Thesis (M.A.)--George Washington University. / Bibliography: p. 43-49.

Thesis (M.A.)--George Washington University. / Bibliography: p. 43-49.

Thesis (DPhil (SW Play Therapy))--University of Pretoria, 2004. / Includes bibliographical references.

Thesis (M.S.)--University of Michigan, 1982.

Thesis (M.H.A.)--University of Michigan, 1974.

Thesis (Ph. D.)--University of Wisconsin--Madison, 1960. / Typescript. Vita. eContent provider-neutral record in process. Description based on print version record. Includes bibliographical references.

Submitted by Simone Souza (simonecgsouza@hotmail.com) on 2018-06-13T15:41:14Z No. of bitstreams: 1 DISS_2013_ Ivete Meneguzzi.pdf: 1450057 bytes, checksum: 78b9188ebfaad4e686a82664138d264a (MD5) / Approved for entry into archive by Jordan (jordanbiblio@gmail.com) on 2018-06-15T16:32:51Z (GMT) No. of bitstreams: 1 DISS_2013_ Ivete Meneguzzi.pdf: 1450057 bytes, checksum: 78b9188ebfaad4e686a82664138d264a (MD5) / Made available in DSpace on 2018-06-15T16:32:51Z (GMT). No. of bitstreams: 1 DISS_2013_ Ivete Meneguzzi.pdf: 1450057 bytes, checksum: 78b9188ebfaad4e686a82664138d264a (MD5) Previous issue date: 2013-11-29 / Aproximadamente 2/5 da população mundial encontra-se em áreas de risco para contrair dengue. Anualmente ocorrem 50 milhões de infecções, destes 500.000 casos de Febre Hemorrágica de Dengue e 21.000 óbitos. No Brasil a doença foi reintroduzida no início da década de 1980. Em Mato Grosso, desde 2002 sucessivas epidemias são registradas. A capital tem sido bastante afetada pela doença e sua letalidade se mostra alta mostrando a necessidade de se avaliar a assistência prestada aos pacientes com dengue. OBJETIVO: Avaliar a implementação da assistência hospitalar para os casos de dengue em quatro hospitais de referência no município de Cuiabá - MT no período de janeiro de 2012 a julho de 2012. MÉTODO: Trata-se de um estudo de caso e a estratégia utilizada foi análise de implementação das ações de assistência hospitalar aos casos de dengue em quatro unidades hospitalares a partir da avaliação do contexto interno (insumos e atividades), político organizacional. Os critérios e parâmetros utilizados foram adaptados do estudo de VINHAL (2008). As fontes de dados foram: aplicação de questionário com os responsáveis pelo programa de controle da dengue, diretores, profissionais médicos e enfermeiros plantonistas das unidades hospitalares; análise documental e roteiro para revisão de prontuários. Análise das informações pela quantificação dos dados segundo as categorias de conformidade (disponibilidade, adequação, qualidade técnica e oportunidade) e gerencial (planejamento e educação permanente). RESULTADOS: O contexto político organizacional para a assistência a pessoa com dengue atingiu um grau de implementação parcial. Na avaliação do contexto interno uma unidade apresentaram implementação insatisfatória com grau de pontuação observado em relação ao desejado de 34,3% e três unidades apresentaram um grau de implementação parcial, 55,7, 68,6 e 51,4%, respectivamente O que concorreu para os resultados negativos foi principalmente a conformidade das ações segundo a qualidade técnica-científica relacionadas às ações de assistência à dengue são executadas. CONCLUSÃO: A assistência hospitalar se configura ainda como um dos grandes problemas na assistência ao paciente com dengue. Os resultados observados se devem principalmente pela ausência de um planejamento específico para as ações de assistência, a não utilização do protocolo clínico e a inexistência de uma política de educação continuada. / Approximately two-fifths of the world population is at risk areas for contracting dengue. Currently, 50 million infections occur, of these 500.000 cases of Dengue Hemorrhagic Fever and 21.000 deaths. In Brazil the disease was reintroduced in the early eighties. In Mato Grosso, since 2002 successive epidemics are recorded. The capital has been greatly affected by the disease and its high lethality shows the need to evaluate the assistance given to the patients with dengue. OBJECTIVE: To evaluate the implementation in the delivery of hospital care for dengue cases in four reference hospitals in the municipality of Cuiabá - MT from January 2012 to July 2012. METHOD: This is a case study and the strategy used was the analysis of the implementation of the hospital assistance procedures to treat the dengue cases in four hospital units from the evaluation of the internal (inputs and activities) political, organizational context. The criteria and parameters used were adapted from VINHAL study (2008). The data sources were: a questionnaire completed by those responsible for the program of dengue control, directors, healthcare professionals and on-duty nurses of hospital units; document analysis and guide for review of medical records. Data analysis was performed through data quantification according to the conformity (availability, adequacy, technical quality and opportunity) and managerial (planning and continuing education) categories. RESULTS: The organizational political context for the assistance of people with dengue has reached a degree of partial implementation. In the evaluation of the internal context a unity presented unsatisfactory implementation with a score observed in relation to the one expected of 34,3% and three units presented a degree of partial implementation, 55,7, 68,6 e 51,4%, respectively. What contributed to these negative results was mainly the conformity of actions according to the technical-scientific quality related to the assistance procedure to treat dengue cases. CONCLUSION: Hospital care is still one of the major problems in the assistance to patients with dengue. The results observed are mainly due to the lack of a specific plan for care procedures, non-observance of a clinical protocol and the absence of a continuing education policy.

This study explores the use of early warning scores (EWS) in deteriorating patients. These are widely used tools to measure vital signs and highlight abnormal physiology in acutely unwell patients. Measurements of the process in the management of the deteriorating patient includes time to first assessment of such patients. The level of clinician involved in the subsequent management is also investigated to determine whether escalation of care was appropriate. This work is a retrospective case note analysis of the recognition and management of deteriorating patients prior to critical care admission. Research Questions 1. What violations in the optimum process are associated with sub-optimal recognition and management of deteriorating patients and delayed critical care admission in patients triggering early warning scores in acute care wards? 2. Are there independent variables which can predict the delay in the recognition and management of deteriorating patients and subsequent critical care admission? Methods The literature was reviewed to determine the optimum process of recognition and management of deteriorating patients in acute care wards. A data collection tool was then specifically designed and locally validated to extract objective data from the case records. A sample of 157 patients admitted to critical care from acute wards over a 6 month period were included in the study. The case records were then retrospectively reviewed and information was extracted using the data collection tool. Results The accuracy and frequency of early warning scores were measured and findings demonstrated that 59% of Early Warning Scores (EWS) were miscalculated. The most frequent of those miscalculated were the intermediate scores (4 or 5) (error rate - 52%) followed by the higher scores (6 or more) (error rate - 32%). The least frequently miscalculated were the lower scores (0 -3) (error rate 15%). Descriptive data from the sample such as age, ward, diagnosis, time of hospital admission, time and day of transfer / EWS triggering were included. From the total case records reviewed, 110 patients had abnormal Early Warning Scores (4 or more) and were included in the inferential data analysis. The independent variables related to the processes objectively measurable in the recognition and management of deteriorating patients were included. After descriptive analysis the independent variables were cross-tabulated with the dependent variable using Pearson chi-square. The dependent variable was identified from the literature. This was whether time from triggering an abnormal EWS to critical care admission was delayed more than 6 hours. The subsequent predictor variables were then entered in to a binary logistic regression model for statistical analysis using SPSS version 21 software. Binominal Logistic Regression Analysis identified three significant variables predicting delay of the recognition and management of deteriorating patients. • Frequency of EWS measurement not increased appropriately • Length of stay prior to critical care admission 12-36 hours • If no consultant review during 6 hours of abnormal EWS Implications for Future Practice This study highlights areas of risk in the detection of patients’ clinical deterioration in acute wards. These findings should guide quality improvement to prevent unnecessary morbidity and mortality. As a key area of patient risk included the lack of frequency and accuracy of EWS measurements, staff education is required to ensure staff are given the appropriate knowledge to understand the use of the tool. Regular review of the frequency of measurement is also required as this was statistically significant in the delay to critical care admission. The high risk time from admission of 12-36 hours needs further investigation. This study also highlights the need for senior decision makers to be involved in the care of deteriorating patients to improve outcomes.

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.

This work approaches the perception of coercion, on the part of the patient, n the process of informed consent which constitutes an important element in health. The perception of coercion may be associated with this practice so that the subject perceives that has not been able to express their will with respect to its treatment. One searched to evaluate if the patient perceived himself able to express his opinion in the authorization process for the realization of care procedures and understand the involved factors in this perception, according to these subjects. Also one used instruments of evaluation of the level of literacy and development psychological-moral in order to better understand the factors involved in decision making in healthcare. The present work consists in a transversal study, which was applied Expression Scale of Coercion in Care, the Instrument of Evaluation of the Development Psychological-moral and the instrument of Evaluation of Literacy in two samples: one consisting of 143 outpatients and another of 142 patients admitted to HUSM. The technique of half-structuralized interview was also used to understand the factors that had taken the patients to indicate discomfort in expressing themselves. These subjects constitute a sub-sample, consisting of six subjects who responded to the questionnaires mentioned above showing some degree of expression of coercion on the scale applied in order to evaluate this data. In the found results, the relative data to this measure are not differentiated between the samples, and indicate a low level of perception of coercion when expressing itself. It was observed that the research subjects, in its majority, meet in the concientious level of the development scale psychological-moral. In both the samples had prevalence of the rudimentary level of literacy. In sub-sample interviewed may be noted the identification by the patient, of whom did not have voice in the treatment seems linked to the supply of information, the experiences with the hospital, and also the elements as the time of attachment to the institution, the gratitude and the way as the experiences had been integrated psychically by the subject / Este trabalho aborda a percepção de coerção, por parte do paciente, no processo de consentimento livre e esclarecido o qual se constitui como elemento importante na área da saúde. A percepção de coerção pode estar associada a essa prática de modo que o sujeito perceba que não foi capaz de expressar sua vontade com relação ao seu tratamento. Buscou-se avaliar se o paciente percebeu-se capaz de expressar sua opinião no processo de autorização para a realização de procedimentos assistenciais e compreender os fatores envolvidos nesta percepção, de acordo com estes sujeitos. Também utilizou-se instrumentos de avaliação do nível de alfabetismo funcional e desenvolvimento psicológicomoral a fim de melhor compreender os fatores envolvidos na tomada de decisão em assistência à saúde. O presente trabalho constituiu-se em um estudo transversal, onde foi aplicada a Escala de Expressão de Coerção em Assistência, o Instrumento de Avaliação do Desenvolvimento Psicológico-moral e o Instrumento de Avaliação de Alfabetismo Funcional em duas amostras: uma constituída de 143 pacientes ambulatoriais e outra de 142 pacientes internados no HUSM. Utilizou-se também a técnica de entrevista semi-estruturada para poder compreender os fatores que levaram os pacientes a indicar desconforto ao expressar-se. Estes sujeitos constituem uma sub-amostra, sendo composta por 6 dos sujeitos os quais responderam aos questionários citados anteriormente e apresentaram algum grau de expressão de coerção na escala aplicada com a finalidade de avaliar este dado. Nos resultados encontrados, os dados relativos a esta medida não se diferenciam entre as amostras, e indicam um nível baixo de percepção de coerção ao expressar-se. Foi observado que os sujeitos da pesquisa, em sua maioria, encontram-se no nível consciencioso da escala de desenvolvimento psicológico-moral. Em ambas as amostras houve prevalência do nível rudimentar de alfabetismo funcional. Na sub-amostra entrevistada pode-se observar que a identificação, pelo paciente, de que não teve voz no tratamento parece interligada ao fornecimento de informação, às vivências junto ao hospital, e ainda a elementos como o tempo de vinculação à instituição, à gratidão e ao modo como as vivências foram integradas psiquicamente pelo sujeito.