Contexte : Pour les patients atteints d’une polyarthrite rhumatoïde débutante (PARD), l’utilisation de médicaments antirhumatismaux à longue durée d’action améliore les résultats pour les patients de manière significative. Les patients traités par un rhumatologue ont une plus grande probabilité de recevoir des traitements et donc d’avoir de meilleurs résultats de santé. Toutefois, les délais observés entre le début des symptômes et une première visite avec un rhumatologue sont souvent supérieurs à la recommandation de trois mois énoncée par les guides de pratiques. Au Québec, le temps d’attente pour voir un rhumatologue à la suite d’une demande de consultation est généralement long et contribue aux délais totaux. Objectifs : Nous avons évalué la capacité d’un programme d’accès rapide avec un triage effectué par une infirmière à correctement identifier les patients avec PARD et à réduire leur temps d’attente, dans le but d’améliorer le processus de soin. Méthodes : Une infirmière a évalué tous les nouveaux patients référés en 2009 et 2010 dans une clinique de rhumatologie située en banlieue de Montréal. Un niveau de priorité leur a été attribué sur la base du contenu de la demande de consultation, de l’information obtenue à la suite d’une entrevue téléphonique avec le patient et, si requis, d’un examen partiel des articulations. Les patients avec PARD, avec une arthrite inflammatoire non différentiée, ou atteints d’une autre pathologie rhumatologique aiguë étaient priorisés et obtenaient un rendez-vous le plus rapidement possible. Les principales mesures de résultat étudiées étaient la validité (sensibilité et spécificité) du triage pour les patients atteints de PARD ainsi que les délais entre la demande de consultation et la première visite avec un rhumatologue. Résultats : Parmi les 701 patients nouvellement référés, 65 ont eu un diagnostic final de PARD. Le triage a correctement identifié 85,9% de ces patients et a correctement identifié 87,2% des patients avec l’une des pathologies prioritaires. Le délai médian entre la demande de consultation et la première visite était de 22 jours pour les patients atteints de PARD et de 115 pour tous les autres. Discussion et conclusion : Ce programme d’accès rapide avec triage effectué par une infirmière a correctement identifié la plupart des patients atteints de PARD, lesquels ont pu être vus rapidement en consultation par le rhumatologue. Considérant qu’il s’agit d’un programme qui requiert beaucoup d’investissement de temps et de personnel, des enjeux de faisabilités doivent être résolus avant de pouvoir implanter un tel type de programme dans un système de soins de santé ayant des ressources très limitées. / Background : In patients with early rheumatoid arthritis (ERA), use of disease-modifying anti-rheumatic drugs substantially improves patient outcomes. Patients treated by rheumatologists are more likely to receive these treatments and to have better disease outcomes. However, delays from symptoms onset to first rheumatologist visit often exceed the guideline recommendations of 3 months. Waiting time to see a rheumatologist after a referral is made, is generally long in Quebec and contributes to those delays. Objectives : We evaluated the ability of a nurse-led triage and rapid access program to identify patients with ERA and reduce their waiting time, in order to improve process of care. Methods : A nurse assessed all new referrals received between 2009 and 2010, in a suburban Montreal rheumatology clinic. Priority level was assigned based on the written content of the referral, a telephone interview with the patient and, if needed, an partial joint examination. Patients with ERA, including undifferentiated inflammatory arthritis, and other acute rheumatologic conditions were prioritized and given an appointment as early as possible. The main outcome measures were validity (sensibility and specificity) of the priority level for patients with ERA and delay from referral to first visit with rheumatologist. Results : Of 701 newly referred patients, 65 had a final diagnosis of ERA. The triage correctly identified 85.9% of patients with ERA and 87.2% of patients with other high priority conditions. The median delay between referral date and first visit was 22 days for patients with ERA and 115 days for all others. Discussion and implications : This nurse led triage and rapid access program correctly identified most patients with ERA and resulted in rapid consultation for these patients. Since this is a labor intensive program, feasibility issues need to be resolved before implementing this type of triage in a resource constrained healthcare system.

Au Québec, des réseaux ont été implantés afin de contrer le manque d’intégration des services offerts aux personnes vivant avec un traumatisme cranio-cérébral (TCC). Toutefois, l’évaluation de leur performance est actuellement limitée par l’absence de description et de conceptualisation de leur performance. Le but de cette thèse est de poser les bases préliminaires d’un processus d’évaluation de la performance des réseaux TCC. Nos objectifs sont de 1) décrire les organisations, la nature et la qualité des liens ainsi que la configuration d’un réseau TCC; 2) connaître les perceptions des constituants du réseau quant aux forces, faiblesses, opportunités et menaces propres à cette forme organisationnelle; 3) documenter et comparer les perceptions de répondants provenant de divers types d’organisations quant à l’importance de 16 dimensions du concept de performance pour l’évaluation des réseaux TCC; 4) réconcilier les perceptions différentes afin de proposer une hiérarchisation consensuelle des dimensions de la performance. En utilisant la méthode de l’analyse du réseau social, nous avons décrit un réseau de petite taille, modérément dense et essentiellement organisé autour de quatre organisations fortement centralisées. Les constituants ont décrit leur réseau comme présentant autant de forces que de faiblesses. La majorité des enjeux rapportés étaient relatifs à l’Adaptation du réseau à son environnement et au Maintien des Valeurs. Par ailleurs, les représentants des 46 organisations membre d’un réseau TCC ont perçu les dimensions de la performance relatives à l’Atteinte des buts comme étant plus importantes que celles relatives aux Processus. La Capacité d’attirer la clientèle, la Continuité et la Capacité de s’adapter pour répondre aux besoins des clients étaient les trois dimensions les plus importantes, tandis que la Capacité de s’adapter aux exigences et aux tendances et la Quantité de soins et de services étaient les moins importants. Les groupes TRIAGE ont permis aux constituants de s’entendre sur l’importance accordée à chaque dimension et d’uniformiser leurs différentes perspectives. Bien que plusieurs étapes demeurent à franchir pour actualiser le processus d’évaluation de la performance des réseaux TCC québécois, nos travaux permettent de poser des bases scientifiques solides qui optimisent la pertinence et l’appropriation des résultats pour les étapes ultérieures. / Networks have been implemented in Québec to address the lack of coordination and integration of services provided to persons who sustain a traumatic brain injury (TBI). The evaluation of the networks’ performance is hindered by the lack of a clear description of the networks and because the concept of network performance is poorly defined. The goal of this thesis is to conduct the necessary preliminary steps of network performance evaluation. We sought to: 1) describe the organizations, nature and quality of the links between organizations within an existing TBI network; 2) explore the perceptions of network constituencies about the strengths, weaknesses, opportunities and threats of this organizational form; 3) report and compare network members’ perceptions of the importance of 16 dimensions of performance to include within an evaluation of TBI networks; 4) reconcile the various perceptions to propose a consensual hierarchy of performance dimensions. Social network analysis was used to describe a small network, with a moderate density, essentially organized around four organizations with high centrality. The constituents reported their network as having as many strengths as weaknesses. The major issues reported concerned the network’s Adaptation to its environment and Value maintenance. The representatives from 46 organization members of a TBI network felt that performance dimensions related to Goal Achievement were more important than those related to Process. The Capacity to attract the clientele, Continuity and the Capacity to adapt and meet client’s needs were the three most important dimensions, while the Capacity to adapt to requirements and tendencies and Quantity of care and services were the least important. TRIAGE groups enabled the constituents to reach a consensus about the importance of each dimension, and harmonized their different perspectives about network performance evaluation. Although much work remains, our research provides a solid basis upon which to pursue the network performance evaluation process towards optimizing TBI network services.

Digital platforms in healthcare have become an increasingly implemented tool to facilitate and streamline daily care work in hospitals and health centers. In parallel with the new digitized era, this digital transformation has had a major impact on individuals' ways of working in healthcare. It is thus significant that digital competence is prioritized to achieve the intended goals regarding streamlining patient management. The qualitative study sheds light on how digi-physical care affects everyday care work and the patient journey. The study also intends to conclude how digital care platforms affect everyday care work, what advantages and disadvantages can be distinguished. The main purpose of the study is to investigate how digital platforms can be implemented to streamline healthcare and thereby investigate such care platforms from an informatics perspective. The research question refers to, how digital platforms can be applied to streamline patient management, is framed from a supplier perspective of such care platforms. The methodology includes an online survey with 10 questions that 11 respondents answered. The survey is supplemented with three in-depth interviews. These in-depth interviews are conducted via the digital tool Microsoft Teams. These respondents are carefully selected to generate relevant first-hand information about the research topic. Based on the respondents' answers, it can be stated that all respondents considered that there are many positive advantages of using digital platforms in healthcare. These positive effects are achieved by implementing digital platforms in a well-thought-out and structured way. Respondents also then pointed out that care providers must be given the right conditions to adequately use the digital care platforms as part of their works. The extensive criticism that digital care providers have received has been encountered in the study. The main criticism is then that digital care providers more easily prioritize more manageable matters such as easier physical ailments especially for patients with higher socioeconomic status. Based on the survey, the importance of implementing digital care platforms from an equal opportunity perspective is emphasized. In the future, digital platforms need to be implemented and developed with the common goal of increasing accessibility for patients and offering more patient-centered healthcare. / Digitala plattformar inom hälso- och sjukvården implementeras allt mer med syfte att underlätta samt effektivisera det vardagliga vårdarbetet på sjukhus och vårdcentraler. Parallellt med den nya digitaliserade eran har denna digitala transformation haft en stor påverkan på individers arbetssätt inom hälso- och sjukvården. Det är därmed signifikant att den digitala kompetensen prioriteras för att uppnå de avsedda målen gällande effektivisering av patienthantering. Den kvalitativa undersökningen belyser hur den digifysiska vården påverkar det vardagliga vårdarbetet samt patienthantering. Studien ämnar även att dra slutsatser kring hur digitala vårdplattformar påverkar det vardagliga vårdarbetet, vilka för och nackdelar som går att urskilja. Syftet med studien är att undersöka på vilket sätt digitala plattformar kan implementeras för att effektivisera sjukvården och därmed bidra med ett forskningsbidrag till informatikämnet. Forskningsfrågan avser hur digitala plattformar kan tillämpas för att effektivisera patienthantering, ur ett leverantörsperspektiv. Datainsamlingen innefattar en online enkät i form av Google formulär med 10 frågor som 11 respondenter fick besvara. Detta kompletteras med tre intervjuer som utförs via det digitala kommunikationsverktyget Microsoft teams. Dessa respondenter är noggrant utvalda för att generera relevant kunskap kring forskningsämnet. Baserat på respondenternas svar går det att konstatera att samtliga respondenter ansåg att det finns många positiva fördelar med tillämpning av digitala plattformar inom hälso- och sjukvård. Positiva effekter uppnås genom att implementeringen av digitala plattformar sker på ett väl genomtänkt och strukturerat sätt. Merparten av respondenterna poängterade att det är viktigt att vårdgivarna ges rätt förutsättningar för att kunna arbeta utifrån den digitala plattformen. Den omfattande kritiken som digitala vårdgivare har fått påvisas i studien. Den främsta kritiken är att digitala vårdgivare prioriterar mer lätthanterliga ärenden såsom lättare fysiska åkommor för dem som har högre socioekonomisk status. Baserat på undersökningen poängteras vikten av att implementera digitala vårdplattformar ur ett jämställdhetsperspektiv. Framöver behöver digitala plattformar implementeras och utvecklas med den gemensamma målsättningen att öka tillgängligheten för patienter och erbjuda en mer patientcentrerad vård.

Worldwide, patients who visit health-care facilities generally have to wait very long to be attended by physicians and professional nurses. In South Africa, the Cape Triage Score system was implemented with great success in Emergency departments in the Cape Metropole. In primary health-care clinics the concern is that patients have to wait too long for service delivery, even if they are very ill and need hospitalisation. In this research study the role of triage in reducing waiting times in primary health-care clinics was examined. The Cape Triage Score system that was used in Emergency departments in the private sector and also in public hospitals was adapted for a pilot intervention study. This was done to determine if the utilisation of this system can reduce the waiting times of patients visiting primary health-care clinics. The researcher utilised a quantitative design with an intervention, after measuring the baseline waiting time. The strategies applied included an exploratory, descriptive and contextual strategy. The study was carried out in three steps according to the objectives set for the study. Firstly, the baseline assessment of the current waiting times in two PHC clinics in a sub-district of the North West Province was done. A waiting-time survey checklist was used to determine the baseline waiting time of patients visiting primary health-care clinics. These waiting-time survey checklists consisted of a few components that assessed different aspects of waiting time. The second objective was to explore and describe literature in order to understand primary health-care waiting times, triage and related constructs. The third objective was to pilot an adapted Cape Triage Score system to determine if the intervention contributed to reducing waiting times for patients visiting primary health-care clinics. Data was analysed according to Cohen’s effect sizes. The comparison between the baseline waiting times and pilot intervention waiting-time assessment was done according to Cohen’s effect sizes. The analysis of the data indicated a practical significance for the component where the pilot Cape Triage Score system was applied, as patients were referred to the physician and professional nurse according to the severity of their condition. The outcome of the study indicated no reduction in the overall waiting time of patients visiting primary health-care clinics due to the different components of the waiting-time survey checklist. Finally, the research was evaluated, limitations were identified and recommendations were stipulated for nursing practice, education, research and policy. / MCur, North-West University, Potchefstroom Campus, 2014

Worldwide, patients who visit health-care facilities generally have to wait very long to be attended by physicians and professional nurses. In South Africa, the Cape Triage Score system was implemented with great success in Emergency departments in the Cape Metropole. In primary health-care clinics the concern is that patients have to wait too long for service delivery, even if they are very ill and need hospitalisation. In this research study the role of triage in reducing waiting times in primary health-care clinics was examined. The Cape Triage Score system that was used in Emergency departments in the private sector and also in public hospitals was adapted for a pilot intervention study. This was done to determine if the utilisation of this system can reduce the waiting times of patients visiting primary health-care clinics. The researcher utilised a quantitative design with an intervention, after measuring the baseline waiting time. The strategies applied included an exploratory, descriptive and contextual strategy. The study was carried out in three steps according to the objectives set for the study. Firstly, the baseline assessment of the current waiting times in two PHC clinics in a sub-district of the North West Province was done. A waiting-time survey checklist was used to determine the baseline waiting time of patients visiting primary health-care clinics. These waiting-time survey checklists consisted of a few components that assessed different aspects of waiting time. The second objective was to explore and describe literature in order to understand primary health-care waiting times, triage and related constructs. The third objective was to pilot an adapted Cape Triage Score system to determine if the intervention contributed to reducing waiting times for patients visiting primary health-care clinics. Data was analysed according to Cohen’s effect sizes. The comparison between the baseline waiting times and pilot intervention waiting-time assessment was done according to Cohen’s effect sizes. The analysis of the data indicated a practical significance for the component where the pilot Cape Triage Score system was applied, as patients were referred to the physician and professional nurse according to the severity of their condition. The outcome of the study indicated no reduction in the overall waiting time of patients visiting primary health-care clinics due to the different components of the waiting-time survey checklist. Finally, the research was evaluated, limitations were identified and recommendations were stipulated for nursing practice, education, research and policy. / MCur, North-West University, Potchefstroom Campus, 2014

A triagem de pacientes em serviços de emergência constitui um campo de atuação para o enfermeiro, entretanto faltam instrumentos que possam ser utilizados para classificar a gravidade do paciente e a adequação de recursos ao seu atendimento. A finalidade deste estudo é obter um instrumento confiável que possa classificar as condições do paciente, melhorando a qualidade da assistência e diminuindo os riscos decorrentes da espera para o atendimento.O presente estudo teve como objetivo validar a escala de classificação de pacientes “Canadian Triage and Acuity Scale" (CTAS). Esta escala classifica o paciente em cinco níveis (1 a 5), respectivamente: situações de risco de vida, emergência, urgência, semi-urgência, não urgência. O instrumento foi submetido à tradução, versão à língua de origem, avaliação semântica, idiomática , cultural e conceitual. Após esta fase de validação, realizou-se a fase de confiabilidade interobservadores, entre a pesquisadora e duas enfermeiras voluntárias. A concordância expressa pelo índice kappa, foi de 0,739. Após esta etapa a pesquisadora avaliou 127 pacientes atendidos em um serviço privado, utilizando a CTAS. Houve predominância de pacientes classificados como nível 4 (46,00%) . O tempo médio entre a chegada do paciente, avaliação pelo serviço de triagem e entrada no serviço foi de 3,71 minutos. Houve associação estatisticamente significante entre o nível de classificação e as variáveis, sexo, idade, sinais vitais, dor, tempo de permanência, realização de procedimentos, avaliação de especialista e destino. Não houve pacientes classificados como nível 1. As mulheres corresponderam a 75,00% dos pacientes classificados como nível 2 e 3. Pacientes classificados como nível 2 e 3 apresentaram maior média de idade (58,75 anos), maior freqüência de alterações nos sinais vitais (60,00% do total de pacientes com alterações), maior média de permanência (188,45 minutos), necessidade de avaliação por especialistas (54,20% dos pacientes que necessitaram de avaliação) e de internação (73,30 % do total de pacientes que internaram). Pacientes classificados como nível 4, corresponderam a 66,70% dos pacientes com dor no momento da avaliação e a 47,60% dos pacientes que necessitaram de consultas, exames e procedimentos. Entre os homens, 53,80% foi classificado como nível 5. Neste nível destaca-se a menor média de idade (38,45 anos), a menor média de permanência (79,94 minutos), a maior freqüência de pacientes que necessitaram apenas de consulta médica (69,40%) e a alta do serviço para todos os pacientes. A concordância entre a queixa de entrada e o diagnóstico médico de saída da unidade foi de 0,884, expressa pelo índice kappa. Os resultados deste estudo mostram que a escala canadense representa um novo instrumento a ser utilizado pelos serviços de emergência, porém faz-se necessário a realização de novos estudos, com ampliação do tamanho da amostra e aplicação em serviços de complexidades diferentes. / The triage of patients in emergency facilities is a field of work for nurses. However, there is a lack of tools, which may be used to rate the severity of the patient’s condition and the suitability of the resources available. This study aims at obtaining a reliable tool that may be used to rate the patient’s condition, improve the quality of care and reduce the risks arising from the waiting time to care. This study aimed at the validation of the “Canadian Triage and Acuity Scale" (CTAS), which classified patients in five levels (from 1 to 5) respectively: resuscitation, emergent, urgent, semi-urgent, non urgent. The document was translated into Portuguese, translated back into the original language, and assessed from a semantic, idiomatic, cultural and conceptual perspective. The validation was followed by inter-observer reliability of the tool including the researcher and two volunteer nurses. The agreement reflected by the Kappa statistic was 0,739. Following this stage the researcher assessed 127 patients of a private facility using the CTAS. The majority of the patients were classified in level 4 (46,00%). The average time between the patient’s arrival, assessment by the triage service and admission was 3.71 minutes. There was a statistically significant co-relation between the level of triage and the following variables: sex, age, vital signs, pain, length of stay, procedures, specialist assessment and destination. No patients were classified in triage level 1. Women accounted for 75.00% of the patients classified in levels 2 and 3. Patients classified in levels 2 and 3 had the highest age average (58,75 years), the highest rate of changes in vital signs (60,00% of the total number of patients had changes), the highest average length of stay (188,45 minutes). This group also had the highest rate of patients who required specialist assessment (54,20% of the patients who required assessment) and admission (73,30 % of the total patients who were admitted). Patients classified in level 4 accounted for 66,70% of the patients with pain at the time of assessment and 47,60% of the patients who required visits, tests and procedures. Of the male patients, 53,80% were classified in level 5. Patients in this level had the lowest age average (38.45 years) and the lowest length of stay (79,94 minutes). This group also had the highest rate of patients who required only a medical visit (69,40%) and the highest rate of discharge among all patients served by the department. The agreement between the presenting complaint and the medical diagnosis was reflected by a kappa statistic of 0.884. The results of this study show that the Canadian scale is a new tool available to emergency departments. However, further studies, which apply the tool to larger samples and departments with different degrees of complexity, are necessary.

Introdução: A apneia obstrutiva do sono (AOS) é uma condição subdiagnosticada na prática clínica. A falta relativamente frequente de sintomas típicos para a AOS bem como a restrição da oferta da polissonografia (considerado o exame de escolha para o diagnóstico da AOS) são responsáveis em parte pelo subdiagnóstico desta doença. Diversos estudos exploraram o desenvolvimento de métodos de triagem para identificação de indivíduos com AOS. O excesso de peso é um fator de risco bem estabelecido para a AOS. As medidas antropométricas globais (índice de massa corporal, IMC) e regionais (por exemplo: circunferências do pescoço e cintura) de adiposidade são ferramentas simples e de baixo custo que têm sido correlacionadas com a AOS. Além disto, questionários de triagem da AOS, embora validados, tem uma acurácia não ideal em detectar este distúrbio do sono. No entanto, não está claro se a combinação de duas ou mais destas medidas antropométricas melhorariam o desempenho em identificar indivíduos com AOS. Portanto, o objetivo principal deste estudo foi o de comparar o desempenho de diversas medidas antropométricas isoladamente ou de forma combinada na identificação da AOS em adultos não referidos para o Laboratório do Sono derivados da coorte do Estudo Longitudinal da Saúde do Adulto (ELSA-Brasil). Métodos: Trata-se de um estudo transversal que recrutou adultos de ambos gêneros, participantes do ELSA-Brasil, centro São Paulo. Os participantes realizaram avaliações do sono com a poligrafia portátil domiciliar (Embletta GoldTM) e questionários que avaliam risco para a AOS (questionário de Berlim e escore NoSAS). As medidas antropométricas - IMC, circunferência do pescoço (CC), circunferência da cintura abdominal (CC), circunferência do quadril (CQ), razão cinturaestatura (RCE), razão cintura-quadril (RCQ) e índice de forma corporal (IFC) - foram feitas de forma padronizada e sem o conhecimento sobre os dados do sono. A análise da curva Receiver Operating Characteristic (ROC) foi realizada e a área sob a curva (AUC) foi calculada para avaliar a acurácia das medidas antropométricas na detecção da AOS. A análise de regressão logística foi realizada combinando as medidas antropométricas globais com as regionais (cervical e/ou abdominal) ajustando para dois outros importantes fatores de risco para a AOS: a idade e o sexo. Além disto, comparamos o desempenho das medidas antropométricas com o questionário de Berlim e o escore NoSAS. Resultados: No período de dois anos recrutamos inicialmente 2.334 participantes, dos quais 2.059 completaram todas as avaliações propostas. A amostra geral era predominantemente do sexo feminino (56%) e a média de idade foi de 49 ± 8 anos. A frequência da AOS foi de 32,3%, sendo que a porcentagem de homens (58 vs. 37%) e a idade (51 ± 8 vs. 48 ± 8 anos) foi significantemente maior no grupo com versus sem AOS, respectivamente. Aproximadamente um terço da amostra total era composta por indivíduos com sobrepeso ou obesidade. Participantes com AOS tiveram maior frequência de sobrepeso/obesidade e maiores valores das medidas antropométricas do que aqueles sem AOS. Todas as medidas antropométricas isoladamente apresentaram razoável capacidade de identificar a AOS (AUC aproximadamente de 0,700). Houve uma discreta melhora na acurácia após o ajuste para a idade e o sexo, sendo que a maior AUC foi encontrada para o IMC (AUC=0,760 [IC 95%: 0,739 - 0,781]), seguido por RCE (AUC=0,758 [IC 95%: 0,737 - 0,780]), CC (AUC=0,753 [IC 95%: 0,732 - 0,775]), CP (AUC=0,733 [IC 95%: 0,711 - 0,755]), RCQ (AUC=0,722 [IC 95%: 0,699 - 0,745]) e IFC (AUC=0,680 [IC 95%: 0,656 - 0,704]). Não foi observado diferenças significantes nas AUCs exceto para o menor valor observado para o IFC (p < 0,05 vs. demais medidas). A combinação de diferentes medidas antropométricas não resultou em melhora da acurácia em descriminar a AOS. Na comparação das medidas antropométricas com os questionários de triagem, não observamos diferenças significativas no desempenho do IMC ajustado para a idade e o sexo (AUC=0,748 [IC 95%: 0,727 - 0,770]) em relação ao escore NoSAS (AUC=0,760 [IC 95%: 0,739 - 0,781]). No entanto, o questionário de Berlim (AUC=0,676 [IC 95%: 0,653 - 0,699]) apresentou um desempenho inferior em relação ao IMC ajustado e ao escore NoSAS (p < 0,05 para cada comparação). Conclusões: Entre diversas medidas antropométricas globais e regionais de adiposidade, o IMC ajustado para a idade e sexo teve a melhor acurácia para detectar a AOS em uma coorte de indivíduos não referidos para estudo do sono. A combinação de medidas de adiposidade regional ou a combinação destas com o IMC não melhorou a capacidade de detectar a AOS. No entanto, considerando os valores das AUCs para as variáveis antropométricas bem como as AUCs dos questionários de sono disponíveis, esses dados reforçam a necessidade de ferramentas adicionais para reduzir o subdiagnóstico da AOS / Introduction: Obstructive sleep apnea (OSA) is an undiagnosed condition in clinical practice. The lack of typical symptoms in a subset of OSA patients as well as the limited availability of polysomnography (considered the gold standard method for diagnosing OSA) may partly explained this underdiagnosis. Several studies have explored the development of screening methods for identifying individuals with OSA. Overweight is a well-established risk factor for OSA. Global (body mass index, BMI) and regional (e.g., neck and waist circumferences) anthropometric measurements of adiposity are simple and low-cost tools that correlate with OSA. In addition, OSA screening questionnaires, although validated, have a non-ideal accuracy in detecting this sleep-disordered breathing. However, it is unclear whether the combination of two or more of these anthropometric measures would improve performance in identifying individuals with OSA. Therefore, the main aim of this study was to compare the performance of several anthropometric measurements alone or in combination to identify OSA in adults not referred to the Sleep Laboratory derived from the cohort of the Longitudinal Study of Adult Health (ELSA-Brasil). Methods: This is a cross-sectional study that recruited adults of both genders, participants of the ELSA-Brasil, Sao Paulo center. The participants performed sleep assessments with portable polygraphy (Embletta GoldTM) and questionnaires assessing the risk of OSA (Berlin questionnaire and NoSAS score). The anthropometric measures - body mass index (BMI), neck circumference (NC), waist circumference (WC), waist-to-height ratios (WHtR), waist-hip ratio (WHR) and body shape index (BSI) - were performed in a standardized way with no access to the sleep data. A receiver operating characteristic curve analysis was performed, and the area under the curve (AUC) was calculated to evaluate the accuracy of the anthropometric measurements to detect OSA. A logistic regression analysis was performed combining the global anthropometric measures with other regional (cervical and/or abdominal) measures adjusting for the two other important risk factors for OSA: age and gender. We also compared the performance of the anthropometric measurements with the Berlin questionnaire and the NoSAS score. Results: During two years, 2,334 participants were initially recruited and 2,059 completed all evaluations. Overall, our sample comprised predominantly females (56%) and the mean age was 49 ± 8 years. The frequency of OSA was 32.3% and the percentage of men (58 vs. 37%) and age (51 ± 8 vs. 48 ± 8 years) were significantly higher in the OSA group compared to their counterparts, respectively. Approximately one third of our sample consisted of overweight or obese individuals. Participants with OSA had a higher frequency of overweight/obesity and higher values of anthropometric measures than subjects without OSA. All anthropometric measurements alone showed a reasonable ability to identify OSA (approximately AUC 0.700). There was a modest improvement in the accuracy to identify OSA after adjustment for sex and age, and the highest AUC was found for BMI (AUC=0.760 [95% CI: 0.739 - 0.781]), followed by WHtR (AUC=0.758 [95% CI: 0.737 - 0.780]), WC (AUC=0.753 [95% CI: 0.732 - 0.775]), NC (AUC=0.733 [95% CI: 0.711 - 0.755]), WHR (AUC=0.722 [95% CI: 0.699 - 0.745]) and BSI (AUC=0.680 [95% CI: 0.656 - 0.704]). No significant differences were observed in AUCs except for the lower value of BSI (p < 0.05 vs. other measurements). The combination of different anthropometric measurements did not improve the accuracy in discriminating OSA. In the comparisons of anthropometric measurements with the screening questionnaires, we did not observe significant differences in the performance of for age- and gender-adjusted BMI (AUC=0.748 [95% CI: 0.727 - 0.770]) compared to the NoSAS score (AUC=0.760 [95% CI: 0.739 - 0.781]). However, the Berlin questionnaire (AUC=0.666 [95% CI: 0.653 - 0.699]) had a lower performance than adjusted BMI and the NoSAS score (p < 0.05 for each comparison). Conclusions: Among several global and regional anthropometric measurements of adiposity, age- and gender-adjusted BMI had the best accuracy to detect OSA in a cohort of individuals not referred to the sleep study. The combination of regional adiposity measurements or the combination of these with BMI did not improve the ability to detect OSA. However, considering the AUC values for the anthropometric variables as well as the AUC of the available sleep questionnaires, these data underscore the need of additional tools to reduce the underdiagnosis of OSA

Made available in DSpace on 2016-08-10T10:54:02Z (GMT). No. of bitstreams: 1 SOLANGE MARIA SEIXAS MARTINS.pdf: 6696788 bytes, checksum: 209fdfa09ac23f069a02890863dae15d (MD5) Previous issue date: 2012-03-05 / The growing demand and insufficiently structured health care network for emergency hospital care has contributed to the overload of these services, making them one of the most problematic areas in the Brazilian health system. A caring and welcoming triage protocol in the hospital emergency room, stands out among the guidelines proposed in Brazilian public policies to address this issue. In this context, we developed a qualitative case study aiming to describe the perception of patients and nurses concerning to the triage of patients in the emergency room service in Goiânia, GO, Brazil. A total of 19 nurses and 21 patients participated in the study. Data were collected from November 2010 to April 2011 through participant observation and semi-structured interviews. The analysis and interpretation of data revealed that the meanings held by the participants concerning to the implementation of a caring and welcoming triage protocol were related to the transformation of the care model and to the limitations and challenges faced in emergency care services. The participants mentioned that before this protocol was implemented, the emergency service was characterized by long wait lines, overcrowding, disorganized service flow, and deaths during waiting in lines. The delayed service, its poor problem-solving capacity, lack of consistency with patient needs, and the presence of work overload were identified as factors that created frustrations not only to the service users but also to the health professionals. organization, priority treatment, efficiency and, consequently, improved quality of care. The limitations and challenges of this protocol implementation are related to promote a caring and welcoming reception in a more respectful way at the emergency room, which involves time, and a greater availability to see, listen, and inform users. The nurses noted the need for continuing education to improve technical competencies (triage protocol) and human skills (welcoming) to care. Among the difficulties mentioned were the lack of capability to problem-solving in ambulatory emergency care, which is hard for the professional during the triage protocol to refer the patient to this service. The outcomes suggested that the protocol enabled the organization and definition of access to the service according to levels of priority. There are, however, many challenges to implementing a welcoming and humanized care provided to people who require emergency care in the hospital and pre-hospital environments. / A crescente demanda e a insuficiente estruturação da rede de atenção às urgências hospitalares têm contribuído para a sobrecarga destes serviços, transformando-os em uma das áreas mais problemática do sistema de saúde brasileiro. Entre as diretrizes propostas pelas políticas públicas brasileiras para solução desta problemática destaca-se o Acolhimento com Avaliação e Classificação de Risco. Neste contexto, optou-se por desenvolver um estudo de caso qualitativo com o objetivo de descrever a perspectiva de usuários e enfermeiros sobre o Acolhimento com Avaliação e Classificação de Risco em um serviço de urgência e emergência hospitalar em Goiânia, Goiás. Participaram 19 enfermeiros e 21 usuários. Os dados foram coletados de novembro de 2010 a abril de 2011, por meio de observação direta e entrevistas semi-estruturadas. A partir da análise e interpretação dos dados, constatou-se que os sentidos atribuídos pelos participantes para a implementação do acolhimento com avaliação e classificação de risco relacionaram-se à transformação do modelo assistencial e aos limites e desafios para o serviço de urgência. Os participantes mencionaram que antes da implantação deste protocolo, o serviço de urgência e emergência hospitalar era caracterizado por longas filas de espera, superlotação, desorganização do fluxo de atendimento, pessoas que morriam na fila. A demora no atendimento, a baixa resolutividade, a falta de atendimento condizente às necessidades dos usuários e a sobrecarga de trabalho foram mencionados como fatores geradores de frustração não apenas para os usuários, mas também para os enfermeiros. As mudanças foram percebidas de modo positivo e estiveram relacionadas à organização do serviço, ao tipo de atendimento, à eficiência da equipe e, conseqüentemente, à melhor atenção ao usuário. Os limites e desafios para implementação do protocolo referem-se à promoção do efetivo acolhimento que envolve tempo, maior disponibilidade para ver, ouvir e informar o usuário. Os enfermeiros destacaram a necessidade do processo de educação continuada para o aprimoramento de competências e habilidades técnicas (avaliação com classificação de risco) e humanas (acolhimento) para cuidar. Entre as dificuldades mencionaram a falta de resolutividade do serviço de urgência pré-hospitalar fixo (atenção básica), o que prejudica o encaminhamento resolutivo para a rede básica de urgência (contra-referência). Os resultados sugerem que o protocolo trouxe organização e definição do acesso ao serviço por nível de prioridade. No entanto, ainda são muitos os desafios para o acolhimento e a humanização do cuidar de pessoas que requerem atendimento de urgência no âmbito hospitalar e pré-hospitalar.

O Sistema de Triagem de Manchester (STM) é proposto como importante protocolo para assegurar o atendimento dos pacientes por critérios de gravidade clínica. Dentre os pacientes priorizados estão os com dor precordial ou cardíaca. Contudo, a heterogeneidade da dor torácica pode levar à classificação de menor gravidade, retardando o início da terapêutica de pacientes com Infarto Agudo do Miocárdio (IAM). Assim, esta pesquisa objetivou analisar os determinantes da prioridade de atendimento pelo STM para pacientes com IAM. Desenvolveu-se um estudo de coorte retrospectivo em uma emergência do sul do Brasil, com amostra de 217 pacientes com diagnóstico médico primário de IAM. A coleta de dados foi realizada em prontuário, no período entre março/2014 a fevereiro/2015. Para a análise estatística dos dados os pacientes foram agrupados em dois grupos: prioridade elevada (emergente e muito urgente) e prioridade não elevada (urgente, pouco urgente e não urgente). O projeto de pesquisa foi aprovado em comitê de ética. Os resultados demonstraram que o sexo masculino foi majoritário, com média de idade de 62,1 ±12,4 anos e predominância dos fatores de risco hipertensão e tabagismo. Para 116 (53,4%) pacientes foi atribuída a prioridade não elevada de atendimento pelo STM. Sessenta e quatro (29,5%) pacientes tiveram IAM com supradesnivelamento do segmento ST, 29 (45,3%) deles recebeu prioridade não elevada. O fluxograma Dor torácica (77,9%) e os discriminadores Dor precordial ou cardíaca (27,6%) e Dor moderada (22,5%) foram os mais selecionados. Tosse e dor abdominal (p = 0,039), tempo de início dos sintomas superior há 24 horas (p <0,001) e intensidade de dor leve ou moderada (p = 0,002) foram preditores clínicos associados à determinação de prioridade não elevada. Sudorese (p = 0,048) e níveis elevados de pressão arterial sistólica (p = 0,011) e diastólica (p = 0,003) foram associados à prioridade elevada. Houve associação entre prioridade não elevada com tempos para classificação de risco (p <0,001), porta-ECG (p <0,001) e porta-troponina maiores (p = 0,008). Não foi identificada diferença estatisticamente significativa entre os dois grupos para os tempos porta-agulha (p = 0,600) e porta-balão (p = 0,345). Os resultados forneceram subsídios para o julgamento clínico do enfermeiro triador. / The Manchester Triage System (MTS) risk classification is proposed as an important protocol to assure the assistance of patients based on clinical severity criteria. Among priority patients are who have precordial or cardiac pain. However, the heterogeneity of the clinical presentation of chest pain for individuals can lead to its classification as minor severity, delaying the start of appropriate treatment for Acute Myocardial Infarction (AMI) patients. Thus, this research aimed to analyze determinants for service priority based on the MTS for patients with AMI. A retrospective cohort study in an emergency department of southern Brazil with a sample of 217 patients with a primary medical diagnosis of AMI was developed. Data collection was carried out from medical records between March 2014 and February 2015. For data analysis, patients were grouped into two groups: high priority (emergency and very urgency) and non-high priority (urgency, less urgency, and non-urgency). The study was approved by the Research Ethics Committee. Results showed a majority of males, with a mean age of 62.1 ± 12.4 years, and with prevalence of the risk factors hypertension and smoking. For 116 (53.4%) patients, a non-high priority based on MTS was attributed. Sixty-four (29.5%) patients had AMI with segment ST supradepression, where 29 (45.3%) received non-high priority. The flowchart Thoracic Pain (77.9%) and the discriminators precordial or cardiac Pain (27.6%) and moderate Pain (22.5%) were the most selected. Clinical predictors associated with the determination of non-high priority were: cough and abdominal pain (p=0.039), start time of symptoms greater than 24 hours (p<0.001), and mild or moderate pain intensity (p=0.002). High priority was associated with sweating (p=0.048), and elevated levels of arterial systolic (p=0.011) and diastolic (p=0.003) blood pressure. There was an association between non-high priority with greater time to risk classification (p<0.001), door-to-ECG (p<0.001), and greater door-to-troponin (p=0.008). No statistically significant difference was found between the two groups for door-to-needle (p=0.600) and door-to-balloon (p=0.345) time. Results provide resources to support triage nurses’ clinical judgment. / El Sistema de Triaje Manchester (STM) es propuesto como un importante protocolo para asegurar la atención a los pacientes por criterios de gravedad clínica. Entre los pacientes priorizados están los que tienen dolor precordial o cardiaco. Sin embargo, la heterogeneidad del dolor torácico puede llevar a una clasificación de menor gravedad, lo que retrasa el inicio de la terapia para los pacientes con Infarto Agudo de Miocardio (IAM). Por lo tanto, este estudio tuvo como objetivo analizar los determinantes de la prioridad de atención por el STM para los pacientes con IAM. Se desarrolló un estudio de cohorte retrospectivo en el servicio de urgencias en el sur de Brasil, con una muestra de 217 pacientes con diagnóstico médico primario de IAM. La recolección de datos fue realizada en la historia clínica, en el periodo entre marzo/2014 y febrero/2015. Para el análisis estadístico de los datos los pacientes fueron clasificados en dos grupos: prioridad elevada (inmediata y muy urgente) y prioridad no elevada (urgente, menos urgente y no urgente). El proyecto de investigación fue aprobado por el comité de ética. Los resultados mostraron que el sexo masculino eran la mayoría, con una edad media de 62,1± 12,4 años y predominio de los factores de riesgo hipertensión y tabaquismo. Para 116 (53,4%) pacientes fue atribuida la prioridad no elevada de atención por el STM. Sesenta y cuatro (29,5%) pacientes tuvieron IAM con supradesnivel del segmento ST, 29 (45,3%) de ellos recibió prioridad no elevada. El flujograma Dolor torácica (77,9%) y los discriminadores Dolor precordial o cardiaco (27,6%) y Dolor moderado (22,5%) fueron los más seleccionados. Tos y dolor abdominal (p=0,039), tiempo de inicio de los síntomas superior a 24 horas (p<0,001) e intensidad del dolor leve a moderado (p=0,002) fueron predictores clínicos asociados a la determinación de la prioridad no elevada. Sudoración (p=0,048) y niveles elevados de presión arterial sistólica (p=0,011) y diastólica (p=0,003) fueron asociados a la prioridad elevada. Hubo asociación entre prioridad no elevada con tiempos para clasificación de riesgo (p<0,001), puerta-ECG (p<0,001) y puerta-troponina mayores (p=0,008). No fue identificada diferencia estadísticamente significativa entre los dos grupos para los tiempos puerta-aguja (p=0,600) y puerta-balón (p=0,345). Los resultados proporcionaron subsidios para el juicio clínico del enfermero que realiza el triaje.

INTRODUÇÃO: A disfagia orofaríngea gera impacto negativo na qualidade de vida e saúde dos indivíduos que a possuem, aumentando também a taxa de morbidade e a necessidade de cuidados. A utilização de protocolos padronizados para a triagem da disfagia em serviços hospitalares auxilia o diagnóstico e tratamento precoce, reduzindo complicações clínicas, tempo de permanência e custos hospitalares. Essas ferramentas devem ser simples e apresentar alta sensibilidade quando comparadas aos exames objetivos de avaliação da deglutição. OBJETIVO: o objetivo do presente estudo foi realizar a validação de um instrumento simples de triagem da disfagia utilizado em um hospital público de grande porte no Brasil em população adulta heterogênea. MÉTODO: O Protocolo de Avaliação de Risco para Disfagia versão de triagem (PARDt) contém quatro itens (ausculta cervical alterada, alteração da qualidade vocal, tosse e engasgo antes/durante/após a deglutição) que foram previamente indicados como fatores de risco independentes associados à presença de disfagia no teste de deglutição com água. Fonoaudiólogos treinados administraram e classificaram o PARDt para pacientes consecutivos encaminhados pela equipe médica do hospital para realizar a videofluoroscopia da deglutição (VDF). Vinte por cento de todos os pacientes inscritos foram aleatoriamente alocados para a realização da VDF, menos de 24 horas após serem submetidos ao PARDt. RESULTADOS: No total, 211 pacientes receberam a triagem da deglutição, sendo que desses, 99 falharam (com disfagia) e 112 passaram (sem disfagia). Um em cada cinco pacientes foi randomizado para receber a VDF, ou seja, 42 pacientes. Comparando os achados da avaliação clínica da deglutição com os achados da VDF, a versão de triagem do PARD demonstrou excelente validade, com sensibilidade de 92,9%, especificidade de 75,0%, valores preditivos negativos de 95,5% e acurácia de 80,9%. CONCLUSÃO: O PARDt é uma ferramenta simples e precisa para identificar a penetração e/ou aspiração em pacientes que não são alimentados por sonda, que apresentam bom nível de alerta, sem histórico de pneumonias de repetição, que não estejam em vigência de pneumonia e que não façam uso de cânula de traqueostomia / INTRODUCTION: Oropharyngeal dysphagia can have a negative impact on the quality of life and health of the individuals who have it, increasing the morbidity rate and the need for care. The use of standardized dysphagia screening protocols in hospital services helps diagnosis and early treatment, reducing clinical complications, length of stay and hospital costs. These tools should be simple and have high sensitivity when compared to objective examinations of swallowing assessment. OBJECTIVE: The purpose of the present study was to assess the validity of a simple instrument for screening dysphagia used in a large public hospital in Brazil with heterogeneous adult population. METHODS: The Dysphagia Risk Evaluation Protocol (DREP) - screening version contains four items (altered cervical auscultation, altered vocal quality, coughing and choking before / during / after swallowing) that were previously indicated as independent risk factors associated to the presence of dysphagia in the swallowing test with water. Trained speech therapists administered and scored DREP - screening version to consecutive patients referred by hospital\'s medical team to perform videofluoroscopy for swallowing (VSFF). Twenty percent of all enrolled patients were then randomly allocated to perform VSFF, less than 24 hours after being submitted to the DREP - screening version. RESULTS: A total of 211 patients were screened for swallowing, of which 99 failed (with dysphagia) and 112 passed (without dysphagia). One in five patients was randomized to receive VSFF, that is, 42 patients. Comparing the findings of the clinical evaluation of swallowing with the VSFF findings, the DREP - screening version showed excellent validity, with sensitivity of 92.9%, specificity of 75.0%, predictive values of 95.5% and accuracy of 80.9%. CONCLUSION: The DREP - screening version is a simple and accurate tool to identify penetration and / or aspiration in patients who are not tube-fed, who have a good level of alertness, have no history of recurrent pneumonia, are not on pneumonia, and that do not use a tracheostomy cannula