cujas capacidades de investimento no setor são reduzidas em razão do limitado orçamentos disponível, as crescentes necessidades dos cidadãos, o avanço do aparato tecnológico e seus custos e principalmente o ganho por meio de editais de aquisição, compras ou contratação em escala seja de serviços, exames ou insumos. / The Brazilian SAMU uses the French model and operates with a regionalized, hierarchical and decentralized Single Regulated Medical Regulation Center in the composition of rescue teams and mobile units such as USBs (Basic Support Unit) and USAs (Advanced Support Unit) that vary according to with the type of severity of the event. In the city of Ribeirão Preto, the SAMU service, implemented in 1996, was municipal until 2012, but following the resolutions and ordinances of the Ministry of Health, there was a need to transition from SAMU Municipal to SAMU Regional, with a single number (192) for the 26 municipalities of the Regional Health Department of Ribeirão Preto (DRS XIII) consisting of 38 (thirty-eight) USBs, with 1 USB for each decentralized base, 13 USB for Ribeirão Preto, 01 (one) motolance team and more 03 (three) USAs (advanced life support units) for each base in the microregional poles municipalities (Ribeirão Preto, Sertãozinho and Batatais). Based on this information, this study aimed to characterize the structure and functioning of the Municipal SAMU and its Central Emergency Regulation and the transition to regionalization in its structural aspects, human resources, technological and mainly financial viability, considering the tripartite pass-through insufficient. (2013 to 2016). For the financial viability, the CIS-AVH Consortium (inter-municipal health consortium - Aquifer, Guaraní, Vale das cachoeiras and Horizonte verde) was instituted. The Intermunicipal Health Consortiums (CISs) are very important instruments of cooperation and 11management among integrated municipalities, with common interests defined through the Annual Work Plan described by municipal managers, councils and public entities that establish the priorities and needs of a given place and region. With the objective of creating a solution to common problems, rationalizing government action through joint activities to promote, protect and recover health. The strengthening of shared co-management in health is observed, especially for smaller municipalities, whose investment capacities in the sector are reduced due to the limited budgets available, the growing needs of the citizens, the advancement of the technological apparatus and its costs, and especially the gain through purchase, purchase or scale calls for services, examinations or inputs.

M. Curr. / Mental health challenges are a worldwide phenomenon, and more people are experiencing these challenges which are related to the life style and psychological stressors facing them. Addressing this burden is a challenge to health care providers, as some are influenced by their perceptions about mental illness in facing the demands made be society. Registered nurses who are not trained in psychiatric nursing do not have the appropriate background information or skill of how to cope with patients with mental health challenges even if they have undergone an introduction into nursing psychology at college. This increases their fears and anxieties when having to interact with these patients. The aim of this study is thus to explore the experiences of registered nurses in interaction with patients with mental health challenges so as to be able to formulate and describe guidelines to facilitate the registered nurses mental health.

In the hospital environment is observed profound and constant change, with the growing and accelerated technological innovation that makes available to health professionals and users, various types of technologies, where there are the educational technologies, management technologies and assistive technologies. The technologies are part of the nursing inserting in health in the workplace, especially in hospitals. This scenario is constituted by various kinds of technologies which constantly change so as to require professional development suitability for dealing with them accurately and efficiently. In this technological age sometimes the conception of the term technology also has been used in an emphatic, incisive and decisive manner, but mistaken, it has been seen only as a product or equipment. technology concepts are different, and from a scientific knowledge, systematized, organized, applied and practical - which requires human presence and is concretized in the act of caring, to a transformative and emancipatory conception of the subject. The cuidativo-educational technologies are covered in this research as a set of knowledge / scientific knowledge, that support the operation of the process of caring for and educating each other directly and indirectly in the nurse practice, from everyday experience and research within a critical perspective, reflective, creative, transformative and multidimensional between humans and the environment in which they operate. This study aimed to analyze the insertion of cuidativo-educational technologies in the practice of nurses working in a university hospital. This is a field research with a qualitative approach, descriptive and exploratory, developed with 21 nurses of a university hospital in Rio Grande do Sul. The data were collected through non-participant observation and semi-structured interview period March to December 2015. the analysis and interpretation of data occurred through Content analysis. the ethical aspects were respected under Resolution 466/2012. Emerged as a result the design of the nurses on the concept that these attributed to the terms: technologies, care technology, educational and cuidativo-educational. He was perceived hegemony of reductionist design the machine, tool, artifact in the speeches of the participants, however, some nurses considered as technological ability, knowledge of the professional. The cuidativo-type education was seen as the intertwining of care-educate and educate care, where one can not (co) exist without the other. In the context of hospital work, brochures, manuals, brochures, websites, among others, detached cuidativo-educational possibility, then, with the interrelationship people-person, person-tool or person-universe. As a contribution, the Cuidativo-educational technologies allow to develop or strengthen the autonomy of the subjects involved in the health-disease, with the foundation, the empowerment of the human being in their living conditions in its multidimensionality. / Em âmbito hospitalar observa-se profundas e constantes mudanças, com a crescente e acelerada inovação tecnológica, que disponibiliza aos profissionais da saúde e usuários, os mais diversos tipos de tecnologias, onde destacam-se as tecnologias educacionais, tecnologias gerenciais e tecnologias assistenciais. As tecnologias fazem parte da enfermagem inserindo-se no contexto de trabalho em saúde, principalmente em hospitais. Este cenário é constituído por diversos tipos de tecnologias, as quais se modificam constantemente, de modo a exigir dos profissionais o desenvolvimento de aptidão para lidar com as mesmas de forma precisa e eficaz. Nesta era tecnológica por vezes a concepção do termo tecnologia ainda tem sido utilizado de forma enfática, incisiva e determinante, porém equivocada, pois tem sido vista somente como um produto ou equipamento. Os conceitos de tecnologia são vários, sendo desde um conhecimento científico, sistematizado, organizado, aplicado e prático - o que requer a presença humana e se concretiza no ato de cuidar, até uma concepção transformadora e emancipatória dos sujeitos. As tecnologias cuidativo-educacionais são tratadas nesta pesquisa como um conjunto de saberes/conhecimentos científicos, que sustentam a operacionalização do processo de cuidar e educar do outro de modo direto e indireto na práxis do enfermeiro, a partir da experiência cotidiana e da pesquisa dentro de uma perspectiva crítica, reflexiva, criadora, transformadora e multidimensional entre os seres humanos e o meio em que se inserem. Objetivou-se analisar a inserção das tecnologias cuidativo-educacionais na práxis dos Enfermeiros que atuam em um Hospital Universitário. Trata-se de uma pesquisa de campo, com abordagem qualitativa, do tipo descritivo e exploratório, desenvolvida com 21 enfermeiras de um Hospital Universitário do Rio Grande do Sul. A coleta de dados ocorreu por meio de observação não participante e entrevista semiestruturada no período de março a dezembro de 2015. A análise e interpretação dos dados ocorreu por meio da Análise de Conteúdo. Foram respeitados os aspectos éticos conforme a Resolução 466/2012. Emergiram como resultados a concepção das enfermeiras acerca do conceito que estas atribuíram aos termos: tecnologias, tecnologia de cuidado, educacionais e cuidativo-educacionais. Percebeu-se a hegemonia da concepção reducionista a máquina, ferramenta, artefato nos discursos das participantes, contudo, algumas enfermeiras consideraram como possibilidade tecnológica, o conhecimento do profissional. A tipologia cuidativo-educacional foi vista como o entrelaçamento do cuidar-educar e educar-cuidar, onde uma não pode (co)existir sem a outra. No contexto do trabalho hospitalar, os folders, manuais, cartilhas, web site, entre outros, desprenderam possibilidade cuidativo-educativa, logo, havendo a inter-relação pessoa-pessoa , pessoa-ferramenta ou pessoa-universo. Como contribuição, as Tecnologias Cuidativo-educacionais permitem o desenvolver ou fortalecer da autonomia dos sujeitos envolvidos no processo saúde-doença, tendo como fundamento, o empoderamento do ser humano sob sua condição de vida na sua multidimensionalidade.

Masters in Public Administration - MPA / South Africa

The aim of this study was to investigate the attachment styles of children between the ages of six and twelve years of age who were admitted as inpatients in a children’s ward of a psychiatric hospital. Attachment theory (Bowlby, 1997, 1998) proposes that children develop certain attachment styles towards their primary caregivers from birth through to three years of age, after which the styles remain relatively constant as can be seen through attachment behaviours later on in life. These attachment styles can be secure, insecure-ambivalent / anxious or insecure-avoidant (Ainsworth, Blehar, Waters&Wall, 1978). Green and Goldwyn (2002) also refer to a fourth category that was established through later research on attachment, named disorganised attachment. Psychiatric hospitalisation of a child implies the assumption of psychopathology and through institutionalisation, he or she is literally separated from the primary caregivers and inevitably placed in unfamiliar surroundings with strangers, making it an ideal setting to investigate attachment features. The researcher worked from the supposition that the mere fact of hospitalisation and implied pathology would thus point to insecure attachment styles in these children. A qualitative research design was implemented to gather information regarding the children’s attachment styles. Two projective techniques were used, namely the Children’s Apperception Test and the Picture Test of Separation and Individuation. Analysis of the information consisted of a first- and second-order process of thematic content analysis. The results yielded thirteen categories of experience. An extensive description of each category was provided, and the categories were then related to theory. The results obtained support previous research findings that found that institutionalised children tend to show more insecure attachment styles. The results from this study also indicated that these insecure attachment styles tend to be predominantly insecure-avoidant or insecure-disorganised. / Dissertation (MA(Psychology))--University of Pretoria, 2007. / Psychology / unrestricted

The primary motivation of this PhD by publication has been the apparent disconnect between the metrics of hospital quality of care at national and board level and patients’ experiences. Exploration of the gap led to the realisation of two key points. Firstly, the concept of healthcare quality continually evolves. Secondly, the NHS Scotland Measurement Framework does not include a measure of patient experience at the microsystem level (e.g. hospital ward). This is needed to counterbalance easier to obtain metrics of quality (e.g. waiting times). Resource tends to follow measurement. Papers 1 and 2 were exploratory, investigating theoretical and practical aspects of measuring quality of hospital care at the clinical microsystem level. With the associated Chapters, they highlighted both the necessity and the possibility of measuring the patient experience at the micro level of the healthcare system. They also drew attention to the inadequacy of “satisfaction” as a metric, leading to closer examination of “experience” as the decisive metric. This required the development of a systematic review protocol (Paper Three), then a systematic review (Paper Four). The review (Paper Four) examined the utility (validity, reliability, cost efficiency, acceptability and educational impact) of questionnaires to measure the patient experience of hospital quality of care, with a newly devised matrix tool. Findings highlighted a gap for an instrument with high utility for use at the clinical microsystem level of healthcare. Paper Five presents the development and preliminary psychometric testing of such an instrument; the Care Experience Feedback Improvement Tool (CEFIT). The thesis provides, as well as the matrix tool and CEFIT, theoretical and methodological contributions in the field of healthcare quality. It contributes to an aspiration that the patient’s voice can be heard and acknowledged, in order to direct improvements in the quality of hospital care.