A segurança do paciente tornou-se indispensável para o sistema de saúde, portanto iniciativas vêm sendo implantadas, no decorrer dos anos, com vistas a reduzir os eventos adversos. A atuação do time de resposta rápida (TRR) consolida-se como estratégia para prover atendimento ao paciente que apresente sinais de deterioração clínica no setor de internação geral em hospitais. O serviço é formado por equipe multiprofissional capacitada para prestar tratamento intensivo ao paciente com quadro de deterioração clínica aguda no setor de internação, por meio de códigos (amarelo e azul) instituídos para seu acionamento, com vistas a reduzir a probabilidade de agravamento do quadro clínico ou risco de óbito imediato do paciente, durante o seu período de hospitalização. O estudo objetiva caracterizar as exigências críticas nos atendimentos emergenciais realizados por TRR, em um hospital público no estado do Paraná e um filantrópico no estado de São Paulo. Pesquisa descritiva, exploratória, qualitativa, com utilização da Técnica do Incidente Crítico como guia do processo metodológico, realizada por meio de entrevistas com 19 médicos, 20 fisioterapeutas e 23 enfermeiros. Os resultados encontrados foram agrupados em 89 incidentes críticos extraídos das entrevistas. A análise dos dados constou da identificação e do agrupamento de 220 comportamentos e 130 consequências. A partir das situações, comportamentos e consequências identificadas, destacam-se a necessidade da melhoria na via aferente do TRR (reconhecimento da deterioração clínica e acionamento do TRR na unidade), a capacitação dos profissionais das unidades de internação para exercer as habilidades técnicas iniciais necessárias frente ao atendimento de emergência até a chegada do TRR, a falha na interação entre os diversos profissionais durante o atendimento do código azul com prejuízo na sistematização do atendimento de emergência para reverter o quadro de parada cardiorrespiratória dos pacientes e os sentimentos e emoções negativas geradas nos profissionais como dificultadores dos atendimentos emergenciais em código azul. Em relação aos destaques positivos a partir das situações, comportamentos e consequências identificados, ressaltam-se o tempo de chegada do TRR na unidade para realizar o atendimento de emergência, a sistematização do atendimento de reanimação cardiopulmonar realizada pela equipe multiprofissional, o restabelecimento das funções vitais do paciente após o atendimento e a sua transferência após a finalização do atendimento da unidade de internação para um ambiente de cuidados intensivos. Como principais sugestões ao TRR, os entrevistados pontuaram a importância da capacitação de atendimento de emergência aos profissionais das unidades de internação, a necessidade de mantê-los atuando exclusivamente no TRR, o número adequado de profissionais no quarto durante o atendimento de emergência e a importância do registro em prontuário do paciente sobre a decisão de não reanimação frente aos cuidados paliativos. Destaca-se a expressiva frequência dos resultados positivos comparados aos negativos que permearam as situações, comportamentos e consequências decorrentes das entrevistas. Infere-se que mesmo ocorrendo dificuldades, enfrentadas por esses profissionais durante os atendimentos realizados aos pacientes que se tornam críticos nas enfermarias, predominaram os relatos positivos nas diversas categorias que legitimaram a importância da implantação desse serviço, como contribuição à qualidade e segurança dos que estão hospitalizados / Patient safety has become indispensable for the health system. Therefore, initiatives have been implemented over the years to reduce adverse events. The performance of the Rapid Response Team (RRT) has been consolidated as a strategy to provide care to patients who get in critical conditions at the general hospital admission unit. The service is constituted by a multiprofessional team with an approach in the intensive treatment of patients with signs of acute clinical deterioration in the inpatient unit, through codes established for its activation, in order to reduce the probability of worsening of the clinical condition or imminent death risk of the patient during the hospitalization period. The study aims to characterize the critical requirements in emergency care provided by the RRT at a public hospital in the state of Paraná and a philanthropic hospital in the state of São Paulo, Brazil. This is a descriptive, exploratory study with a qualitative approach, adopting the Critical Incident Technique to guide the methodological procedures, performed with 62 health professionals, being 19 physicians, 20 physiotherapists and 23 nurses. The results were grouped into 89 critical incidents extracted from the interviews. Data analysis consisted of the identification and grouping of 220 behaviors and 130 consequences. Based on the situations, behaviors and consequences identified, there is a need to improve the afferent pathway of RRT (recognition of clinical deterioration and activation of the RRT in the unit), the qualification of the professionals of the inpatient units to perform the necessary initial technical skills in the emergency response until the arrival of the RRT, the failure in the interaction among the different professionals during blue-code care with negative effects for the systematization of emergency care to revert the patients\' CPA and the negative feelings and emotions generated in the professionals as impediments to code-blue emergency care. Regarding the positive highlights from the situations, behaviors and consequences identified, the arrival time of the RRT in the unit to perform the emergency care, the systematization of the cardiopulmonary resuscitation service performed by the multiprofessional team, the restoration of the patient\'s vital functions after the care and transfer of the patient after the end of the care from the inpatient unit to an intensive care environment. As the main suggestions to the RRT, the interviewees pointed out the importance of emergency care training for the professionals of the inpatient units, the need to keep the professionals working exclusively in the RRT, the appropriate number of professionals in the room during emergency care and the importance of registering the patient\'s decision not to reanimate in the patient file in view of palliative care. The significant frequency of positive over negative results was highlighted, which permeated the situations, behaviors and consequences deriving from the interviews. It is inferred that, even though these professionals encountered difficulties during the visits to patients who became critical in the wards, the positive reports predominated in the various categories that legitimized the importance of implementing this service, as a contribution to the quality and safety of hospitalized patients

Workplace violence is a persistent problem in health care, and incidence rates have increased over the years. Traditional reporting systems, relying mostly on paper formats, are inadequate for developing effective predictive models for intervention and reducing acts of violence by patients to staff. The purpose of the development and deployment of the psychiatric emergency response team (PERT) was to provide effective intervention within the MIAHTAPS (Altered Mental status, Irritability, Agitation, History of Violence, Threatening, Attacking Objects, Pacing, and Staring) behavior prediction tool to reduce the severity and rates of violence in a hospital setting. Lewin's change theory was used to implement the necessary cultural change for effective deployment of PERT and MIAHTAPS. MIAHTAPS, with PERT as an integral component, was used by the primary nurse on admission and during every care shift to assess patients' potential for violence. Pre- and post- intervention assessments were completed to determine the effectiveness of the intervention. Quantitative and open-ended question responses from 200 nurse participants, who completed the 2 online surveys, were analyzed using descriptive and frequency distributions. Findings from the project showed that nurses could identify patient potential for violence and recognize how to diffuse situations effectively 34% of the time, compared to 14% before PERT. A post-implementation survey showed that 75% of the nurses found the MIAHTAPS and PERT system useful and easy to use. Having an easy-to-use tool that helps to identify potential for violence will help hospital and other workplace staff to develop and implement preventive interventions and as a result promote positive social change.

Orientador: Salomón Soriano Ordinola Rojas / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T13:47:55Z (GMT). No. of bitstreams: 1 Veiga_VivianeCordeiro_D.pdf: 789153 bytes, checksum: 3624e101d10d419b28899a4d4fc5c966 (MD5) Previous issue date: 2013 / Resumo: Introdução: A segurança do paciente tornou-se prioridade estratégica para o sistema de saúde. Ações têm sido implantadas nas Instituições, na tentativa de reduzir a mortalidade hospitalar e os eventos não previsíveis. Objetivo: O objetivo deste trabalho é avaliar a atuação do time de resposta rápida nos indicadores de melhoria da qualidade assistencial, comparando dois períodos de seguimento. Casuística e Método: No período de maio de 2010 a dezembro de 2012, foram avaliados os atendimentos realizados pelo time de resposta rápida, em pacientes com idade maior ou igual a 18 anos. O estudo foi dividido em dois períodos, denominado "antes" e "depois", sendo que o primeiro compreendeu o intervalo de maio de 2010 a julho de 2011 e o segundo, entre agosto de 2011 e dezembro de 2012. O acionamento do grupo era feito por qualquer profissional da equipe assistencial, baseado em critérios preestabelecidos e amplamente divulgados na Instituição. Após 15 meses de seguimento, optou-se pela alteração nos critérios de acionamento (período "depois"), visando à detecção precoce da deterioração clínica e baseados no perfil epidemiológico da Instituição. No período, foram atendidos 8009 pacientes, sendo 1830 no "antes" e 6179 no "depois", com idade média de 66,37±16,88 e 65,99±20,08 anos, respectivamente. O gênero masculino foi predominante em ambos os períodos, representando 52,5% dos atendimentos no primeiro e 53% no segundo. No período "antes", as alterações respiratórias representaram o maior número de chamados, enquanto que, no período "depois", a busca ativa de sepse foi o critério mais acionado, seguido pelas alterações respiratórias. Foi denominado código azul, os atendimentos de parada cardiorrespiratória e código amarelo, os atendimentos decorrentes de deterioração clínica. Os indicadores de qualidade assistencial mensurados foram: reinternação precoce em terapia intensiva (UTI), transferências para UTI, chamados de código amarelo, número de paradas cardiorrespiratórias fora da UTI e mortalidade hospitalar. Resultados: No período analisado, não houve diferença estatisticamente significante de perfil dos pacientes nos dois períodos, quanto ao gênero e idade (p=0,631 e p=0,550, respectivamente). Ao longo dos meses avaliados, houve um aumento significativo no número total de atendimentos, com 98,1% de chamados de código amarelo no segundo período. A proporção encontrada de códigos azuis foi de 7,59% no período "antes" e 1,91% no período "depois". O número de pacientes atendidos que necessitaram transferência para a UTI representava 33,3% dos atendimentos no período "antes", com redução para 20,8% no "depois" (p<0,001). Houve redução no número de reinternações em UTI na comparação entre os dois períodos (p <0,001). Não houve diferença estatisticamente significante no número de paradas cardiorrespiratórias fora da UTI e na mortalidade entre os períodos, no entanto, com tendência de redução no decorrer do tempo. Conclusão: A implantação do time de resposta rápida resulta em melhoria da qualidade assistencial, com redução no número de transferências e reinternação precoce em UTI. O número de paradas cardiorrespiratórias e a mortalidade apresentaram tendência de redução ao longo do tempo estudado / Abstract: Introduction: Patient safety has become a strategic priority for the health system. Actions have been implemented in health institutions in an attempt to reduce mortality and adverse events. Objective: The objective of this study is to evaluate the performance of the rapid response team on indicators of improving quality of care, comparing two periods of follow-up. Methods: Between May 2010 and December 2012, we assessed the care provided by a rapid response team in patients aged greater than or equal to 18 years. The study was divided into two periods, "before" and "after", the first of which included the period May 2010 to July 2011 and the second between August 2011 and December 2012. The group was called by any professional health care team, based on predetermined criteria. After 15 months of follow-up, we decided to drive change in criteria (period "after"), aimed at early detection before clinical deterioration and based on the epidemiological profile of the institution. During the period, 8009 patients were treated, and 1830 in the period "before" and in 6179 "after", with a mean age of 66.37 ± 16.88 and 65.99 ± 20.08 years, respectively. The male gender predominated in both periods, representing 52.5% of visits in the 1st period and 53% in the second. In the period "before", the respiratory changes accounted for the largest number of calls, while in the period "after" sepsis was the most called, followed by respiratory disorders. Blue code was called the attendance of cardiac arrest and yellow code, the clinic visits resulting from deterioration. The quality of care indicators measured were: unplanned admission to intensive care unit (ICU), ICU transfers, time-driven service, called code yellow and number of cardiac arrests outside the ICU. Results: During the period analyzed, there was no statistically significant difference in the profile of patients in both periods, according to gender and age (p = 0.631 and p = 0.550, respectively). Over the months studied, there was an increase of approximately 300% in the total number of visits, with 98.1% of calls to code yellow in the second period. The proportion of code blue was 7.59% in the period "before" and 1.91% in the period "after." The number of patients seen who required transfer to the ICU represented 33.3% of attendances in period "before", with a reduction to 20.8% in the "after" (p <0.001). There was a reduction in the number of unplanned ICU admissions when comparing the two periods (p <0.001). There was no statistically significant difference in the number of cardiac arrests outside the ICU and mortality between the periods. Conclusion: The implementation of the rapid response team results in improving quality of care, reducing the number of transfers and early readmission to the ICU. The number of cardiopulmonary arrests and mortality tended to decrease over time studied / Doutorado / Fisiopatologia Cirúrgica / Doutora em Ciências

Bakgrund: Intensivvård är den högsta vårdinstansen på ett sjukhus, en av sjukvårdens mest resurskrävande behandlingsformer. När en patient blir kritiskt sjuk eller påvisar försämrade vitalparametrar kontaktar vårdpersonalen mobil intensivvårdsgrupp (MIG) som utgår ifrån intensivvårdsavdelningen (IVA). Problemformulering: De kritiskt sjuka patienterna vårdas inte längre bara på IVA men också på vårdavdelningar. I ett omvårdnads- och professionsperspektiv som intensivvårdssjuksköterska är det av betydelse och centralt att förstå orsakerna till kontakt med MIG. Syfte: Att kartlägga kontakter, orsaker och skillnader med mobil intensivvårdsgrupp på ett sjukhus i Västra Götalandsregionen. Metod: En icke-experimentell studie med ett konsekutivt urval och retrospektiv journalgranskning av 386 patientkontakter med MIG under åren 2017–2019. Resultat: Studiens resultat påvisar en hög medelålder. Ingen skillnad återfanns i patientgruppen ur ett könsperspektiv. Den framträdande gruppen är den geriatriska patienten ≥65år som är utsatt och en högriskgrupp vid kontakt med MIG. De utgör majoriteten av alla kontakter med MIG åren 2017–2019. Diskussion: Studiens kartläggning och resultat påvisar behov av kompetenshöjande utbildning och optimeringsteam. Geriatriska patientgruppen behöver vårdinsatser i rätt tid och med rätt kompetens för att minska antalet MIG kontakter och initiera insatser i förtid och motverka svikt av vitala parametrar.

This master's thesis describes methodologies used in malware forensic analysis including methods used in static and dynamic analysis. Based on those methods a tool intended to be used by Computer Security Incident Response Teams (CSIRT) is designed to allow fast analysis and decisions regarding malware samples in security incident investigations. The design of this tool is thorougly described in the work along with the tool's requirements on which the tool design is based on. Based on the design a ForensIRT tool is implemented and then used to analyze a malware sample Cridex to demonstrate its capabilities. Finally the analysis results are compared to those of other comparable available malware forensics tools.

The Institute for Healthcare Improvement (IHI) has promoted implementing a RRS to provide safer care for hospitalized patients. Additionally, the Joint Commission made implementing a RRS a 2008 National Patient Safety Goal. Although mandated, the evidence to support the effectiveness of a RRS to reduce cardiac arrests on hospital medical or surgical floors and un-anticipated ICU transfers remains inconclusive, partly because of weak study designs and partly due to a failure of published studies to report all critical aspects of their intervention. This study attempted to evaluate the effectiveness and the implementation of a RRS on the two campuses of the UMass Memorial Medical Center (UMMMC). The first study presented was an attempt to identify the preventability and timeliness of floor to ICU transfers. This was done using 3 chief residents who reviewed 100 randomly selected medical records. Using Cohen’s kappa to assess the inter-rater reliability it was determined that 13% of the cases could have possibly been preventable with earlier intervention. The second study was an evaluation of the effectiveness of the Rapid Response System. Outcomes were cardiac arrests, code calls and floor to ICU admissions. There were two study periods 24 months before the intervention and 24 months after. A Spline regression model was used to compare the two time periods. Though there was a consistent downward trend over all 4 years there were no statistically significant changes in the cardiac arrests and ICU transfers when comparing the before and after periods. There was a significant reduction in code calls to the floors on the University campus. The third study was a modified process evaluation of the Rapid Response intervention that will assess fidelity of RRS implementation, the proportion of the intended patient population that is reached by the RRS, the overall number of RRS calls implemented (dose delivered) and the perceptions of the hospital staff affected by the RRS with respect to acceptability and satisfaction with the RRS and barriers to utilization. The process evaluation showed that that the Rapid Response System was for the most part being used as it was designed, though the nurses were not using the specific triggers as a deciding factor in making the call. Staff satisfaction with the intervention was very high. Overall these studies demonstrated the difficulty in clearly defining outcomes and data collection in a large hospital system. Additionally the importance of different study designs and analysis methods are discussed.

Akutsjuksköterskans roll är att tillhandahålla omedelbar vård till människor eller att utföra en omvårdnadsåtgärd som kan förhindra att en nödsituation uppstår. Akutsjuksköterskan ska leda, initiera och samordna patientvården. Faktorer som påverkar patientsäkerheten är ledarskapet, att arbeta i team, att arbeta evidensbaserat, kommunikation, utbildning och att arbeta patientcentrerat. Rapid response system (RRS) utvecklades för att förbättra patientsäkerheten inom akutsjukvården. Det finns fyra enheter som är grundläggande för systemet. Den afferenta komponenten som omfattar av sjuksköterskan som ansvarar för identifiering av varningssignaler för kritiskt sjuka patienter och aktivering av RRS. Till sin hjälp har sjuksköterskan ett track- and triggersystem som baseras på patientens vitalparametrar för att identifiera kritiskt sjuka patienter på avdelning. De vanligaste förekommande vitalparametrarna inom akutsjukvården är: respiration, temperatur, blodtryck, hjärtfrekvens, medvetandegrad samt urinproduktion. Den efferenta komponenten är den hjälpinsats som den afferenta komponenten tillkallar vid aktivering av RRS när avvikande vitalparametrar är observerade och genererar hög poängsumma i ett track- and triggersystem alternativt på inrådan av sjuksköterskans instinktiva känsla av att patientens tillstånd försämrats. Syftet var att belysa sjuksköterskans upplevelser av att arbeta utefter ett rapid response system och belysa dess påverkan på patientsäkerheten. Metoden som användes var litteraturöversikt. Databassökningar gjordes i PubMed, CINAHL och Web Of Science, vilket resulterade i att 16 artiklar inkluderades i studien. Inklusionskriterier som användes var att artikeln skulle vara publicerad på engelska, ’peer- reviewed’ och publicerade i vetenskapliga tidskrifter mellan år 2006–2016. En integrerad analysmetod användes för att finna likheter och skillnader i resultatet. I resultatet framkom det att RRS ökade identifieringen av kritiskt sjuka patienter och flertalet artiklar konstaterade att RRS minskade antalet hjärtstopp och oväntade dödsfall. I resultatet framkom svårigheter och begränsningar med att arbeta utefter RRS så som otillräcklig kompetens, hög arbetsbelastning och hierarki. Avvikande vitalparametrar togs mer på allvar jämfört med ”tysta” förändringar. Sjuksköterskorna aktiverade systemet på grund av oro relaterat till klinisk erfarenhet, trots att vitalparametrarna var normala RRS var till hjälp att hantera kritiskt sjuka patienter och fungerade som sjukhusets 112. Avdelningssjuksköterskorna upplevde att de mestadels fick stöttning av det medicinska akutvårdsteamet men tillfällen då sjuksköterskan upplevde otrevligt bemötande påverkade det beslutsfattandet av aktivering av RRS negativt framöver. Slutsatsen av denna litteraturöversikt tyder på att RRS främjar patientsäkerheten och hjälper sjuksköterskan i sitt dagliga arbete genom att främja säker vård. Sjuksköterskans upplevelser belyser gynnsamma omständigheter och upplevda svårigheter med RRS som kan användas till vidare forskning för att utveckla systemet. / The role of the emergency nurse is to provide immediate care to patients or to perform a nursing intervention that can prevent an emergency. They should lead, initiate and coordinate patient care. Factors that affect patient safety could be leadership, working in teams, evidence-based work, communication, training, or patient-centered work. Rapid response system (RRS) was developed to improve patient safety in emergency care. There are four units that are essential for the system to function. The afferent component includes the nurse who is responsible to identify warning signs if the patient is deteriorating and activate RRS. A track-and trigger system based on the patient’s vital signs is used to assist the nurse to identify deteriorating patients on wards. The most common vital signs in emergency care are: respiration, temperature, blood pressure, heart rate, consciousness and urine production. The efferent component is the relief effort that the afferent component calls for by activating RRS when abnormal vital signs are observed and generate a high score in the track-and trigger system. Alternatively, on the advice of the nurse's instinctive feeling that the patient's condition has deteriorated. The aim of this study was to highlight nurses' experiences of applying rapid response system in their work and illustrate its impact on patient safety. The method used was a literature review. Database searches were made in PubMed, CINAHL and Web of Science, which resulted in 16 articles being included in the study. Inclusion criteria used were English language, ’peer-reviewed’ and published in scientific journals between the years 2006-2016. An integrated analysis was used to find similarities and differences in the results. The result showed that RRS increased identification of critically ill patients, resulting in reduced number of cardiac arrests and unexpected deaths and led to more patients being moved to a higher level of care. Difficulties or limitations that emerged were inadequate skills, high workload and hierarchy. Abnormal vital signs were taken more seriously compared to "silent" changes. The nurses sometimes activated the system due to concerns based on their clinical experience, despite vital signs being normal. RRS was a help to manage critically ill patients and served as the hospital's Department 112. The emergency medical team mostly supported the nurses, but sometimes they experienced negative attitudes, which affected the future activations negatively. The conclusion of this literature review indicates that RRS for patient safety could help nurses in their daily work by promoting safe care. The nurse's experiences highlight the favorable circumstances and perceived difficulties with the RRS, which could be used for further research to develop the system.