Submitted by Silvana Teresinha Dornelles Studzinski (sstudzinski) on 2015-07-02T12:50:52Z No. of bitstreams: 1 Mariana Ferreira Arrieche Lopez.pdf: 1432775 bytes, checksum: 4eecaefa9d4fccd4d37ec474366634d2 (MD5) / Made available in DSpace on 2015-07-02T12:50:52Z (GMT). No. of bitstreams: 1 Mariana Ferreira Arrieche Lopez.pdf: 1432775 bytes, checksum: 4eecaefa9d4fccd4d37ec474366634d2 (MD5) Previous issue date: 2014-12-19 / Nenhuma / A temática da segurança do paciente vem sendo discutida sob diferentes abordagens e significados, entre elas, as questões que caracterizam a ocorrência de eventos adversos nos serviços de saúde. Objetivo: rastrear a ocorrência de eventos adversos utilizando a ferramenta Global Trigger Tool proposta pelo Institute for Healthcare Improvement (IHI) em uma Unidade de Internação Pediátrica de um hospital de ensino na cidade de Porto Alegre-RS. Método: estudo retrospectivo de abordagem transversal e analítica realizado na Unidade de Internação Pediátrica (UIP) do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (HSL-PUCRS). A amostra foi constituída de 209 prontuários de pacientes que tiveram alta da UIP durante o período de janeiro a dezembro de 2013. A coleta dos dados foi realizada através da metodologia proposta pelo Institute for Healthcare Improvement (IHI). Para análise dos dados foi criado um banco de dados em planilha Excel e foi utilizado o software SPSS versão 13.0. Os dados foram analisados através de tabelas, gráficos, porcentagens, médias e desvio padrão. Resultados: Houve uma predominância de crianças do sexo masculino sendo 124 (59,3%), além disto, foram encontradas 111 (53,1%) lactentes e 60 (28,7%) escolares. Observa-se que a média de internação foi de 6,9 + 18 dias. Aproximadamente 51% das crianças permaneceu hospitalizada por até sete dias e 22,0% por mais de sete dias. Os pacientes eram em sua grande maioria provenientes da emergência pediátrica (63,1%) e dos postos de saúde (18,6%). Dos gatilhos rastreados, dois (1,0%) casos foram do C4 (Hemocultura positiva), um (0,5%) do C14 (complicação relacionada a procedimento) e nenhum caso referente ao gatilho infecções causadas pelos cuidados em saúde. Todos os gatilhos rastreados nos prontuários se enquadraram na categoria de dano E (contribuiu para o dano temporário e necessitou de intervenção). Não foi evidenciado registro referente à ocorrência de evento adverso e nenhum dos danos identificados teve seu desfecho como evento adverso. O desfecho hospitalar de 208 (99,5%) pacientes foi o domicílio e um paciente (0,5%) foi transferido para a emergência pediátrica por agravamento do quadro clínico. Conclusão: A metodologia de revisão retrospectiva de prontuários como método para mensuração de eventos adversos é uma ferramenta de grande utilidade pensando na Segurança do Paciente, porém é necessário adaptá-la para populações pediátricas. A segurança do paciente ainda é um desafio para as instituições de saúde, o maior desafio dessas instituições é transformar o ambiente de saúde para a cultura de segurança do paciente. / The patient safety issue has been discussed under different approaches and meanings, among them the issues that characterize the occurrence of adverse events in health care. Objective: To track the occurrence of adverse events using the Global Trigger Tool proposed by the Institute for Healthcare Improvement (IHI) in a pediatric inpatient unit of a teaching hospital in the city of Porto Alegre – RS. Method: Retrospective study in a comprehensive and analytical approach performed in the Pediatric Inpatient Unit (UIP) of the Hospital São Lucas of PUCRS. The sample consisted of 209 records of patient who were discharged from the UIP during the period of January to December/2013. Data collection was performed using the methodology proposed by the Institute for Healthcare Improvement (IHI). Data analysis was created a database into an Excel spreadsheet and used the SPSS software version 13.0. Data were analyzed using tables, graphs, percentages, means and standard deviations. Results: There was a predominance of male children and 124 (59.3%), moreover, found 111 (53.1%) infants and 60 (28.7%) students. It is observed that the average hospital stay was 6.9 + 18 days. Approximately 51% of children hospitalized remained for up to seven days and 22.0% for more than seven days. The patients were mostly from the pediatric emergency (63.1%) and primary care units in health (18.6%). The traced triggers, two (1.0%) cases were of C4 (positive blood culture), one (0.5%) of C14 (complication related procedure) and no cases related to trigger infections caused by health care. All triggers traced in the records fit in the category of damage E (contributed to the temporary damage and required intervention). There is no evidence record for the occurrence of adverse events and none of the identified damage had its outcome as an adverse event. The hospital outcome of 208 (99.5%) patients was the home and one patient (0.5%) was transferred to the pediatric emergency for worsening of clinical status. Conclusion: The retrospective review of medical records of methodology as a method for measurement of adverse events is a very useful tool in thinking Patient Safety, however it is necessary to adapt it to pediatric populations. Patient safety is still a challenge for health institutions, the biggest challenge of these institutions is to transform the healthcare environment for patient safety culture.

Medicaid Disproportionate Share Hospital (DSH) payment is one of the major funds supporting health care providers as they treat low-income patients. However, Medicaid DSH payments have been targeted for major budget cuts in many health policy reforms. This study examines the association between the changes in Medicaid DSH payments resulting from the BBA policy changes and hospital outcomes, in terms of hospital provision of uncompensated care and quality of care. Economic theory of non-profit hospital behavior is used as a conceptual framework, and longitudinal data for California short-term, non-federal general acute care hospitals for 1996-2003 are examined. California was especially affected by DSH changes because it is one of the states with highly concentrated DSH payments and high uninsured rate. Economic theory suggests that hospitals would change their uncompensated care provision as well as quality of care when confronted with a reduction in public payments. Hospital uncompensated care costs and percent of operating costs devoted to uncompensated care are used to measure the provision of hospital uncompensated care. Six AHRQ’s Patient safety indicators (PSIs) and one composite measure are selected to measure hospital quality of care provided for Medicaid and uninsured patients as well as privately insured patients. The key independent variable is Medicaid DSH payments received by individual hospitals. This study also includes control variables such as other governmental financial subsidies, market characteristics, and hospital characteristics. The primary data sources include the detailed hospital annual financial data and Medicaid annual report data at the county level from California Office of Statewide Health Planning and Development, Healthcare Cost and Utilization Project (HCUP) state inpatient data (SID), American Hospital Association Annual Survey, Area Resource File, Interstudy HMO Data and Medicare cost report data. After controlling for different factors, the study findings suggest that not-for-profit hospitals may reduce their provision of uncompensated care in response to reductions of Medicaid DSH payments. The results, however, do not support the hypotheses that for-profit hospitals may reduce uncompensated care by a smaller degree than not-for-profit hospitals for a comparable DSH decline. With respect to quality of care model, the overall study findings do not strongly support there is an association between net Medicaid DSH payments and patient adverse events for both Medicaid/uninsured and privately insured.

<p>The overall aim of this thesis was to gain a deeper understanding about parents’ perceptions of quality of care and their own involvement in pediatric hospital care.</p><p>Parental involvement in the care of hospitalized children has gained increased attention in recent years. The aim of this thesis was to study parental involvement in pediatric hospital care and investigate its association to the work conditions of pediatric hospital staff. </p><p>The first study validated a parent questionnaire that measured parents’ views of the quality of care. The questionnaire measures quality of care by means of eight indices and an overall quality grade. Results showed that the questionnaire demonstrated satisfactory validity and reliability. </p><p>Study 2 examined whether there were differences in quality ratings between respondents and non-respondents to the parent questionnaire. The main parent questionnaire was distributed in hospital and a follow-up questionnaire was sent home to a random sample of parents three week after the hospital visit. This study pinpointed a number of difficulties that need to be considered when conducting investigations of non-response.</p><p>The third study aimed at gaining a deeper understanding of factors that influence parents’ views of their own involvement in pediatric care. Semi-structured interviews were conducted with parents of chronically ill children. Four themes emerged from the interviews: support, professionalism, work environment and responsibility. Underlying these four themes is a need for a clear communication between staff and parents.</p><p>The fourth study examined hospital staff’s perceptions of parental involvement and possible consequences for staff work environment. A questionnaire was sent out to hospital staff at oncology, neurology and surgery units at three university children’s hospitals. Hospital staff on oncology units gave higher ratings to their workplace routines for involving parents in the child’s care, and experienced less work strain from parental demands, compared to staff on the other units. </p><p>The results of this thesis indicate a clear association between parental involvement in pediatric care and the work conditions of pediatric hospital staff. </p>

<p>Insufficient competence among nursing staff is a major concern in elderly care worldwide as the healthcare needs of the elderly become increasingly complex. In previous research, insufficient competence has been associated with work dissatisfaction and stress among elderly care nurses, and with lower quality of care. This thesis describes the development, implementation and evaluation of an educational intervention for nursing staff in elderly care. In a prospective, controlled study, evaluation of the educational toolbox was based on nursing staff ratings of their competence and psychosocial work environment, as well as on care recipients’ and family relatives’ ratings of the quality of elderly care.</p><p>Paper I validated a questionnaire measuring care recipient relatives’ perceptions of quality of care. Paper II compared self-rated competence, work strain, stress, and work satisfaction between staff working in home-based care and nursing homes. Papers III and IV evaluated the impact of the educational intervention on staff perceptions of their competence and psychosocial work environment (Paper III) and on care recipients’ and relatives’ perceptions of the quality of care (Paper IV).</p><p>The results showed that staff ratings of their competence and psychosocial work environment, including work satisfaction and work stress, improved significantly over time in the intervention municipality, compared to the reference group. Neither care recipients’ nor relatives’ ratings of the quality of care changed significantly over time in the intervention organization. Furthermore, there were no significant interaction effects over time between the intervention and reference groups for quality ratings. These results indicate that an educational toolbox that can be used according to local workplace needs may be an effective and sustainable intervention for improving staff competence and the psychosocial work environment. However, further studies are needed to investigate whether, and under what conditions, improved staff competence and work environment have an impact on quality of care.</p>

The overall aim of this thesis was to describe experiences of emergency treatment among people injured in traffic accidents, and to test and evaluate the effects of follow-up telephone calls from a nurse during the subsequent phase. The thesis is based on four sub-studies of motorists, bicyclists, and pedestrians who had fallen in traffic during the years 2002-2005. The participants were aged 18 to 70 years old and had minor (MAIS 1) or nonminor (MAIS 2+) injuries. Sub-study I was a qualitative study in which individual narrative interviews were conducted with nine persons who had sustained traffic injuries. The aim of this study was to describe the injured individuals’ experiences of pre-hospital and hospital care and subsequent rehabilitation. The interviews were analysed using content analysis, and the experiences of the interviewees were formulated into four themes: facing commotion, experiencing trust and security, lacking security and support, and struggling to return to everyday life. The results showed that a sensitive caregiver who provides comprehensible information facilitates both the emergency treatment and the subsequent period of care and rehabilitation. Sub-study II was a cross-sectional study in which the participants (n=565) estimated their perceptions of the quality of care in the accident and emergency department (A&amp;E) after an injury event. The Mini-KUPP (“Quality from the Patient’s Perspective”) questionnaire was used to estimate quality of care at the A&amp;E. The questionnaire was posted to the subjects’ home addresses three weeks after the visit to the A&amp;E. The results showed that the quality of care was scored on the top half of the scale by all three road user categories. In a multiple logistic regression analysis, significant connections emerged between good quality of care and a short waiting time, non-minor injuries (MAIS2+), higher age, and higher levels of education. The factor most closely associated with the perception of good quality of care was a short waiting time. Sub-study III was a stratified and randomised intervention study including 568 injured persons. In addition to modern trauma care, the intervention group received follow-up via telephone, three weeks after the injury, by a nurse who provided advice and support during the rehabilitation period. The control group received modern trauma care but no follow-up. Both groups estimated their health-related quality of life two weeks (baseline) and six months after the injury. After six months, estimates of health-related quality of life were generally higher in the intervention group than in the control group. A sub-group analysis found that the differences were most pronounced for the group who had received adequate advice in connection with the telephone follow-up. Of the three road user categories, the motorists gained the greatest benefit from the telephone intervention, with milder problems with regard to pains/difficulties and essential activities. Sub study IV was a health economic study. The calculations were built on the results from study III (n=568). A cost utility analysis was performed, including the costs for the intervention and the QALYs gained. The results showed that the telephone intervention was cost-effective. The total gain in the intervention group was 2.60 QALYs, while the car occupants gained 1.54 QALYs. The cost per QALY gained was 16 000 SEK overall and 8 500 SEK for car occupants. Conclusion: A sensitive caregiver who also provides good information can instil security and trust in the patient. For the purposes of generally improving the quality of care in an A&amp;E, the aim above all should be a short waiting time, but the treatment of minor injuries should also be improved. Access to a supportive nurse who is able to provide advice during the subsequent phase has the potential to improve health-related quality of life in a cost-effective way.

The overall aim of this thesis was to gain a deeper understanding about parents’ perceptions of quality of care and their own involvement in pediatric hospital care. Parental involvement in the care of hospitalized children has gained increased attention in recent years. The aim of this thesis was to study parental involvement in pediatric hospital care and investigate its association to the work conditions of pediatric hospital staff. The first study validated a parent questionnaire that measured parents’ views of the quality of care. The questionnaire measures quality of care by means of eight indices and an overall quality grade. Results showed that the questionnaire demonstrated satisfactory validity and reliability. Study 2 examined whether there were differences in quality ratings between respondents and non-respondents to the parent questionnaire. The main parent questionnaire was distributed in hospital and a follow-up questionnaire was sent home to a random sample of parents three week after the hospital visit. This study pinpointed a number of difficulties that need to be considered when conducting investigations of non-response. The third study aimed at gaining a deeper understanding of factors that influence parents’ views of their own involvement in pediatric care. Semi-structured interviews were conducted with parents of chronically ill children. Four themes emerged from the interviews: support, professionalism, work environment and responsibility. Underlying these four themes is a need for a clear communication between staff and parents. The fourth study examined hospital staff’s perceptions of parental involvement and possible consequences for staff work environment. A questionnaire was sent out to hospital staff at oncology, neurology and surgery units at three university children’s hospitals. Hospital staff on oncology units gave higher ratings to their workplace routines for involving parents in the child’s care, and experienced less work strain from parental demands, compared to staff on the other units. The results of this thesis indicate a clear association between parental involvement in pediatric care and the work conditions of pediatric hospital staff.

Insufficient competence among nursing staff is a major concern in elderly care worldwide as the healthcare needs of the elderly become increasingly complex. In previous research, insufficient competence has been associated with work dissatisfaction and stress among elderly care nurses, and with lower quality of care. This thesis describes the development, implementation and evaluation of an educational intervention for nursing staff in elderly care. In a prospective, controlled study, evaluation of the educational toolbox was based on nursing staff ratings of their competence and psychosocial work environment, as well as on care recipients’ and family relatives’ ratings of the quality of elderly care. Paper I validated a questionnaire measuring care recipient relatives’ perceptions of quality of care. Paper II compared self-rated competence, work strain, stress, and work satisfaction between staff working in home-based care and nursing homes. Papers III and IV evaluated the impact of the educational intervention on staff perceptions of their competence and psychosocial work environment (Paper III) and on care recipients’ and relatives’ perceptions of the quality of care (Paper IV). The results showed that staff ratings of their competence and psychosocial work environment, including work satisfaction and work stress, improved significantly over time in the intervention municipality, compared to the reference group. Neither care recipients’ nor relatives’ ratings of the quality of care changed significantly over time in the intervention organization. Furthermore, there were no significant interaction effects over time between the intervention and reference groups for quality ratings. These results indicate that an educational toolbox that can be used according to local workplace needs may be an effective and sustainable intervention for improving staff competence and the psychosocial work environment. However, further studies are needed to investigate whether, and under what conditions, improved staff competence and work environment have an impact on quality of care.

Physical restraint use and falls are common in institutional care of old people and various attempts have been made to reduce their occurrence. Falls and concomitant injuries are a major problem due to their negative effect on morbidity and mortality. Prevention of falls and injuries is the most common reason for physically restraining old people in institutional care. Its use has, however, been questioned both from an ethical perspective, since restraints can be perceived as coercive and also because of the lack of sound evidence of their effectiveness in preventing falls, as well as the adverse effects associated with their use. The main purposes of this thesis were to investigate differences in the us of physical restraints over time, to identifify risk factors for falls among people with dementia, to evaluate the effects of a restraint minimization program on staff knowledge, attitudes, and work environment and use of physical restraints and the quality of care. The present thesis is based on three main data collections, two census surveys conducted within institutional care for old people in the county of Västerbotten in 2000 (n=3,804) and 2007 (n=2,970) and one cluster-Randomized Controlled Trial (RCT) including 40 group dwellings for people suffering from dementia where the intervention consisted of staff education. The use of physical restraints increased slightly between 2000 and 2007 (16.2% to 18.4%, p=0.016). Analyses suggest that the increase might be independent of any change in resident characteristics. Restrained residents were also subjected to restraints for longer times in 2007. During a six-month follow-up 64/160 (40.0%) residents in group dwellings for those with dementia sustained at least one fall. Independent risk factors for falls were ‘requiring help with hygiene’, ‘displaying verbally disruptive/attention-seeking behavior’, ‘able to rise from a chair’, ‘walking with assistive devices’, and ‘participating in outdoor walks’, which explained 36.1% of the falls. The majority of the 191 falls were un-witnessed, 35% occurred during the night and anxiety and confusion were the most common symptoms preceding the falls. A six-month restraint minimization program showed a positive impact on staff knowledge, attitudes and work environment as well as on the use of physical restraints and subjectively estimated quality of care. Residents in the intervention group present throughout the entire study period had lower odds, relative to the residents in the control group of being physically restrained at follow-up (OR= 0.21, CI 95%=0.08-0.57) after controlling for potential confounders and the cluster effect. Adjusted analyses including all residents present at either baseline or follow-up also showed that the use of physical restraints was less in the intervention group relative to the control group at follow-up. There was no change in the occurrence of falls or use of psychoactive drugs. The intervention also reduced stress of conscience, job demands and strain in the staff, and improved their job control and the caring climate. Subgroup analysis indicated a greater effect in units where the use of physical restraints had been reduced or remained constant. In conclusion, physical restraint use and falls remains common in institutional care of old people. The practice of physical restraint seems to have changed. In the RCT it was found that it is possible to change restraint practice and also to improve staff work environment. Falls among residents with dementia require a certain mobility function and anxiety and confusion are common symptoms preceding falls.

Der Beitrag untersucht auf der Grundlage neuer primärärztlicher Befunde die Versorgungsqualität bei der hinsichtlich Chronizität und Arbeitsausfall schwerwiegendsten Angsterkrankung, der Generalisierten Angststörung. Neben einer knappen Einführung in das Störungsbild werden die an über 20 000 Patienten in 558 Hausarztpraxen gewonnenen Kernbefunde der GAD-P-Studie (Generalisierte Angst und Depression in der Primärärztlichen Versorgung) zusammengefasst und Ansatzpunkte zur Verbesserung der Versorgungsqualität dieses selten adäquat behandelten Störungsbildes diskutiert. Insbesondere wird auf die zentrale Bedeutung einer sichereren diagnostischen Erkennung als Voraussetzung für therapeutische Verbesserungen hingewiesen. In Ergänzung zur Verbesserung bestehender Weiterbildungsangebote wird auf Arzt- und Patientenebene der breitere Einsatz bestehender Screeningverfahren, die Nutzung krankheitsspezifischer Patientenratgeber, sowie eine breitere Öffentlichkeitsarbeit zur Information über dieses bislang vernachlässigte, häufig chronisch verlaufende Krankheitsbild empfohlen. / Based on new empirical findings in a large-scale primary care study, the quality of care for the most chronic and debilitating anxiety problem, generalised anxiety disorder, is examined. Following a brief introduction of this disorder, the core findings of the GAD-P study (generalised anxiety and depression in primary care) with more than 20,000 patients of 558 family doctor practices are summarised and measures to improve the quality of care of patients with generalised anxiety disorder, a disorder which is rarely adequately treated, are discussed. This paper particularly emphasises the standard use of time-efficient diagnostic screening instruments, because improved recognition and diagnosis is the prerequisite for appropriate treatment. Further the role of the media to increase awareness of this disorder as well as patient education materials to improve compliance and to enhance treatment outcome effects are highlighted.

The United States is ranked 27th in the world for maternal mortality, yet spends twice as much on maternity care services as countries with better maternal health indicators. Stuck in a technocratic and physician-dominated maternity care system, the U.S. depends on expensive technologies to control birth out of fear of pain and litigation, costing Americans billions of dollars and depriving women of the opportunity to have a transformative birth experience. Through an analysis of the medicalization of birth and the current biomedical model in birth, in conjunction with open-ended interviews with 5 hospital midwives and 3 homebirth midwives, the benefits and challenges of incorporating a midwifery model of care into our maternity services are explored. The midwifery model emphasizes that birth is not pathology and that psychosocial factors play a large role in birth outcomes. Basing their practice on collaboration, education, and support, midwives empower women, avoid unnecessary interventions, and offer a lower cost and higher quality care alternative. The current monopoly of women’s health services by physicians is unsustainable. Incorporating midwives into the maternity care team could provide a sustainable alternative with the caliber of maternity care services that U.S. women and families deserve.