Heart failure is a complex heart disease that incapacitates more than 5 million people, is associated with increasing healthcare cost, and remains the leading cause of admission in the United States. As the United States faces increasing financial burden related to readmission of heart failure patients within 30 days of discharge, many healthcare institutions are evaluating interventions to determine the most effective opportunities to improve systems, including nursing practice. The purpose of this doctoral project was to improve readmission rates within 30 days of discharge from an acute care facility through the development and implementation of a standardized, evidence-based, patient-centered discharge education toolkit using the Teach-Back method. Orem's self-care theory and the situation-specific theory of heart failure self-care were utilized as a theoretical framework to inform this doctoral project. The sources of evidence were obtained from the Get With The Guidelines-Heart Failure database and through a review of nursing and health-related databases. Descriptive statistics were used to compare the pre- and posteducation session readmission rates. The rate of readmissions occurring within thirty days of discharge pre- and post-educational session retrieved from the GWTG-Heart Failure database were 9.4% and 0.0% respectively. These results showed that this discharge toolkit reduced heart failure 30-days readmission rates. The limitations and strengths of this project will be used to guide further research on heart failure readmission and self-care management. This DNP project will promote positive social change for clinicians, who can use this discharge toolkit to improve self-management in adults with heart failure and thus decrease the costs related to readmission.

Unplanned hospital readmission after a recent hospitalization is an indication of poor healthcare quality and a waste of healthcare resources. The Centers for Medicare and Medicaid Services (CMS) initiated the Hospital Readmission Reduction Program (HRRP) to improve healthcare quality and reduce costs; however, studies found the risk adjustment method used in calculating the standardized readmission rate was less accurate without hospital region or community factors. Accordingly, this cross-sectional quantitative study was designed to examine spatial patterns in hospital readmission rates following Andersen's behavioral model of health service utilization. This study was the first geospatial analysis on risk standardized hospital readmissions (RSRR) based on hospital geographic locations. Secondary data from the CMS was used in assessing the global and local geospatial cluster patterns using Global Moran's Index, Anselin local Moran's Index, and graphical analysis tool to identify cluster groups. The study found hospital-wide RSRR was significantly clustered across the country or at the local level. A total of 15 optimal cluster groups were identified with wide variability in cluster size. The hospital-wide and other seven CMS published RSRRs were significantly different among all clusters. The geographically bounded hospital RSRRs provided evidence in support of adding community or regional layer to risk adjustment of RSRR. The specific cluster groups with extremely high or low readmission rates can assist national and local policymakers and hospital administrators to identify specific targets to take actions. This research has social change implications for reducing hospital readmission rates and saving healthcare costs.

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Background Screening for prostate cancer is debated, there is conflicting data on the net benefit of screening. Men who consider screening need to be informed on the pros and cons. Rehospitalization after surgery can be used as an indicator of general quality of care. For radical prostatectomy, little is known on the readmission rate after surgery. Men diagnosed with low- and intermediate-risk prostate cancer have low prostate-cancer specific mortality. However, adverse effects after curative treatment can be severe and decrease quality of life. Curative treatments for prostate cancer differ mainly in the pattern of adverse effects but detailed analysis of long-term adverse effects is lacking. The aim of this thesis was to assess the perioperative quality of radical prostatectomy and the risk of adverse effects after curative treatment for prostate cancer. Material and Methods In this thesis, data from the National Prostate Cancer Register (NPCR) and other nationwide Swedish registers were used. By use of the Swedish personal identity number, NPCR was cross-linked to other registers creating Prostate Cancer data Base Sweden (PCBaSe), a large dataset for research. Results The proportion of men who had received information on the pros and cons of screening for prostate cancer with PSA testing was low (14%) indicating that the majority of men who were screened did not make an informed decision. The risk of rehospitalization within 90 days after radical prostatectomy was approximately 10% and similar after retropubic and robot-assisted radical prostatectomy. Compared to controls, there was an increased risk of adverse effects after both radiotherapy and radical prostatectomy up to twelve years after treatment and the overall risk was quite similar after retropubic and robot-assisted radical prostatectomy. Conclusion Improved information to men on the pros and cons of PSA screening is warranted. The risk of adverse effects was elevated up to 12 years after curative treatment for prostate cancer. The pattern of adverse effects was different after radiotherapy and radical prostatectomy but quite similar after retropubic and robot-assisted radical prostatectomy.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / BACKGROUND: In order to improve the quality and efficacy of healthcare while reducing the overall cost to deliver that healthcare, it has become increasingly important to manage utilization of services for populations of patients. Healthcare systems are aggressively working to identify patients at risk for hospital readmissions. Although readmission rates have been studied before, parameters for identifying patients at risk for readmission appear to vary depending the patient population. We will examine existing Electronic Health Record (EHR) data at Banner Health to establish what parameters are clinical indicators for readmission risk. Three conditions were identified by the CMS to have high and costly readmissions rates; heart failure (HF), acute myocardial infarction (AMI), and pneumonia. This study will focus on attempting to determine the primary predictive variables for these three conditions in order to have maximum impact on cost savings. METHODS: A literature review was done and 68 possible risk variables were identified. Of these, 30 of the variables were identifiable within the EHR system. Inclusion criteria for individual patient records are that they had an index admission secondary to AMI, heart failure, or pneumonia and that they had a subsequent readmission within 30 days of the index admission. Pediatric populations were not studied since they have unique factors for readmission that are not generalizable. Logistics regression was applied to all data including data with missing data rows. This allowed all coefficients to be interpreted for significance. This model was termed the full model. Variables that were determined to be insignificant were subsequently removed to create a new reduced model. Chi square testing was then done to compare the reduced model to the full model to determine if any significant differences existed between the two. RESULTS: Several variables were determined to be the significant predictors of readmission. The final reduced model had 19 predictors. When analyzed using ROC analysis, the area under the curve (AUC) was 0.64. CONCLUSION: Several variables were identified that could be significant contributors to readmission risk. The final model had an AUC on it ROC of 0.64 suggesting that it would only have poor to moderate clinical value for predicting readmission.

As concepções sobre a loucura, bem como as formas de tratá-la, vêm sofrendo consideráveis transformações de acordo com a cultura e as épocas. A partir da década de 1990, foi oficializada a Reforma Psiquiátrica no Brasil, dando início à política de desinstitucionalização e reinserção social. Todavia, ainda são verificados alguns desafios, entre estes, as reinternações no setor de internação breve em um hospital psiquiátrico, o que traz sérias consequências, como a propensão a uma nova modalidade de institucionalização. Este estudo teve como objetivos: analisar o fenômeno da reinternação psiquiátrica no contexto da Atenção Psicossocial, a partir da visão dos pacientes reinternantes em um hospital psiquiátrico público; compreender o processo de reinternação psiquiátrica ao qual o paciente está sujeito; investigar o cenário assistencial e sociofamiliar e suas interferências no fenômeno da reinternação psiquiátrica; explorar, junto aos pacientes, a existência de perspectivas que vislumbrem saídas às repetidas internações psiquiátricas. Inicialmente, com vistas a sintetizar e analisar a produção científica nacional e internacional acerca do fenômeno da reinternação psiquiátrica, no contexto da desinstitucionalização, foi realizada uma revisão integrativa da literatura publicada em fontes de pesquisa de impacto que detectou deficiência de estudos que investigassem variáveis psicossociais envolvidas na problemática, bem como ausência da perspectiva do paciente sobre o assunto. O presente estudo fundamentou-se na Atenção Psicossocial, enquanto corpo teórico-prático e ético, e orientou-se pela reabilitação psicossocial como categoria analítica. A Atenção Psicossocial emerge no atual contexto de transição paradigmática, a partir da crise do paradigma da racionalidade científica, e baseia-se no pensamento da complexidade. Para a coleta dos dados, foi aplicado um roteiro de entrevista semiestruturada a 22 pacientes reinternantes no hospital investigado, bem como coletadas informações sociodemográficas constantes dos seus prontuários. Os dados colhidos foram submetidos à análise de conteúdo, por meio da qual foram construídas as seguintes categorias temáticas: Funções e disfunções do tratamento hospitalar: os sentidos da internação psiquiátrica; Tratamento ambulatorial: repetir ou inovar?; A medicação e seus impasses: benefícios e limites percebidos; Família laços e embaraços: uma convivência possível?; A dimensão social extramuros: construindo lugares possíveis; O momento da alta: o que está por vir daqui para frente. A partir da análise dos dados, constatou-se uma combinação de carências: ausência de apoio familiar desejável, inexistência de trabalho ou de ocupação agradável, dificuldade na apropriação do espaço de moradia, falta de redes de apoio ou de laços sociais, insuficiência dos serviços extra-hospitalares e a ineficiência da assistência que resultam na não adesão ao tratamento, incluindo o medicamentoso. Este cenário favorece o isolamento social e contribui para que, nos momentos de crise, não havendo possibilidade de acolhida do sofrimento no serviço, o hospital seja o recurso mais utilizado pelo paciente. Assim, a coexistência de modelos antagônicos, hospitalar e comunitário, produz um novo fenômeno, que, no entanto, reproduz o velho: a reinternação psiquiátrica que leva à reedição da institucionalização. Nessa direção, a reinternação psiquiátrica, como fenômeno atual, desvela o processo ainda inconcluso e não consolidado da Reforma Psiquiátrica, bem como confirma que a efetiva desinstitucionalização só ocorre com a devida substituição do modelo hospitalar pelo modelo de Atenção Psicossocial. / Conceptions about madness, as well as how to treat it, have been undergoing considerable changes according to culture and period. From the 1990s, the Psychiatric Reform was official in Brazil, starting the policy of deinstitutionalization and social reintegration. However, a few challenges are still observed, including the readmissions in the sector of brief hospitalization in a psychiatric hospital, which has serious consequences, such as the propensity to a new form of institutionalization. This study aimed to: analyze the phenomenon of psychiatric readmission in the context of Psychosocial Care, from the perspective of readmitted patients in a public psychiatric hospital; understand the process of psychiatric readmission to which the patient is likely to be submitted; investigate the assistance, social and familial scenario and their interference in the phenomenon of psychiatric readmission; explore, together with the patients, the existence of perspectives that envisage other possibilities to repeated psychiatric hospitalizations. Initially, in order to synthesize and analyze the national and international scientific production about the phenomenon of psychiatric readmission in the context of deinstitutionalization, an integrative review of the literature was conducted in research sources of impact. It was found a deficiency of studies that investigate psychosocial variables involved in the problem, as well as an absence of the patient\'s perspective on the subject. The present study was based on the Psychosocial Care, as a theoretical, practical and ethical reference, and was also guided by psychosocial rehabilitation as an analytical category. The Psychosocial Care emerges in the current context of paradigmatic transition, from the crisis of the scientific rationality´s paradigm, and it is based on the thought of complexity. To collect data, a semi-structured interview was applied to 22 readmitted patients in the investigated hospital, as well as the collection of their social and demographic information contained in their hospital records. Data were submitted to content analysis, through which the following thematic categories we developed: Functions and dysfunctions of hospital treatment: the meanings of psychiatric hospitalization; Outpatient treatment: repeat or innovate?; Medication and its impasses: perceived benefits and limits; Family ties and embarrassments: a possible coexistence?; The extramural social dimension: building possible places; The time of discharge: what is to come hereafter. From the data analysis, it was found a combination of deficiencies: lack of desirable family support, lack of pleasant work or occupation, difficulties in the appropriation of the living space, lack of support networks or social ties, lack of outpatient care services and assistance´s inefficiency, that result in noncompliance with treatment, including medication treatment. This scenario favors social isolation and contributes to that, in times of crisis, when there is no possibility of acceptance of suffering in the service, the hospital becomes the most used tool by the patient. Thus, the coexistence of opposing models, hospital and community, produces a new phenomenon, which, however, reproduces the old one: the psychiatric readmission that leads to the repetition of the institutionalization. Accordingly, the psychiatric readmission, as current phenomenon, reveals the unfinished and unbound process of the Psychiatric Reform, and confirms that the effective deinstitutionalization occurs only with proper replacement of the hospital model for the Psychosocial Care model.

Introdução: Nas últimas décadas, vários fatores determinaram importantes modificações no modo de prover assistência psiquiátrica. Entre estes, destacam-se as mudanças no modo como entendemos os transtornos mentais, os avanços e melhora na disponibilidade de tratamentos psiquiátricos, o aumento do interesse político em saúde mental, além da ênfase nos custos da assistência médica. Com isto, a internação psiquiátrica passou a representar uma parcela menor entre os recursos utilizados na assistência em saúde mental. A Psiquiatria hospitalar atual cumpre a função de realizar diagnóstico e tratar sintomas agudos com a finalidade de esbater riscos, focada em estabilização, segurança do paciente e curta permanência. Neste contexto, o estudo de desfechos negativos entre pacientes que internam em leito psiquiátrico de hospital geral torna-se cada vez mais necessário. Objetivos: Identificar determinantes de desfechos negativos entre pacientes que internaram em leito psiquiátrico de hospital geral, definidos a priori como tempo de internação prolongado, reinternação e morte por qualquer causa em um ano a partir do momento da alta hospitalar. Métodos: Estudo naturalístico, longitudinal e prospectivo, realizado em unidade psiquiátrica de um hospital geral universitário de nível terciário. Pacientes admitidos entre junho de 2011 e dezembro de 2013 com 18 anos ou mais foram considerados elegíveis, exceto os que tivessem transtorno por uso de substâncias como diagnóstico principal, agitação psicomotora grave nas primeiras 72 horas da admissão, comprometimento cognitivo suficiente para comprometer a avaliação ou recusa em participar da pesquisa. Dados sociodemográficos e clínicos foram coletados na admissão, alta e um ano após a alta. Resultados: No artigo 1, seis variáveis explicaram 14,6% da variabilidade no tempo de internação: ausência de renda própria, história de internações psiquiátricas nos últimos dois anos, escore total na Brief Psychiatric Rating Scale e na Clinical Global Impression, diagnóstico de Esquizofrenia e história de tentativas de suicídio. O artigo 2 reafirmou o papel das internações anteriores em predizer internações futuras (RC1.38; IC 1.16-1.60) e demonstrou que para pacientes que internaram em episódio depressivo, não estar em remissão no momento da alta aumenta o risco de reinternação (RC 2.40; IC 1.14-5.07), assim como maiores escores na Brief Psychiatric Rating Scale no momento da alta para aqueles admitidos por Esquizofrenia. O artigo 3 reportou a mortalidade entre os pacientes acompanhados um ano 9 após a alta, mais de três vezes maior que a mortalidade da população geral para o mesmo período e área geográfica. Discussão: Os três estudos produzidos por esta tese colaboram para o corpo de evidências sobre desfechos adversos entre pacientes que internaram em leito psiquiátrico de hospital geral. O modelo de internação psiquiátrica em hospital geral é amplamente defendido pela Psiquiatria contemporânea como o melhor para tratamento de agudizações de transtornos mentais graves. Entretanto, não é o modelo majoritário tanto no Brasil como no mundo. Portanto, os resultados desta tese refletem os desfechos de um modelo assistencial preconizado, porém não predominante. Considerações finais: Ainda carecemos de pesquisas que se dediquem a avaliar desfechos negativos em internação psiquiátrica de hospital geral. / Introduction: In the last decades, several factors have determined significant changes in the way to provide psychiatric care. These include changes in the way we understand mental disorders, advances and improvements in the availability of psychiatric treatments, increased political interest in mental health, and emphasis on health care costs. With this, psychiatric hospitalization started to represent a smaller portion of the resources used in mental health care. It fulfills the function of diagnosing and treating acute symptoms with the purpose of avoiding risks, being focused on stabilization, patient safety and short stay. In this context, the study of negative outcomes among patients hospitalized in the psychiatric beds of general hospital becomes more and more necessary. Objectives: To identify determinants of adverse outcomes in patients admitted in psychiatric beds of a general hospital, defined a priori as longer hospital stay, rehospitalization and death from any cause one year after discharge. Methods: This is a naturalistic, longitudinal and prospective study carried out in a psychiatric unit of a general university-level tertiary care hospital. Patients admitted between June 2011 and December 2013 aged 18 years and over were considered eligible, except those who had substance use disorders as the main diagnosis, severe psychomotor agitation in the first 72 hours of admission, cognitive impairment sufficient to compromise the evaluation or refusal to participate in the research. Sociodemographic and clinical data were collected on admission, discharge and one year after discharge. Results: In article 1, six variables explained 14,6% of the variability of length-of-stay: absence of own income, history of psychiatric hospitalizations in the last two years, the total score of Brief Psychiatric Rating Scale and Clinical Global Impression, Schizophrenia diagnosis and history of suicide attempts. Article 2 reaffirmed the role of previous admissions in predicting future hospitalizations. Also, for patients admitted in a depressive episode, not being in remission at discharge increases the chance to be readmitted (OR 2.40; CI 1.14-5.07), as well as higher scores in the Brief Psychiatric Rating Scale at discharge for patients with Schizophrenia (OR 1.28, CI 1.11-1.48). Article 3 reported the mortality among patients followed up, more than three times greater than the mortality of the general population for the same period and geographical area. Discussion: The three studies produced by this thesis collaborate to the body of evidence about adverse outcomes among patients admitted in psychiatric beds of a general hospital. Contemporary psychiatry widely advocates the model of psychiatric hospitalization in general hospital as the best for treatment of acute mental disorder exacerbations. However, it is not the majority model in Brazil as in the world. Therefore, the results of this thesis reflect the outcomes of a recommended, but not predominant, care model. Final considerations: We still lack researches that focus on evaluating negative outcomes in general hospital psychiatric hospitalization.

A crescente preocupação sobre as infecções relacionadas à assistência à saúde levou a Organização Mundial da Saúde a promover a criação da Aliança Mundial para a Segurança do Paciente, enfatizando ações básicas de controle de infecções. A redução de sua incidência implica em proteção para o paciente, profissionais e instituições, favorecendo a prestação da assistência livre de riscos. Dentre as mais frequentes, a infecção do sítio cirúrgico deve ser compreendida como elemento qualificador do cuidado e, os dados relacionados, o ponto de partida para as ações preventivas e de controle. Os hospitais têm dificuldades para realizar a vigilância epidemiológica pós-alta, tarefa complexa haja vista a tendência de redução do tempo de internação. Conhecer dados sobre a readmissão contribui para melhorar os dados de vigilância pós-alta. Foi realizado um estudo exploratório com o objetivo de descrever a epidemiologia das readmissões por infecções de sítio cirúrgico em pacientes em um hospital público de Belo Horizonte (MG). Foram avaliados 98 registros médicos e da Comissão de Controle de Infecção Hospitalar referentes aos indivíduos readmitidos por este motivo entre janeiro/2008 e dezembro/2009. Os resultados demonstraram que um quarto dos pacientes que desenvolveu infecção do sítio cirúrgico na instituição necessitou de nova internação. A idade média dos indivíduos foi de 57,2 anos; mais da metade apresentava diabetes mellitus, e um terço, hipertensão arterial sistêmica; no entanto, o risco anestésico para a maioria foi classificado como baixo. As infecções ocorreram com maior frequência em cirurgias limpas e potencialmente contaminadas, e as especialidades com maior número de pacientes readmitidos foram ortopedia, com mais da metade dos procedimentos relacionados à correção de fraturas, e cirurgia geral, na qual as hernioplastias/rafias e colecistectomias predominaram. Metade dos indivíduos recebeu biomaterial em suas intervenções. Os tempos cirúrgicos e de internação não diferiram dos estudos encontrados na literatura. Praticamente todos os pacientes utilizaram antibioticoprofilaxia, segundo protocolo da instituição. Os primeiros sinais e sintomas surgiram, em média, após 33,2 dias, e metade dos infectados teve o diagnóstico nos primeiros 30 dias de pós-operatório. A classificação das infecções mostrou que metade dos pacientes apresentou infecção de órgãos e cavidades e, para 60% deles, foram necessárias novas intervenções cirúrgicas, além do tratamento antimicrobiano. O micro-organismo predominante nas infecções ortopédicas foi Staphylococcus aureus e nas infecções da cirurgia geral Escherichia coli, ambos com perfil de resistência abaixo daqueles encontrados na literatura. O estudo permite concluir que a vigilância pós-alta e o monitoramento das taxas de readmissão contribuem para o redimensionamento do problema e definição de ações pontuais para seu controle. / The growing concern about infections related to health care led the World Health Organization to promote the creation of the World Alliance for Patient Safety, emphasizing basic actions to infection control. The reduction in the incidence of surgical site infection implies protection for patients, professionals and institutions favoring the assistance free of risks. Among the most frequent, surgical site infection should be understood as a qualifying element of care, and related data, the starting point for preventive and control measures. Hospitals have difficulties in achieving post-discharge surveillance, complex task given the trend of reduced hospital stay. Knowledge of the of readmission rates helps to improve reporting of post-discharge surveillance. An exploratory and descriptive study was conducted in order to describe the epidemiology of readmissions for surgical site infections in patients in a governmental hospital in Belo Horizonte (MG). We evaluated 98 medical records and the reports of the Hospital Infection Control Committee related to readmitted patients for this reason among january/2008 and december/2009. The results showed that one quarter of patients who developed surgical site infection in the hospital needed a new hospitalization. The mean age of subjects was 57.2 years; more than a half had diabetes mellitus, and a third, hypertension, however, the anesthetic risk for the majority was classified as low. The infections occurred more frequently in clean and potentially contaminated surgeries and the medical specialties with higher number of patients readmitted was orthopedic, with more than half of surgeries related to the correction of fractures, and general surgery, where the hernia and gallbladder surgery predominated. Half of the subjects received biomaterial in its proceedings. The surgical and hospitalization times did not differ from others studies in the literature. Virtually all patients received antibiotic prophylaxis for indications mentioned in the protocol. Early signs and symptoms appeared after an average of 33.2 days, and half of the patients were diagnosed within the first 30 days postoperatively. The classification of infections showed that half of the patients had infection of organs and cavities and 60% were required surgical interventions, in addition to antimicrobial treatment. Staphylococcus aureus predominated in orthopedic procedures and Escherichia coli in general surgery, both with multi-resistance profile below the results presented in other studies. The study concludes that the post-discharge surveillance and monitoring of readmission rates contribute to the scaling of the problem and define specific actions for its control.