No description available.

No description available.

Watershed models are powerful tools for simulating different scenarios to understand the impact of management practices and are used to support and guide decision-making. However, there are often challenges and limitations to using watershed models in some areas of watershed modeling; 1) model calibration in the areas with data limitations; 2) acquiring complete weather data that accurately reflect watershed model responses; 3) accurate representation of manure operation in watershed models. This dissertation addresses each of the aforementioned challenges using new approaches and tools in three studies with the main objective of achieving a better prediction of water quality and quantity and enhancing watershed models. Chapter 2 presents a method (multi-basin calibration (MBC)) to estimate watershed model parameters that lack long-term streamflow records. In the MBC method, first, the Soil and Water Assessment Tool (SWAT) models are initialized individually for several similar neighboring watersheds with a short period of measured streamflow. Then, we aggregate the simulated and observed flows from each initialization with short histories to generate a combined observed-simulated streamflow record that is longer than the initial length of each individual member in order to increase the information content. The Nash-Sutcliffe efficiency (NSE) from this merged time series was used as the basis for calibrating using a differential evolution algorithm. To evaluate the MBC, SWAT models for three newly instrumented USGS gages in Lake Champlain Basin of Vermont, USA, were compared to the commonly used similarity-based regionalization (SBR) approach. Results demonstrate that short periods of hydrological measurement from multiple locations in a basin can represent a system similar to long-term measurements. Chapter 3 develops a method to generate a complete weather data time series with the integration of multiple Global Historical Climatology Network (GHCN) stations and to assess the benefit of much higher density, lower reliability precipitation measurements from private citizens collected by the Community Collaborative Rain, Hail, and Snow (CoCoRaHS) network data that was integrated into the GHCN. To evaluate the performance of the methodology, generated weather data is used to force the Soil and Water Assessment Tool (SWAT) models of 21 United States Department of Agriculture (USDA)-Agricultural Research Service (ARS)-Natural Resource Conservation Service (NRCS)-Conservation Effects Assessment Project (CEAP) watersheds to simulate daily streamflow. The results demonstrated that integration of multiple GHCN stations including higher-density, but perhaps lower-quality weather data can enhance model performance. A comparison with published SWAT model results further corroborated improved model performance using newly combined GHCN data. Chapter 4 develops a hybrid SWAT model, SWAT-Dairy, to accurately represent the impact of manure operation on nutrient transport. The SWAT-Dairy model incorporates process-based livestock routines, developed in the R platform, which quantify daily manure production, stored manure, daily total nitrogen (N) and phosphorus (P), organic and mineral N and P, and dynamic manure nutrient fractions based on animal characteristics, feed characteristics, and environmental conditions. Outputs are then used in SWAT to simulate the impact of livestock manure production. The new model, with simulated manure application management, is applied to a farm in the Little Otter Creek Basin in Vermont, US. Subbasin- and farm-level N and P losses from manure management using the new model were compared for different feed management scenarios. / Doctor of Philosophy / In the past few decades, watershed management has become more challenging due to rapid population growth, climate change, and agricultural practices. In order to achieve better watershed management strategies, it is essential to understand the complex interaction between different biological, physical, and chemical processes occurring in the watershed. Watershed models are useful tools that help scientists and engineers to understand and predict how climate and land-use changes and agricultural management practices affect different components of a watershed system. While watershed models have many advantages, they are often limited by challenges and obstacles, such as model parameter estimations in the areas with limited measured streamflow data, acquiring complete and accurate weather data, and explicit representation of animal management impacts on water quality in manure applications. This dissertation addresses the challenges mentioned earlier by developing new approaches and methods that improve water quality and quantity using watershed models. A long record of measured streamflow data is necessary for watershed models to accurately represent watershed systems and estimate the parameters that cannot be directly measured. However, many watersheds worldwide are not monitored or are newly instrumented with a short period of recorded data. Chapter 2 introduces a new approach (multi basin calibration (MBC)) that integrates short periods of recorded data from several watersheds to provide a similar representation of the watershed system as long-term records. MBC was compared with a commonly used method that requires long recorded streamflow data from a neighboring watershed. The results showed that MBC improved model results and captured hydrological processes better for the watershed with a short period of recorded data than the traditionally used method. Obtaining accurate weather data for a watershed model can also be challenging since land-based weather stations often contain missing data. In recent years, hydrological modelers and researchers have access to the much higher density of weather measurements from private citizens that collect data with inexpensive equipment. However, no study has evaluated the benefits of using much higher-density data from private citizens for watershed modeling. Chapter 3 presents a new methodology to acquire complete weather data time series with the integration of all weather stations, including higher density private citizen-based measurements. Then the weather data were used to force watershed models of 21 watersheds across the United States. The results showed that the new methodology provides weather data that reflect the watershed model response with satisfactory performance ratings in 18 out of 21 watersheds. Lastly, chapter 4 develops a dairy model and integrates it into one of the most commonly used watershed models, the Soil and Water Assessment Tool (SWAT), to investigate how different farm management scenarios impact manure production and nutrient contents as well as their consequent effect on water quality during manure application on farm fields.

Tout comme la plupart des pays industrialisés, le Canada, et plus particulièrement, le Québec, est caractérisé par une forte concentration de la population immigrante sur son territoire. Encore aujourd’hui, la région métropolitaine de Montréal accueille la majorité des immigrants internationaux admis dans la province, ce qui sous-entend que le reste de la province n’attire qu’une part négligeable de l’immigration. En 1992, le gouvernement du Québec a mis en place une politique de régionalisation dans le but de mieux répartir la population immigrante sur le territoire. Cette politique visait d’une part, à encourager les immigrants internationaux à s’établir en dehors de Montréal et, d’autre part, à faire partager les bénéfices de l’immigration à toutes les régions. Mais qu’en est-il des résultats et des effets de cette politique? Jusqu’à maintenant, on connaît toujours peu de choses sur le sujet et sur les caractéristiques des immigrants qui décident de s’établir en « région ». L’objectif de cette recherche est donc de faire le bilan quantitatif et qualitatif de l’immigration au Québec afin de vérifier si cette politique a eu des répercussions sur le choix de destination des immigrants internationaux. Le premier chapitre est essentiellement consacré à la recension des écrits au sujet de la régionalisation de l’immigration, notamment en ce qui à trait au phénomène de concentration géographique et des tendances à l’échelle nationale et internationale. Un premier portrait des immigrants établis au Canada et au Québec complètera ce chapitre. Le deuxième chapitre analyse l’évolution des flux migratoires et de la régionalisation au Québec de 1982 à 2006. Le dernier chapitre a pour objectif d’évaluer la capacité de rétention des régions. Cela permettra de dresser le portrait actuel de la population immigrée, c’est-à-dire de connaître la région de destination réelle des immigrants. Les résultats de cette recherche nous permettent de croire que les effets de cette politique tardent à se manifester et que les efforts déployés dans le but d’une répartition mieux équilibrée de l’immigration ont porté fruit davantage à la banlieue de Montréal. / Like most industrialized countries, Canada and more specifically, Quebec, is characterized by a high concentration of the immigrant population on its territory. Still today, the Montreal metropolitan area welcomes the majority of international immigrants that enters the province, which means that the rest of the province only receives a negligible portion of the immigrant population. In 1992, the Quebec government put in place a regionalization policy, hoping to better distribute the immigrant population across its territory. This policy had two goals; the first was to encourage the international immigrants to settle outside of Montreal, and the second, to spread the benefits of immigration across the province. What were the results and effects of this policy? Up until now, we know very little on the subject and on the characteristics of the immigrants who choose to settle outside Montreal in the “regions”. The objective of this research is to make a quantitative and qualitative assessment of immigration in Quebec in order to verify if this policy has affected the international immigrants’ settlement choice. The first chapter is essentially devoted to summarizing the various writings on the regionalization of immigration, particularly on the phenomenon of geographic concentration and the national and international trends. A first description of the immigrants established in Canada and Quebec is going to complete this chapter. The second chapter will analyze the evolution of the migratory flows and regionalization in Quebec from 1982 to 2006. The objective of the last chapter is to evaluate the regions’ retention capability. This will permit to depict the current immigrant population (i.e., identifying the current region of settlement of the immigrants). The results of this research suggest that the effects of this policy are not yet apparent and the efforts deployed to achieve a more balanced distribution of immigration benefited the suburbs of Montreal more than they did the regions of Quebec.

Les politiques provinciales en matière d'immigration au Québec s'orientent depuis quelques décennies vers la régionalisation des personnes immigrantes, afin de faire bénéficier aux milieux régionaux et ruraux des avantages de leur présence. La présente étude examine, dans une perspective ethnographique, comment s'articulent les liens entre la reconnaissance sociale démontrée par les Québécois originaires du Haut-Lac-Saint-Jean envers les immigrants qui s'y établissent, et l'intégration de ces derniers à leur nouvelle communauté d'accueil. À travers une recension des variations de l'expérience de l'altérité observées dans le milieu, l'étude révèle les conditions d'émergence de la reconnaissance et les facteurs qui la freinent. / Provincial immigration policies in Quebec are oriented towards the regionalization of immigrants, in order for regional and rural areas to benefit from their presence. This study adopts an ethnographic perspective to examine how social recognition shown by native Quebecers toward immigrants who settle in the Haut-Lac-Saint-Jean area is linked to the integration of the newcomers to their host community. Through a review of the various experiences of alterity observed in the region, my study reveals the conditions that foster the emergence of recognition and the factors that serve to make it less likely.

Commuting became an inseparable part of everyday life of contemporary society and an analysis of commuting flows has a fundamental meaning for capturing social- geographical organization of society. The main object of this thesis is to identify changes in geographical aspects of commuting to work and school in the Benešov district during the period 2001-2011. The second object is to evaluate the impact of macroregional centre of Prague on the commuting in Benešov district. The district is, taking into consideration the nearness and a good traffic connesction to Prague, appropriate example for assessing the impact of macroregional centre on neighbouring micro-regions. This impact is followed by an analysis of commuting flows and also by a questionnare survey. The purpose of the questionnare survey is to capture how people feel about commuting to work and labour market in Prague. Keywords: commuting, socio-geographical regionalization, macro-region, micro- region, functional region, Benesov, Prague, Vlasim, Votice.

This thesis deals with the spatial orientation of transport links in the Karlovy Vary region, with emphasis on links between the centers of the region and its hinterland. The first part describes the general characteristics of this area. It is followed by a selection of the Karlovy Vary Region transport centers and analysis of their acccesibility. This forms the basis for the transport-geographical regionalization of the region, according to the accesibility rates. The final part of this thesis is devoted to the comparison of the individual regionalizations and the identification of factors that affect them.

No description available.

O estudo proposto nesta tese aborda o processo de regionalização do SUS a partir de duas vertentes dinamizadoras. Uma orientada pela diretriz da descentralização político-administrativa e outra pela diretriz de regionalização e hierarquização da rede de saúde com foco na integração de atividades e serviços em regiões. Tal processo pode ter como resultado a mitigação ou o aprofundamento das desigualdades regionais. O processo de regionalização assim considerado foi analisado segundo duas dimensões do desenvolvimento capitalista, a territorial e a da saúde pública. Em relação à dimensão territorial, a divisão inter-regional do trabalho foi considerada elementar para a diferenciação das regiões segundo suas funções na organização da produção. É nessa perspectiva que recorremos à rede urbana como síntese da divisão inter-regional do trabalho. Em relação à dimensão da saúde pública, o norteamento para a compreensão da sua inserção no desenvolvimento capitalista foi dado por dois conceitos dicotômicos de saúde, saúde como ausência de doença e saúde como bem-estar social. É por meio deles que se torna possível identificar as diferentes funções sociais da saúde pública e, a partir daí, desvelar seu papel no aprofundamento do movimento desigual da acumulação do capital ou, ao contrário, como elemento de transformação social. Devido à importância do financiamento na elucidação do processo de regionalização, a tese evidenciou as transferências de recursos da esfera federal para os governos municípios no âmbito do bloco de financiamento da Média e Alta Complexidade Ambulatorial e Hospitalar (Bloco MAC) com foco nas estratégias vinculadas às redes temáticas. Foram observadas as transformações na concentração/desconcentração territorial dos recursos do Fundo Nacional de Saúde (FNS) para os Fundos Municipais de Saúde (FMS) paulistas no período 2009-2014, considerando as condições de urbanização das 63 Regiões de Saúde do estado de São Paulo (Metropolitana, Alta urbanização, Média urbanização e Baixa urbanização) propostas pela tese. A análise assim fundamentada tornou possível verificar que o processo recente de regionalização do SUS no estado de São Paulo, dinamizado pelo financiamento das ações e estratégias vinculadas às redes temáticas, aprofunda as características de distribuição espacial desigual no território paulista. / The study proposed in this thesis discusses the SUS regionalization process from two aspects dynamizing. A guided by the policy of political and administrative decentralization and the other by the regionalization policy and hierarchical health network focused on integration activities in the regions. This process may result in the mitigation or the deepening of regional inequalities. The regionalization process thus considered was analyzed according to two dimensions of capitalist development, territorial and public health. In relation to the territorial dimension, the inter-regional division of labor was considered elementary for the differentiation of the regions according to their roles in the organization of production. It is in this perspective that we used the urban network as a synthesis of the inter-regional division of labor. In relation to the public health, the guideline for understanding of its insertion in capitalist development was given by two dichotomous concepts of health, health as absence of disease and health as welfare. It is through them that it is possible to identify the different social functions of public health and reveal its role in deepening unequal accumulation of capital or as social transformation element.

Introdução: A sepse é uma condição clínica de inflamação disseminada e descontrolada associada a um foco infeccioso. É uma condição de difícil estudo pela variedade de interações existentes entre as diversas instâncias do organismo e um conceito uniforme ainda está sendo debatido na literatura, o que dificulta a pesquisa e o estabelecimento de legislação que garanta fomento específico. Somado a isto, a exemplo de outras condições tempo-dependentes como infarto agudo do miocárdio, trauma e acidente vascular cerebral, a organização do fluxo do paciente através do sistema de saúde, garantindo leitos de terapia intensiva é fundamental. A U.E.- HCFMRP-USP é referência terciária para emergências para uma população de aproximadamente 4,5 milhões de habitantes e vem introduzindo mecanismos de gestão de fluxo como a priorização de leitos de terapia intensiva e desospitalização. Estas duas estratégias são recentes no Sistema Único de Saúde (SUS) e sua avaliação é fundamental para identificar o perfil de pacientes com Sepse e a importância da organização do sistema no prognóstico desta condição. Objetivos: 1) Avaliar a associação da priorização de Vagas em Terapia Intensiva com a mortalidade, morbidade e tempo de permanência hospitalar dos pacientes; 2) Avaliar o perfil epidemiológico dos pacientes com Sepse admitidos na U.E.-HCFMRP-USP; 3) Avaliar a estratégia de priorização de vagas no acesso de pacientes em sepse grave ou choque séptico aos leitos de terapia intensiva; 4) Avaliar a estratégia de transferência para leitos de retaguarda na oferta de leitos de terapia intensiva. 5) Avaliar a estratégia de priorização de vagas no retardo ao acesso de pacientes em sepse grave ou choque séptico aos leitos de terapia intensiva; 6) Avaliar a estratégia de priorização de vagas na mortalidade de pacientes em sepse grave ou choque séptico aos leitos de terapia intensiva; 7) Avaliar o índice prognóstico \"Quick\" SOFA nos pacientes com sepse grave ou choque séptico admitidos na U.E.-HCFMRP-USP. Metodologia: Trata-se de uma coorte retrospectiva realizada a partir de dados administrativos obtidos do sistema eletrônico de gerenciamento de pacientes da UEHCFMRP- USP de 01 janeiro de 2010 a 31 de dezembro de 20016. Foram construídas duas bases de dados. A primeira embasada em internação como identificador, na qual foram derivadas variáveis que representam priorização, dados demográficos, Comorbidade (Índice de Comorbidade de Charlson), a gravidade (\"Quick SOFA\"), linha de cuidado, presença de sepse e variáveis de desfecho. A segunda embasada em cada dia do período de estudo composta por variáveis sobre o número de leitos de CTI disponíveis, número de admissões, número de altas, número de transferências para hospital geral e para hospital de retaguarda. As variáveis quantitativas foram expressas como média e desvio-padrão ou mediana e mínimo e máximo de acordo com o teste de normalidade e as variáveis categóricas como percentagem. Para análise univariada foram utilizados testes t de Student, Análise de Variância ou equivalentes não-paramétricos, qui-quadrado ou teste exato de Fisher e \"Receiver Operating\'\' Curves\". Para a análise multivariada foram utilizadas a regressão logística multivariada com desfecho binário ou categórico conforme apropriado e a regressão multivariada de Poisson. A significância estatística foi expressa por p<0,05 ou a exclusão da unidade do intervalo de confiança. Resultados: 1) O processo de priorização de leitos de terapia intensiva se mostrou apropriado. Os pacientes que receberam prioridade maior para acesso ao CTI (prioridade 1- 5826;62,5%) eram mais jovens (55;12-100 - p<0,01), apresentavam menos comorbidades ( Charlson 0, 3583:61,5% - p<0,01) e menor gravidade (Quick\" SOFA\" 0,2170;37,2% - p<0,01; SOFA <10% - 1782;0,5% - p<0,01). Estes pacientes foram admitidos em maior proporção (2097;35,9% - p<0,01) e tiveram acesso mais rápido ao CTI (1081;52,5% - p<0,01), apresentando menor mortalidade (1853;31,8% - p<0,01). Ao se ajustar os possíveis fatores de confusão para estabelecer a razão de chances de receber prioridade 1 pelo intensivista, maior valor da classe de Charlson (Comorbidade) - OR 0,53; 0,49-0,57, do \"Quick SOFA\" (Gravidade) - OR 0,45; 0,43- 0,48 e a presença da condição Sepse - OR 0,20-0,17;0,23 estiveram associados independentemente à menor chance de receber esta classificação. 2) Os pacientes sépticos identificados neste estudo tinham maior idade (61;12-97 - p<0,01), maior prevalência do gênero masculino (646;56,2% - p<0,01) , menor amparo social (714;61,8% - p=0,048), maior índice de Comorbidade (Charlson 2 - 222;19,3% - p<0,01) e de Gravidade (SOFA >90% - 152;13,2% - p<0,01), apresentaram maior mortalidade intrahospitalar (838;73% - p<0,01), maior retardo para admissão no CTI e maior duração da internação hospitalar (7,3;0-304 - p<0,01). Quando comparados com outras linhas de cuidado bem estabelecidas, observou-se que a Sepse pode ser equiparada com o Trauma em termos de incidência (sepse 1148;22,5% - p<0,01; trauma 1138;22,3% - p<0,01), sendo inferior apenas às Síndromes Coronarianas Agudas (SCA)(1972;38,7% - p<0,01). Na análise multivariada, a Sepse está associada à menor chance de receber prioridade 1(0,2 ; IC 95% - 0,17;0,23) independente de outros fatores de confusão, persistiu como fator independente para mortalidade intra-hospitalar total (2,7; IC 95% - 2,32;3,17) e para a mortalidade de pacientes admitidos no CTI (2,38; IC 95% - 1,82;3,11). 3) A priorização de vagas facilitou o acesso dos pacientes ao CTI; 4) A estratégia de transferência de pacientes de alta dependência que deixaram de requerer recursos de alta complexidade se mostrou importante para o sistema. As três instituições parceiras não se distinguiram com relação ao índice de Comorbidade de Charlson (Altinópolis , Charlson 0, 25;28,1%, Charlson 1, 29;32,6%, Charlson 2, 35;39,3%; Guariba Charlson 0, 60;35,7%, Charlson 1, 50;29,7%, Charlson 2, 58;34,5%; São Simão, Charlson 0, 20;28,5%, Charlson 1, 17;24,3%, Charlson 2, 33;47,2% - p=0,894) e tiveram desempenho semelhante com relação à mortalidade(Altinópolis 35;39,33%, Guariba 78;46,4%, São Simão 33;47,1% - p=0,26) e alta domiciliar (Altinópolis 37;41,5%; Guariba 60;35,71%, São Simão 19;27,1% - p=0,26). Os pacientes com problemas neurológicos foram responsáveis pela maioria das transferências (Altinópolis 61;68,5%, Guariba 92;54,7%, São Simão 40;57,1% - p=0,06). Ao longo dos anos, houve melhora do desempenho das instituições com relação à mortalidade (2013,16 óbitos;44,4%, 2016, 37 óbitos;35,2% - p<0,01) e a relação de permanência na U.E.-HCFMRP-USP comparada à permanência total (soma da internação na U.E.- HCFMRP-USP e da internação nos leitos de longa permanência) decresceu (2013, 67,8 dias;0-97,7, 2016, 58,87 dias;0-100 - p=0,005). Na análise multivariada, observou-se que a transferência para leitos de longa permanência foi fator independente em aumentar a disponibilidade de leitosde CTI na U.E.-HCFMRP-USP (com o ano de 2016 1,54; IC 95% - 1,18-2,01, excluindo-se o ano de 2016 1,73; IC 95% - 1,26;2,39). 5) Não houve retardo de admissão no CTI dos pacientes sépticos que receberam prioridade 1 quando se ajustou por possíveis fatores de confusão (0,43; IC 95% - 0,35;0,53); 6) O índice prognóstico \"Quick\" SOFA teve baixa acurácia nos pacientes com sepse grave ou choque séptico admitidos na U.E.-HCFMRPUSP (AUROC= 0,5646, IC95% - 0,52991;0,59930-p<0,001). Conclusões: A Sepse apresentou elevada mortalidade mesmo quando foi garantida a admissão ao CTI em comparação com outros estudos, o que pode refletir o viés de seleção da Regulação Médica. As estratégias de gerenciamento de fluxo foram eficazes em garantir acesso e aumentar a disponibilidade de leitos. / Introduction: Sepsis is a clinical condition of disseminated and uncontrolled inflammation associated with an infectious outbreak. It is a condition difficult to study because of the variety of interactions between the various organs of the organism and lack of a uniform concept in the literature, which makes it difficult to research and establish legislation that guarantees specific promotion. Added to this, like other timedependent conditions such as acute myocardial infarction, trauma and stroke, the organization of patient flow through the health system, ensuring intensive care beds is critical. The U.E.-HCFMRP-USP is a tertiary reference for emergencies for a population of approximately 4.5 million inhabitants and has been introducing flow management mechanisms such as the prioritization of intensive care and de-hospitalization beds. These two strategies are recent in the Unified Health System (SUS) and their valuation is fundamental to identify the profile of patients with Sepsis and the importance of the organization of the system in the prognosis of this condition. Objectives: 1) To evaluate the association of the prioritization of Vacancies in Intensive Care with the mortality, morbidity and hospital stay time of the patients; 2) To evaluate the epidemiological profile of patients with sepsis admitted to U.E.-HCFMRP-USP; 3) Evaluate the strategy of prioritizing vacancies in the access of patients in severe sepsis or septic shock to intensive care beds; 4) Evaluate the transfer strategy for back beds in the offer of intensive care beds. 5) Evaluate the strategy of prioritization of vacancies in the delay to access of patients in severe sepsis or septic shock to intensive care beds; 6) To evaluate the strategy of prioritization of vacancies in the mortality of patients in severe sepsis or septic shock to intensive care beds; 7) To evaluate the \"Quick\" SOFA prognostic index in patients with severe sepsis or septic shock admitted to U.E.- HCFMRP-USP. Methodology: This is a retrospective cohort based on administrative data obtained from the electronic patient management system of the EU-HCFMRP-USP from January 01, 2010 to December 31, 20016. Two databases were constructed. The first was based on admission as an identifier, in which variables were derived, such as prioritization, demographic data, Comorbidity (Charlson Comorbidity Index), severity (\"Quick SOFA\"), clinical pathway, presence of sepsis and outcome variables. The second, based on each day of the study period, contains variables on the number of CTI beds available, number of admissions, number of discharges, number of transfers to general hospital and back hospital. We expressed quantitative variables as mean and standard deviation or median and minimum and maximum according to the normality test and categorical variables as percentage. We used Student t tests, Analysis of Variance or non-parametric equivalents, chi-square or Fisher\'s exact test and \"Receiver Operating Curves\" for univariate analysis. We used Multivariate logistic regression with binary or categorical outcome and multivariate Poisson regression as appropriate for the multivariate analysis. A p <0.05 or the exclusion of the unit from the confidence interval signaled statistical significance. Results: 1) The process of prioritizing intensive care beds was appropriate. Patients who received higher priority for CTI access (priority 1 - 5826;62,5%) were younger (55;12- 100 - p<0,01), had less comorbidities ( Charlson 0, 3583;61,5%, p<0,01) and less severity (Quick\" SOFA\" 0,2170;37,2% - p<0,01; SOFA <10% - 1782;0,5% - p<0,01). These patients were admitted in greater proportion (2097;35,9% - p<0,01) and had faster access to ICU (1081;52,5% - p<0,01), presenting lower mortality (1853;31,8% - p<0,01). When adjusting the possible confounding factors to establish the odds ratio to receive priority 1 by the intensivist, higher value of the Charlson class OR 0,53; 0,49-0,57, the \"Quick SOFA\" (Severity) - OR 0,45; 0,43-0,48 and the presence of Sepsis condition - OR 0,20-0,17;0,23 were independently associated with a lower chance of being classified as priority 1. 2) The septic patients identified in this study had older age (61;12- 97 - p<0,01), higher prevalence of male gender (646;56,2% - p<0,01), lower social protection (714;61,8% - p=0,048), higher Comorbidity (Charlson 2 - 222;19,3% - p<0,01) and Severity index (SOFA >90% - 152;13,2% - p<0,01), higher in-hospital mortality (838;73% - p<0,01), longer ICU admission delay and longer hospital stay(7,3;0-304 - p<0,01). When compared to other clinical pathways, it was observed that Sepsis can be equated with Trauma in terms of incidence (sepsis 1148;22,5% - p<0,01; trauma 1138;22,3% - p<0,01), being inferior only to Acute Coronary Syndromes (ACS) (1972;38,7% - p<0,01). In the multivariate analysis, Sepsis was more associated to lower chance of receiving priority 1(0,2; IC 95% - 0,17;0,23) independent of other confounding factors, it persisted as an independent factor for total in-hospital mortality(2,7; IC 95% - 2,32;3,17) and for the mortality of patients admitted to the ICU(2,38; IC 95% - 1,82;3,11). 3) The prioritization of vacancies facilitated the access of the septic patients to the ICU. 4) The strategy of transference of patients of high dependence that stopped requesting resources of high complexity proved to be important for the system. The three partner institutions did not differ in relation to the Charlson Comorbidity Index (Altinópolis , Charlson 0, 25;28,1%, Charlson 1, 29;32,6%, Charlson 2, 35;39,3%; Guariba Charlson 0, 60;35,7%, Charlson 1, 50;29,7%, Charlson 2, 58;34,5%; São Simão, Charlson 0, 20;28,5%, Charlson 1, 17;24,3%, Charlson 2, 33;47,2% - p=0,894) and had a similar performance in relation to mortality (Altinópolis 35;39,33%, Guariba 78;46,4%, São Simão 33;47,1% - p=0,26) and household discharge (Altinópolis 37;41,5%; Guariba 60;35,71%, São Simão 19;27,1% - p=0,26). Patients with neurological problems were responsible for most of the transfers (Altinópolis 61;68,5%, Guariba 92;54,7%, São Simão 40;57,1% - p=0,06). Over the years, there has been an improvement in the institutions\' performance in relation to mortality (2013,16 deaths;44,4%, 2016, 37 deaths;35,2% - p<0,01) and the length of stay in the EUHCFMRP- USP compared to the total stay (sum of hospitalization in the EU-HCFMRP-USP and length of stay in long-stay beds) decreased (2013, 67,8 days;0-97,7, 2016, 58,87 days;0-100 - p=0,005).In the multivariate analysis, we observed that the transfer to long-stay beds was an independent factor in increasing the availability of ICU beds in U.E.-HCFMRPUSP (with year 2016 1,54; IC - 95% 1,18;2,01, without year 2016 1,73; IC - 95% 1,26;2,39). 5) There was no delay in ICU admission for septic patients who received priority 1 when adjusted for possible confounding factors (0,43; IC 95% - 0,35;0,53).7) The \"Quick\" SOFA prognostic index had low accuracy in patients with severe sepsis or septic shock admitted to U.E.-HCFMRP-USP (AUROC= 0,5646, IC95% - 0,52991;0,59930 - p<0,001).Conclusions: Sepsis presented a high mortality even when admission to the ICU was guaranteed in comparison to other studies, which may reflect the selection bias of the Medical Regulation. Flow management strategies were effective in securing access and increasing bed availability.