OF MASTER THESIS Author: Bc. Kateřina Králová Supervisor: MUDr. Tereza Gueye Title of master thesis: Evaluation of Occupational Therapy Intervention in Acute Inpatient Rehabilitation of Cerebrovascular Units Abstract This diploma thesis deals with the evaluation of occupational interventions on the specific separation of beds of early rehabilitation of the cerebrovascular center of the General University Hospital in Prague. The subject of interest is primarily the results of the assessment obtained through the Functional Independence Measure (FIM) and the Montreal Cognitive Assessment. The thesis has two main objectives, namely mapping and analyzing the tools used to assess self-sufficiency and cognitive functions in the department. You can find the description of the evaluation tools in the theoretical part of the thesis. It is also an overview of the topic of the selected topic and a brief description of the system of cerebrovascular care in the Czech Republic. The second objective was to evaluate variables such as length of hospitalization and cognitive status in relation to patient self-sufficiency at the end of hospitalization. Three hypotheses have been identified to meet this goal. The practical part describes the results of the used tools for a particular department. The research group...

OF MASTER THESIS Author: Bc. Kateřina Králová Supervisor: MUDr. Tereza Gueye Title of master thesis: Evaluation of Occupational Therapy Intervention in Acute Inpatient Rehabilitation of Cerebrovascular Units Abstract This diploma thesis deals with the evaluation of occupational interventions on the specific separation of beds of early rehabilitation of the cerebrovascular center of the General University Hospital in Prague. The subject of interest is primarily the results of the assessment obtained through the Functional Independence Measure (FIM) and the Montreal Cognitive Assessment. The thesis has two main objectives, namely mapping and analyzing the tools used to assess self-sufficiency and cognitive functions in the department. You can find the description of the evaluation tools in the theoretical part of the thesis. It is also an overview of the topic of the selected topic and a brief description of the system of cerebrovascular care in the Czech Republic. The second objective was to evaluate variables such as length of hospitalization and cognitive status in relation to patient self-sufficiency at the end of hospitalization. Three hypotheses have been identified to meet this goal. The practical part describes the results of the used tools for a particular department. The research group...

Submitted by Simone Souza (simonecgsouza@hotmail.com) on 2017-09-20T14:37:32Z No. of bitstreams: 1 DISS_2014_Miguel Aprelino Alito.pdf: 4695957 bytes, checksum: 0f8d53c15612c14ec0bd4276f60d6c20 (MD5) / Approved for entry into archive by Jordan (jordanbiblio@gmail.com) on 2017-09-26T12:50:06Z (GMT) No. of bitstreams: 1 DISS_2014_Miguel Aprelino Alito.pdf: 4695957 bytes, checksum: 0f8d53c15612c14ec0bd4276f60d6c20 (MD5) / Made available in DSpace on 2017-09-26T12:50:06Z (GMT). No. of bitstreams: 1 DISS_2014_Miguel Aprelino Alito.pdf: 4695957 bytes, checksum: 0f8d53c15612c14ec0bd4276f60d6c20 (MD5) Previous issue date: 2014-08-25 / Introdução: Protocolos multimodais, quando empregados, melhoram variáveis clínicas perioperatórias e pós-operatórias. Existe pouca informação sobre abreviação do jejum préoperatório com oferta de líquidos claros enriquecidos com carboidratos e imunomoduladores em operações ortopédicas. O projeto ACERTO (ACEleração da Recuperação Total pósoperatória) é baseado em um programa europeu já existente (ERAS) e fundamentado no paradigma da medicina baseada em evidências. É antes de tudo um programa educativo. Objetivos: Avaliar variáveis clínicas, bioquímicas inflamatórias e segurança de um protocolo multimodal em pacientes submetidos à cirurgia de artroplastia total do quadril, utilizando-se técnica cimentada em fêmur e sem cimento no acetábulo (artroplastia total de quadril tipo híbrida). Métodos: Estudo prospectivo com 32 pacientes (16 do sexo masculino, com idade média de 58 anos variando de 26 a 85 anos) randomizados em dois grupos: 17 pacientes (Grupo ACERTO) submetidos a jejum abreviado com oferta de maltodextrina a 12,5%, 2h antes da indução anestésica e uso de dieta imunomoduladora por cinco dias previamente a cirurgia; 15 pacientes (Grupo CONTROLE) submetidos a jejum de 8 horas sem terapia nutricional préoperatória. Foram avaliados clinicamente broncoaspiração na indução anestésica e tempo de internação e em exames laboratoriais os níveis de hemoglobina (HB), velocidade de hemossedimentação (VHS) e proteína C reativa (PCR) no pré-operatório e com 48h de pósoperatório. Resultados: Não ocorreram óbitos, infecções, luxações da prótese, necessidade de reoperação, ou transfusões sanguíneas. Nenhum caso de broncoaspiração ocorreu na indução anestésica. Pacientes do Grupo ACERTO apresentaram, em média, dois dias a menos de internação hospitalar (P < 0,01). A taxa de HB foi similar entre os grupos no pré e pósoperatório. Valores de VHS se mantiveram semelhantes entre os grupos no pós-operatório (p = 0,09), mas a PCR foi maior no grupo CONTROLE no pós-operatório (p = 0,01). Conclusão: Abreviação do jejum pré-operatório com oferta de carboidratos na artroplastia total de quadril é segura, podendo ser praticada. O protocolo investigado como um todo diminuiu o tempo de internação hospitalar e valores de PCR no pós-operatório. / Introduction: Multimodal protocols, when used, enhance several perioperative clinical variables. Limited information is available about the reduction of preoperative fasting with administration of clear liquids enriched with carbohydrate and immunomodulators in orthopedic surgeries. The ACERTO (Accelerated Postoperative Total Recovery) is based on an existing European program (ERAS) and based on the paradigm of evidence-based medicine. It is an educational program. Objectives: To evaluate clinical, biochemical inflammatory variables and safety of the method, shortening up the fast with drink containing carbohydrates and use of immunomodulatory diet in patients undergoing surgery for total hip arthroplasty using cementless technique on the femur and the acetabulum without cement (total hip arthroplasty hybrid type). Methods: A prospective study of 32 patients (16 males, with a mean age of 58 years ranging de 26 to 85 years) were randomized into two groups: 17 patients (Group ACERTO) undergoing abbreviated to offer 12,5% maltodextrin fasting, 2h before induction of anesthesia and use of immunomodulatory diet for five days prior to surgery; 15 patients (Group CONTROL) fasted for 8 hours without preoperative nutritional therapy. Clinically aspiration during induction of anesthesia and hospitalization time and in laboratory tests the levels of hemoglobin (Hb), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) preoperatively and 48 hours postoperatively were evaluated. Results: There were no deaths, infections, dislocations of the prosthesis, reoperation, or blood transfusions. No cases of aspiration occurred during anesthetic induction. Group ACERTO patients had, on average, two days less hospitalization (P < 0,01). Results of hemoglobin did not differ among groups in preoperative and postoperative. VHS values remained similar between groups postoperatively (p = 0,09), but CRP was higher in the control group postoperatively (p = 0,01). Conclusion: Preoperative fasting abbreviation with of carbohydrates in total hip arthroplasty is safe and may be practiced. The protocol investigated as a whole, decreased hospital stay and CRP levels postoperatively.

Introdução: A falta de sistemas estruturados de custeio nas organizações hospitalares, principalmente filantrópicas, tem dificultado a análise da cobertura dos custos pelo repasse do Sistema Único de Saúde (SUS) aos procedimentos realizados. Objetivo: Identificar a percentagem de cobertura do repasse de verba do SUS para a cirurgia de revascularização miocárdica (CRM), em um hospital filantrópico do município de São Paulo, que possui um sistema de custeio consolidado. Método: Estudo de abordagem quantitativa, transversal e descritiva. Utilizou-se um banco de dados com registro de CRM denominado REVASC, criado pela instituição em 2009 e de inclusão contínua. As informações para a pesquisa foram coletadas de 13 de março a 30 de setembro de 2012. A escolha do período foi devido ao início da inclusão de informações sobre custo e repasse do SUS. A população alvo foi de 1913 pacientes e amostra de 1362 (71,2%). Resultados: O custo total médio da internação por paciente foi de R$16.196,91. A média de repasse pelo SUS foi de R$6.992,91(48,66%), observando-se um déficit de 9.204,00 (51,34%). A média de idade foi de 61,4 anos e 69,9% eram do sexo masculino. A média do tempo de permanência hospitalar (TPH) foi de 11,23 dias, sendo 2,42 dias na terapia intensiva e 8,49 dias no pós-operatório. A maioria dos pacientes (69,5%) apresentou um TPH maior que sete dias, considerada prolongada pela instituição. Ao comparar o Grupo 1 (TPH7dias) e Grupo 2 (TPH>7dias), este apresentou custo, receita, diferença entre custo-receita e diferença percentual significativamente maiores que os pacientes do Grupo1. Ao associar o TPH com fatores de risco houve diferença apenas no Grupo 2 que apresentou maior idade, maior número de diabetes e de insuficiência renal crônica. Em relação às complicações pós-operatórias houve diferença em relação a transfusão sanguínea, fibrilação atrial, sangramento importante, pneumonia, insuficiência renal aguda, infarto agudo do miocárdio perioperatório, hemodiálise, acidente vascular encefálico, ventilação mecânica prolongada e reoperação por sangramento / mediastinite, também com incidência maior no Grupo2. Conclusão: O repasse do SUS cobriu menos da metade do custo total médio da internação em CRM (48,66%). Embora o valor do repasse do SUS tenha aumentado conforme a elevação do custo, esse ressarcimento foi desproporcional ao custo total, resultando numa diferença percentual de receita cada vez mais negativa a cada aumento do custo e da permanência hospitalar. / Introduction: The lack of structured expense systems in hospital organizations, especially when philanthropic, has hindered the analysis of the coverage of costs by transfer of funds from the Unified Healthcare System (SUS) for the procedures performed. Objective: To identify the percentage of coverage of the transfer of funds from SUS for coronary artery bypass surgery (CABG) in a philanthropic hospital that has a consolidated expense system in the municipality of São Paulo. Method: A quantitative, cross-sectional, and descriptive study. A databank containing data with CABG records called REVASC was used, created by the institution in 2009 with ongoing data inclusion. Information for the research was collected from March 13 to September 30, 2012. The choice of that period was due to the start of inclusion of information on costs and the transfer of funds from SUS. The target population was made up of 1913 patients and a sample of 1362 (71.2%). Results: The total mean cost of hospitalization per patient was R$16,196.91. The mean transfer of funds by SUS was R$6,992.91 (48.66%), with a deficit of 9,204.00 (51.34%). The mean age of the subjects was 61.4 years, and 69.9% of them were men. The mean hospital stay (HS) was 11.23 days, in which 2.42 days were in intensive therapy, and 8.49 days in the postoperative unit. Most of the patients (69.5%) had a HS longer than seven days, considered prolonged by the institution. When comparing Group 1 (HS 7 days) and Group 2 (HS >7 days), the latter group showed costs, revenue, difference between cost and revenue, and percentage difference significantly greater than did the patients from Group 1. In associating the HS with risk factors, there was a greater difference only in Group 2, which showed a higher age, and greater number individuals with diabetes and chronic renal failure. As to postoperative complications, there was a difference as to blood transfusion, atrial fibrillation, significant bleeding, pneumonia, acute renal failure, perioperative acute myocardial infarct, hemodialysis, cerebrovascular accident, prolonged mechanical ventilation, and reoperation due to bleeding/mediastinitis, also with an incidence greater than in Group 2. Conclusion: The financial provision from SUS covered less than half the total mean cost of hospitalization for CABG (48.66%). Although the value transferred from SUS increased according to cost elevation, this reimbursement was disproportional to the total cost, resulting in an increasingly negative percentage difference of revenue for each increase in cost and in hospital stay.

Abstract The purpose of this work was to determine on the basis of the national hospital discharge register and cause-of-death statistics the extent of the hospital treatment required for chronic obstructive pulmonary disease (COPD) in Finland over the period 1972–2001, i.e. the use made of hospital services, factors affecting the length of stay in hospital and the correlation of length of stay with the prognosis. Different intervals within this period were taken for study according to the themes of the individual papers. The results suggest that the length of stay in hospital varies both geographically and seasonally in Finland, the shortest times being recorded in Northern Finland in summer. The main explanations for this would appear to lie in regional differences in health care resources and treatment practises and in climatic variations. The mean length of stay in hospital in the total material in 1987–1998 was nine days. The longest periods applied to cases with concurrent pneumonia or a cerebrovascular disorder. The duration of treatment for the exacerbation stage of COPD decreased by two days between 1993 and 2001, with the longest periods of treatment observed in the case of elderly women. One week of treatment with current modalities may be regarded as optimal, as this was associated with the longest interval before the next exacerbation, just over six months. About 3% of all emergency admissions ended in death, most commonly on a Friday in winter or spring. Patients admitted at a weekend died within the first 24 hours more frequently than did those admitted on a weekday. The mean duration of treatment and frequency of hospitalization increased towards the terminal stage. About one fourth of the patients had died within a year of the first admission for COPD and about a half within five years. Hospital treatment for COPD intensified in Finland during the 1990s as the numbers of hospital beds decreased. Treatment times became shorter and deaths in hospital during exacerbation became less frequent. It will be necessary from now onwards, however, to anticipate the ageing of the population and to develop treatment modalities to replace hospitalization, in order to reduce the costs accruing from this disease. Early diagnosis and outpatient rehabilitation should be developed, and special attention should be paid to appropriate treatment at the terminal stage. / Tiivistelmä Tutkimuksen tarkoituksena oli selvittää valtakunnallisen hoitoilmoitusrekisterin ja kuolemansyytilaston avulla keuhkoahtaumataudista (KAT) aiheutunutta sairaalahoitoa Suomessa 1972–2001: sairaalapalvelujen käyttöä, hoitojakson pituuteen vaikuttavia tekijöitä sekä hoitoajan yhteyttä ennusteeseen. Lähdeaineistosta valittiin erilaisia ajanjaksoja tutkimusasetelman mukaan. Tulokset viittaavat siihen, että hoitoajan pituus vaihtelee Suomessa maantieteellisesti ja vuodenaikojen mukaan: lyhyin hoitoaika on Pohjois-Suomessa kesällä. Ilmiötä selittänevät pääosin terveydenhuollon resurssien ja hoitokäytäntöjen alueelliset erot sekä ilmasto-olosuhteiden vaihtelu. Vuosina 1987–1998 keskimääräinen hoitoaika koko aineistossa oli yhdeksän vuorokautta. Jos potilaalla oli samanaikaisina sairauksina keuhkokuume tai aivoverenkiertohäiriö, nämä johtivat pisimpiin hoitoaikoihin. KAT:n pahenemisvaiheen hoitoaika lyheni kaksi vuorokautta vuodesta 1993 vuoteen 2001. Iäkkäitten naisten hoitoajat olivat pisimmät. Viikon pituinen hoitoaika nykyisillä hoitomuodoilla oli optimaalinen, sillä tällöin aika seuraavan pahenemisvaiheen hoitojakson alkuun oli pisin: vähän yli puoli vuotta. Kaikista päivystyshoitojaksoista potilaan kuolemaan päättyi kolmisen prosenttia. Yleisimmin tällainen hoitojakso päättyi potilaan kuolemaan perjantaisin ja todennäköisimmin talvella tai keväällä. Viikonloppuna sairaalaan tulleista potilaista kuoli ensimmäisen vuorokauden aikana enemmän kuin arkipäivinä tulleista. Keskimääräinen hoitoaika oli pisin ja sairaalahoito runsainta sairauden loppuvaiheessa kuoleman lähestyessä. Ensimmäisen KAT:n aiheuttaman hoitojakson jälkeen noin neljännes potilaista oli kuollut vuoden sisällä ja viiden vuoden kuluessa noin puolet. Keuhkoahtaumataudin sairaalahoito on tehostunut Suomessa 1990-luvulla sairaansijojen vähentyessä. Hoitoajat ovat lyhentyneet ja pahenemisvaiheiden sairaalakuolleisuus on vähäistä. Väestön ikääntyminen on kuitenkin ennakoitava ja sairaalaa korvaavia hoitomuotoja kehitettävä taudista aiheutuneiden kustannusten hillitsemiseksi. Varhaisdiagnostiikkaa ja avokuntoutusta on kehitettävä ja erityinen huomio kiinnitettävä sairauden loppuvaiheen asianmukaiseen hoitoon.

The thesis, Survey of the methods of costing of hospitalization, deals with the characteristics of the classification system DRG used for costing of hospitalization. The first half of the theoretical part of this work describes the Czech health care in general and specific ways of financing it. We focus on the costs related to the emergency care in hospitals which are classified by the DRG system. The second half of the theoretical part studies the actual principles of costing of hospitalization. The method chosen for this is called Activity Based Costing (ABC). It defines the procedures of costing which are being used in hospitals. At the end, we provide a description of the current and suggested procedures of costing of hospitalization and how they are utilized to set up parameters of the reimbursing mechanism. The practical part of this thesis maps the situation of hospitalization financing in Klatovska nemocnice, a. s. We suggest a new way of financing based on the methodology DRG Restart. Base on the data obtained in Klatovska nemocnice, a. s. we summarize and compare the results of the new method to the current one.

Cette étude vise à évaluer l’impact de l’état nutritionnel et de son évolution durant l’attente d’une transplantation pulmonaire sur la mortalité et la morbidité postopératoire. Nous avons examiné les 209 dossiers de patients greffés pulmonaires au Programme de Transplantation Pulmonaire du CHUM entre 2000 et 2007 et regardé la mortalité et les complications post-transplantation en fonction de l’IMC, des apports protéino-énergétiques, de certains paramètres biochimiques et selon l’évolution pondérale durant la période d’attente. Les résultats montrent que la mortalité augmente en fonction de l’augmentation des strates d’IMC avec un risque relatif de décès au cours du séjour hospitalier de 3,31 (IC95% 1,19-9,26) pour un IMC 25-29,9 et de 8,83 (IC95% 2,98-26,18) pour un IMC ≥ 30 avec une issue postopératoire plus sombre en terme de complications chirurgicales (p=0,003), de durée de séjour aux soins intensifs (p=0,031) et de durée de séjour à l’hôpital (p<0,001) chez les patients avec IMC ≥ 30 comparativement aux patients de poids normal. Les patients ayant présenté une évolution inadéquate de l’IMC durant la période d’attente ont connu une durée de séjour hospitalier prolongée (p=0,015). Ceux dont les apports nutritionnels étaient sous-optimaux en pré-greffe ont aussi connu une durée de séjour hospitalier prolongée (p=0,002) et davantage de complications infectieuses (p=0,038), digestives (p=0,003) et chirurgicales (p=0,029) mais sans impact détectable sur la mortalité. Nos résultats suggèrent que l’obésité et l’embonpoint ainsi qu’une évolution inadéquate de l’IMC durant la période d’attente de même que des apports protéino-énergétiques sous-optimaux affectent négativement l’issue d’une transplantation pulmonaire. / This study aims to assess the impact of nutritional status and its evolution while awaiting a lung transplant on the post-operative mortality and morbidity. We reviewed 209 consecutive cases of lung transplantation at the Centre Hospitalier de l’Universite de Montreal between 2000 and 2007 and looked at the mortality and rate of complications post-operatively according to BMI, intake of protein and energy, biochemical parameters and weight changes during the waiting period. The risk of death increased with increasing BMI strata with a relative risk of death during the hospital stay of 3,31 (IC95% 1,19-9,26) for BMI 25-29.9 and 8,83 (IC95% 2,98-26,18) for BMI ≥ 30 with a worse postoperative outcome in terms of surgical complications (p=0,003), length of stay in intensive care unit (p=0,031) and length of hospital stay (p<0,001) for patients with BMI ≥ 30 compared with patients of normal weight. Patients in whom the BMI evolved inadequately during the waiting period experienced a prolonged hospital stay (p=0,015). Patients whose intake was suboptimal in the pre-transplant period have also a prolonged hospital stay (p=0,002) and more infectious (p=0,038), digestives (p=0,003) and surgicals (p=0,029) complications but no detectable impact on the mortality. Our results suggest that obesity and overweight as well as inadequate changes of BMI during the waiting period and suboptimal protein-energy intakes negatively affect the outcome of lung transplantation.

Cette étude vise à évaluer l’impact de l’état nutritionnel et de son évolution durant l’attente d’une transplantation pulmonaire sur la mortalité et la morbidité postopératoire. Nous avons examiné les 209 dossiers de patients greffés pulmonaires au Programme de Transplantation Pulmonaire du CHUM entre 2000 et 2007 et regardé la mortalité et les complications post-transplantation en fonction de l’IMC, des apports protéino-énergétiques, de certains paramètres biochimiques et selon l’évolution pondérale durant la période d’attente. Les résultats montrent que la mortalité augmente en fonction de l’augmentation des strates d’IMC avec un risque relatif de décès au cours du séjour hospitalier de 3,31 (IC95% 1,19-9,26) pour un IMC 25-29,9 et de 8,83 (IC95% 2,98-26,18) pour un IMC ≥ 30 avec une issue postopératoire plus sombre en terme de complications chirurgicales (p=0,003), de durée de séjour aux soins intensifs (p=0,031) et de durée de séjour à l’hôpital (p<0,001) chez les patients avec IMC ≥ 30 comparativement aux patients de poids normal. Les patients ayant présenté une évolution inadéquate de l’IMC durant la période d’attente ont connu une durée de séjour hospitalier prolongée (p=0,015). Ceux dont les apports nutritionnels étaient sous-optimaux en pré-greffe ont aussi connu une durée de séjour hospitalier prolongée (p=0,002) et davantage de complications infectieuses (p=0,038), digestives (p=0,003) et chirurgicales (p=0,029) mais sans impact détectable sur la mortalité. Nos résultats suggèrent que l’obésité et l’embonpoint ainsi qu’une évolution inadéquate de l’IMC durant la période d’attente de même que des apports protéino-énergétiques sous-optimaux affectent négativement l’issue d’une transplantation pulmonaire. / This study aims to assess the impact of nutritional status and its evolution while awaiting a lung transplant on the post-operative mortality and morbidity. We reviewed 209 consecutive cases of lung transplantation at the Centre Hospitalier de l’Universite de Montreal between 2000 and 2007 and looked at the mortality and rate of complications post-operatively according to BMI, intake of protein and energy, biochemical parameters and weight changes during the waiting period. The risk of death increased with increasing BMI strata with a relative risk of death during the hospital stay of 3,31 (IC95% 1,19-9,26) for BMI 25-29.9 and 8,83 (IC95% 2,98-26,18) for BMI ≥ 30 with a worse postoperative outcome in terms of surgical complications (p=0,003), length of stay in intensive care unit (p=0,031) and length of hospital stay (p<0,001) for patients with BMI ≥ 30 compared with patients of normal weight. Patients in whom the BMI evolved inadequately during the waiting period experienced a prolonged hospital stay (p=0,015). Patients whose intake was suboptimal in the pre-transplant period have also a prolonged hospital stay (p=0,002) and more infectious (p=0,038), digestives (p=0,003) and surgicals (p=0,029) complications but no detectable impact on the mortality. Our results suggest that obesity and overweight as well as inadequate changes of BMI during the waiting period and suboptimal protein-energy intakes negatively affect the outcome of lung transplantation.