Improving inpatient pharmacoterapeutic process by Lean Six Sigma methodology

[EN] Background Lean Six Sigma methodology has been used to improve care processes, eliminate waste, reduce costs, and increase patient satisfaction. Objective To analyse the results obtained with Lean Six Sigma methodology in the diagnosis and improvement of the inpatient pharmacotherapy process during structural and organisational changes in a tertiary hospital. Material and methods Scope: 1.000 beds tertiary hospital. Design prospective observational study. The define, measure, analyse, improve and control (DMAIC), were deployed from March to September 2011. An Initial Project Charter was updated as results were obtained. Population and sample: 131 patients with treatments prescribed within 24 h after admission and with 4 drugs. Variables: safety indicators (medication errors), and efficiency indicators (complaints and time delays). Results Proportion of patients with a medication error was reduced from 61.0% (25/41 patients) to 55.7% (39/70 patients) in four months. Percentage of errors (regarding the opportunities for error) decreased in the different phases of the process: Prescription: from 5.1% (19/372 opportunities) to 3.3% (19/572 opportunities); Preparation: from 2.7% (14/525 opportunities) to 1.3% (11/847 opportunities); and administration: from 4.9% (16/329 opportunities) to 3.0% (13/433 opportunities). Nursing complaints decreased from 10.0% (2119/21038 patients) to 5.7% (1779/31097 patients). The estimated economic impact was 76,800 euros saved. Conclusions An improvement in the pharmacotherapeutic process and a positive economic impact was observed, as well as enhancing patient safety and efficiency of the organization. Standardisation and professional training are future Lean Six Sigma candidate projects.[ES] Introducción La metodología Lean Seis Sigma se utilizó para mejorar procesos, eliminar desperdicios, reducir costes y aumentar la satisfacción de clientes. Objetivo Analizar los resultados obtenidos con la metodología Lean Seis Sigma en el diagnóstico y la mejora del proceso farmacoterapéutico del paciente hospitalizado durante el cambio estructural y organizativo de un hospital terciario. Material y métodos Ámbito: hospital general terciario con 1.000 camas. Diseño del estudio: observacional y prospectivo. Se desplegaron las etapas definir, medir, analizar, mejorar y controlar (DMAIC) entre marzo y septiembre de 2011, actualizando el Project Charter inicial según resultados. Población y muestra: 131 pacientes hospitalizados con tratamientos prescritos en las 24 h siguientes al ingreso y con 4 medicamentos. Variables: indicadores de seguridad (errores de medicación) y de eficiencia (tiempos de demora y reclamaciones). Resultados La proporción de pacientes con algún error de medicación se redujo del 61,0 (25/41 pacientes) al 55,7% (39/70 pacientes) en 4 meses. Los porcentajes de errores, con respecto a las oportunidades de error, en distintas fases del proceso disminuyeron: prescripción 5,1 (19/372) a 3,3% (19/572); preparación 2,7 (14/525) a 1,3% (11/847 oportunidades); y administración: 4,9 (16/329) a 3,0% (13/433). Las reclamaciones se redujeron del 10,0 (2.119/21.038 pacientes) a 5,7% (1.779/31.097 pacientes). El impacto económico se estimó en 76.800 euros evitados. Conclusiones Se observó una mejora del proceso farmacoterapéutico y un impacto financiero positivo que ha repercutido en la seguridad del paciente y la eficiencia de la organización. La normalización y la formación de profesionales podrían ser proyectos futuros de Lean Seis Sigma.Font Noguera, I.; Fernández Megía, M.; Ferrer, A.; Balasch Parisi, S.; Edo Solsona, M.; Poveda Andres, J. (2013). Mejora del proceso farmacoterapéutico del paciente hospitalizado mediante la metodología Lean Seis Sigma. Revista de Calidad Asistencial. 28(6):370-380. doi:10.1016/j.cali.2013.04.003S37038028

Bases per a la Gestió del Paisatge de la Serra de Tramuntana : 13 propostes i 55 projectes

Màster Oficial en Estudis Territorials i de la Població. Departament de Geografia, Universitat Autònoma de Barcelona, Programa troncal 2013-2014, Gener 2014Coordinació projecte Troncal: Oriol Nel·lo ColomMòduls docents: Ordenació, Planejament i Gestió del Territori: Oriol Nel·lo Colom, Rufí Cerdán Heredia -- Temes Avançats: Enric Mendizàbal Riera, Albert Pèlachs Mañosa -- Sistemes d'Informació Geogràfica, Planejament i Paisatge: Anna Badia Perpinyà, Albert Pèlachs Mañosa -- Ciutat i Espais Metropolitans: Àngel Cebollada Frontera, Carles Donat MuñozCoordinació continguts: Esteve Dot JutglaConferenciants: Vicent Maria Rosselló Verger, Juli Esteban Noguera, Ricard Pié Ninot, Xavier Campillo Besses, Pere Sala Martí, Joan Nogué FontConferenciants de Mallorca: Miquel Grimalt (Director del Departament de Ciències de la Terra, Universitat de les Illes Balears), Onofre Rullan (Departament de Ciències de la Terra, Universitat de les Illes Balears), Jaume Mateu (Departament de Ciències de la Terra,Universitat de les Illes Balears), Maria Lluïsa Dubon (geògrafa), Bartomeu Deyà (Director gerent del Consorci Serra de Tramuntana Patrimoni Mundial), Miquel Rayó (escriptor), Sebastià Torrens (fotògraf), Joan Sastre (escriptor), Vicenç Sastre (escriptor)Redactors: Grup1: Sara González Pérez, Antón Magarolas Navarro, Ilaria Sanna -- Grup2: Giulia Garolla, Alberto Innocenti, Javier Martín Úceda, Dalila Serusi -- Grup 3: Francesco Finotto, Maria Lidmäe, Sara Serilli, María Torres Bagur -- Grup 4: Giulia Battiston, Sergi Del Olmo Parisi, Elena Vettoretti, Rafael Vicente Salar -- Grup 5: Roberta Fadda, Daniela Pinna, Gloria Veloz, Francesc Vila Palà -- Grup 6: Fernanda Avellaneda Viteri, Giulia Cubadda, Xavier Delclòs Alió, Francesco Luigi FerrariEl Màster d'Estudis Territorials i de la Població és un programa de postgrau del Departament de Geografia de la Universitat Autònoma de Barcelona que té per objectiu la formació de professionals en el camp de la demografia, el planejament i l'ordenació del territori. En el seu itinerari d'Estudis Territorials, el programa ofereix una orientació essencialment aplicada, de tal manera que inclou un exercici troncal en el que els participants elaboren, en equip, amb finalitats didàctiques i sota la direcció dels docents, un document de planejament que compta amb tots els elements d'una proposta professional de planejament. Enguany, el tema escollit per a l'exercici troncal ha estat el reconeixement territorial i la redacció d'una proposta per a la gestió del paisatge de la Serra de Tramuntana de Mallorca. El document que teniu a les mans és el resultat de l'exercici, en el qual 23 alumnes, procedents de 4 països diversos, dividits en 6 equips, i sota la direcció de 10 professors, han redactat efectivament unes Bases per a la Gestió del Paisatge de la Serra de Tramuntana. El document resultant, conté, tal com s'ha indicat, tots els elements propis d'un document d'ordenació del territori: Memòria, Valoració, Diagnosi, Objectius, Propostes i Projectes. D'acord amb les característiques del programa, l'exercici s'ha realitzat a partir d'una voluntat d'integració dels continguts, transversalitat de les propostes, contextualització dels ensenyaments teòrics i un mètode aplicat, en el que han tingut un paper central el treball de camp i el treball en grup. Per això, s'han integrat els quatre mòduls que configuren el primer semestre del Màster en un sol programa i calendari d'ensenyaments i activitats, d'acord amb allò que figura en el Quadern Troncal que podreu trobar al final d'aquest volum

Frequency and Prognostic Impact of ALK Amplifications and Mutations in the European Neuroblastoma Study Group (SIOPEN) High-Risk Neuroblastoma Trial (HR-NBL1).

In neuroblastoma (NB), the ALK receptor tyrosine kinase can be constitutively activated through activating point mutations or genomic amplification. We studied ALK genetic alterations in high-risk (HR) patients on the HR-NBL1/SIOPEN trial to determine their frequency, correlation with clinical parameters, and prognostic impact. Diagnostic tumor samples were available from 1,092 HR-NBL1/SIOPEN patients to determine ALK amplification status (n = 330), ALK mutational profile (n = 191), or both (n = 571). Genomic ALK amplification (ALKa) was detected in 4.5% of cases (41 out of 901), all except one with MYCN amplification (MNA). ALKa was associated with a significantly poorer overall survival (OS) (5-year OS: ALKa [n = 41] 28% [95% CI, 15 to 42]; no-ALKa [n = 860] 51% [95% CI, 47 to 54], [P < .001]), particularly in cases with metastatic disease. ALK mutations (ALKm) were detected at a clonal level (> 20% mutated allele fraction) in 10% of cases (76 out of 762) and at a subclonal level (mutated allele fraction 0.1%-20%) in 3.9% of patients (30 out of 762), with a strong correlation between the presence of ALKm and MNA (P < .001). Among 571 cases with known ALKa and ALKm status, a statistically significant difference in OS was observed between cases with ALKa or clonal ALKm versus subclonal ALKm or no ALK alterations (5-year OS: ALKa [n = 19], 26% [95% CI, 10 to 47], clonal ALKm [n = 65] 33% [95% CI, 21 to 44], subclonal ALKm (n = 22) 48% [95% CI, 26 to 67], and no alteration [n = 465], 51% [95% CI, 46 to 55], respectively; P = .001). Importantly, in a multivariate model, involvement of more than one metastatic compartment (hazard ratio [HR], 2.87; P < .001), ALKa (HR, 2.38; P = .004), and clonal ALKm (HR, 1.77; P = .001) were independent predictors of poor outcome. Genetic alterations of ALK (clonal mutations and amplifications) in HR-NB are independent predictors of poorer survival. These data provide a rationale for integration of ALK inhibitors in upfront treatment of HR-NB with ALK alterations

Elective Cancer Surgery in COVID-19-Free Surgical Pathways During the SARS-CoV-2 Pandemic: An International, Multicenter, Comparative Cohort Study.

PURPOSE: As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19-free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS: This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19-free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS: Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19-free surgical pathways. Patients who underwent surgery within COVID-19-free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19-free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score-matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19-free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION: Within available resources, dedicated COVID-19-free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Elective cancer surgery in COVID-19-free surgical pathways during the SARS-CoV-2 pandemic: An international, multicenter, comparative cohort study

PURPOSE As cancer surgery restarts after the first COVID-19 wave, health care providers urgently require data to determine where elective surgery is best performed. This study aimed to determine whether COVID-19–free surgical pathways were associated with lower postoperative pulmonary complication rates compared with hospitals with no defined pathway. PATIENTS AND METHODS This international, multicenter cohort study included patients who underwent elective surgery for 10 solid cancer types without preoperative suspicion of SARS-CoV-2. Participating hospitals included patients from local emergence of SARS-CoV-2 until April 19, 2020. At the time of surgery, hospitals were defined as having a COVID-19–free surgical pathway (complete segregation of the operating theater, critical care, and inpatient ward areas) or no defined pathway (incomplete or no segregation, areas shared with patients with COVID-19). The primary outcome was 30-day postoperative pulmonary complications (pneumonia, acute respiratory distress syndrome, unexpected ventilation). RESULTS Of 9,171 patients from 447 hospitals in 55 countries, 2,481 were operated on in COVID-19–free surgical pathways. Patients who underwent surgery within COVID-19–free surgical pathways were younger with fewer comorbidities than those in hospitals with no defined pathway but with similar proportions of major surgery. After adjustment, pulmonary complication rates were lower with COVID-19–free surgical pathways (2.2% v 4.9%; adjusted odds ratio [aOR], 0.62; 95% CI, 0.44 to 0.86). This was consistent in sensitivity analyses for low-risk patients (American Society of Anesthesiologists grade 1/2), propensity score–matched models, and patients with negative SARS-CoV-2 preoperative tests. The postoperative SARS-CoV-2 infection rate was also lower in COVID-19–free surgical pathways (2.1% v 3.6%; aOR, 0.53; 95% CI, 0.36 to 0.76). CONCLUSION Within available resources, dedicated COVID-19–free surgical pathways should be established to provide safe elective cancer surgery during current and before future SARS-CoV-2 outbreaks

Outcomes from elective colorectal cancer surgery during the SARS-CoV-2 pandemic

This study aimed to describe the change in surgical practice and the impact of SARS-CoV-2 on mortality after surgical resection of colorectal cancer during the initial phases of the SARS-CoV-2 pandemic

General patterns of circulation, sediment fluxes and ecology of the Palamós (La Fonera) submarine canyon, northwestern Mediterranean

Currents, particle fluxes and ecology were studied in the Palamós submarine canyon (also known as the Fonera canyon), located in the northwestern Mediterranean. Seven mooring arrays equipped with current meters and sediment traps were deployed along the main canyon axis, on the canyon walls and on the adjacent slope. Additionally, local and regional hydrographic cruises were carried out. Current data showed that mean near surface and mid-depth currents were oriented along the mean flow direction (NE-SW), although at 400 and 1200 m depth within the canyon current reversals were significant, indicating a more closed circulation inside the canyon. Mean near-bottom currents were constrained by the local bathymetry, especially at the canyon head. The most significant frequency at all levels was the inertial frequency. A second frequency of about three days, attributed to a topographic wave, was observed at all depths, suggesting that this wave was probably not trapped near the bottom. The current field observed during the most complete survey revealed a meandering pattern with cyclonic vorticity just upstream from and within the canyon. The associated vertical velocity ranged between 10 and 20 m/day and was constrained to the upper 300 m. This latter feature, together with other computations, suggests that during this survey the meander was not induced by the canyon but by some kind of instability of the mean flow. In the canyon, suspended sediment concentration, downward particle fluxes, chlorophyll and particulate C and N were significantly higher up-canyon from about 1200 m depth than offshore, defining, along with the different hydrodynamics, two canyon domains: one from the canyon head to about 1200 m depth more affected by the canyon confinement and the other deeper than 1200 m depth more controlled by the mean flow and the shelf-slope front. The higher near-bottom downward total mass fluxes were recorded in the canyon axis at 1200 m depth along with sharp turbidity increases and are related to sediment gravity flows. During the deployment period, the increase in downward particle fluxes occurred by mid-November, when a severe storm took place. On the canyon walls at 1200 m depth, suspended sediment concentrations, downward particle fluxes, chlorophyll and particulate C and N were higher on the southern wall than on the northern wall inversely to the current's energy. This could be caused by an upward water supply on the southern canyon wall and/or the mean flow interacting with the canyon bathymetry. In the swimmers collected by the sediment traps, the dominant species was an elasipod holothurian, which has not been recorded in other canyons or elsewhere in the Mediterranean, indicating particular speciation. © 2005 Elsevier Ltd. All rights reserved.Peer Reviewe

Recherches sur l'occupation d'Althiburos (Le Kef, Tunisie) et des ses environs à l'époque numide

El desenvolupament durant els anys 2006-2007 del projecte de recerca sobre la formació de l'Estat númida ha revelat l'existència a Althiburos d'un hàbitat preromà d'extensió considerable (almenys 4 ha), l'origen del qual remunta com a mínim al segle VI aC. La prospecció del territori adjacent ha mostrat l'existència de diversos jaciments númides de dimensions més reduïdes, d'algunes estructures funeràries de la mateixa època i d'una cinquantena de dòlmens, la datació dels quals (tal vegada del Bronze final) roman encara incerta. Les dades obtingudes permeten situar en el segle VI aC, o fins i tot abans, l'inici del procés de complexificació social que va conduir a la formació dels regnes númides