Business consulting – Clínica Montefiori S.A.C.

La Clínica Montefiori es una institución privada fundada el 6 de mayo de 1983 por profesionales de gran trayectoria, con experiencia previa en la formación y dirección de clínicas de primer nivel. Inicialmente, la idea fue tener un hospital privado que brindara servicios integrales de consulta ambulatoria, emergencias y hospitalizaciones con altos estándares de calidad y con una preocupación permanente por el cuidado de la salud de sus pacientes. Sin embargo, a raíz del crecimiento y la demanda de los servicios de salud en los últimos 5 años, ha hecho que la Clínica haya estado en permanente expansión, incorporando año a año nueva infraestructura, tecnología y profesionales. Es así que, en 2012 se ampliaron las áreas de Sala de Operaciones, Sala de Partos y Nutrición; y en 2013 se inauguró la nueva área de Emergencias, ampliando la capacidad de atención especializada en Emergencias Pediátricas y Emergencias para Adultos. Para la identificación del problema principal se realizaron entrevistas con la gerencia general, la dirección médica y los jefes de área, determinándose que, el problema principal es que el ciclo de conversión de efectivo es mayor a 30 días. Para tal efecto, se observó que las dos causas primarias fueron: la falta de estructura de control de saldos financieros, y la falta de calendario de vencimiento de las compañías aseguradoras. Por otro lado, se realizó el análisis externo e interno, así como la revisión de literatura que, sirvió como base para proponer cuatro alternativas de mejora, como: la implementación de un software Expediente Electrónico, la implementación de herramientas de orientación gestión estratégica y marketing, la implementación del Tablero de Mando Integral, y la estandarización de los procesos. En ese sentido, se elaboró un cronograma de implementación para cada alternativa de mejora, asignándose presupuesto, plazo y responsables. La estandarización de cada mejora se presentó a través de entregables, en el cual se detalle el beneficio cualitativo. Con respecto al beneficio cuantitativo, se realizó la evaluación económica y financiera demostrándose la viabilidad del proyecto, revisando dos escenarios. En el escenario optimista, el valor actual neto es S/. 143,666.14 la tasa de retorno de 40.88%, y el periodo de recuperación es partir del segundo año. Por su parte, en el moderado, el valor actual neto es S/. 37,952.78, la tasa de retorno de 26.12%, y el periodo de recuperación es partir del quinto año. Finalmente, en el escenario pesimista, el valor actual neto es S/. -110,023.68, la tasa de retorno de 1.04%, y se estima que, el periodo de recuperación, sea del sexto año en adelante.The Montefiori Clinic is a private institution founded on May 6, 1983 by professionals with great experience in the training and management of first- class clinics. Initially, the idea was to have a private hospital that would provide comprehensive outpatient, emergency and hospitalization service with high quality standards and with a permanent concern for the health services in the last 5 years, the Clinic has been constantly expanding, incorporating new infrastructure, technology and professionals year after year. Thus, in 2012, the areas of the Operating Room, Delivery Room, and Nutrition were expanded; and 2013 the new Emergency area was inagurated, expanding the capacity of especialized attention in Pedriatic Emergencies and Emergencies for Adults. To identify the main problems, interviews were conducted the general management, the medical direction and the heads of the area, determining that the main problem is that the cash conversion cycle is greater than 30 days. For this purpose, it was observed that the two primary causes were: The lack of control structure of financial balances, and the lack of expiration Schedule of the insurance companies. On the other hand, the external and internal analysis was carried out, as well as the literature review, which serve as the basis for proposing four improvement alternatives, such as: the implementation of an Electronic File software, the implemantion of guidance tools, strategic management and marketing, the implementation of the Integral Dashboard, and the standardization of processes. In this way, an implementation Schedule was developed for each improvement alternative, assigning a Budget, deadline and responsable parties. The standardization of each improvement was presented through deliverables, in which the qualitative benefit is detailed. Regarding the quantitive benefit, the economic and financial evaluation was carried out, demonstrating the viability of the Project, reviewing two scenarios. In the optimistic scenario, the net present value is S/ 143,666.14, the return date of 40.88%, and the recovery period is rom the second year. For its part, in the moderate, the net present value is S/ 37,952.78, the rate of the return of 26.12%, and recovery period is from the fifth year. Finally, in the pesimistic scenario, the net present value is S/-110,023.68, the return rate of 1.04% and it is estimated that the recovery period will be from the sixth year onwards

Chronic Obstructive Pulmonary Disease in Elderly Patients with Acute and Advanced Heart Failure: Palliative Care Needs—Analysis of the EPICTER Study

Introduction: There are studies that evaluate the association between chronic obstructive pulmonary disease (COPD) and heart failure (HF) but there is little evidence regarding the prognosis of this comorbidity in older patients admitted for acute HF. In addition, little attention has been given to the extracardiac and extrapulmonary symptoms presented by patients with HF and COPD in more advanced stages. The aim of this study was to evaluate the prognostic impact of COPD on mortality in elderly patients with acute and advanced HF and the clinical manifestations and management from a palliative point of view. Methods: The EPICTER study (Epidemiological survey of advanced heart failure) is a cross-sectional, multicenter project that consecutively collected patients admitted for HF in 74 Spanish hospitals. Demographic, clinical, treatment, organ-dependent terminal criteria (NYHA III-IV, LVEF <20%, intractable angina, HF despite optimal treatment), and general terminal criteria (estimated survival <6 months, patient/family acceptance of palliative approach, and one of the following: evidence of HF progression, multiple Emergency Room visits or admissions in the last six months, 10% weight loss in the last six months, and functional impairment) were collected. Terminal HF was considered if the patient met at least one organ-dependent criterion and all the general criteria. Both groups (HF with COPD and without COPD) were compared. A Kaplan-Meier survival analysis was performed to evaluate the presence of COPD on the vital prognosis of patients with HF. Results: A total of 3100 patients were included of which 812 had COPD. In the COPD group, dyspnea and anxiety were more frequently observed (86.2% vs. 75.3%, p = 0.001 and 35.4% vs. 31.2%, p = 0.043, respectively). In patients with a history of COPD, presentation of HF was in the form of acute pulmonary edema (21% vs. 14.4% in patients without COPD, p = 0.0001). Patients with COPD more frequently suffered from advanced HF (28.9% vs. 19.4%; p < 0.001). Consultation with the hospital palliative care service during admission was more frequent when patients with HF presented with associated COPD (94% vs. 6.8%; p = 0.036). In-hospital and six-month follow-up mortality was 36.5% in patients with COPD vs. 30.7% in patients without COPD, p = 0.005. The mean number of hospital admissions during follow-up was higher in patients with HF and COPD than in those with isolated HF (0.63 +/- 0.98 vs. 0.51 +/- 0.84; p < 0.002). Survival analysis showed that patients with a history of COPD had fewer survival days during follow-up than those without COPD (log Rank chi-squared 4.895 and p = 0.027). Conclusions: patients with HF and COPD had more severe symptoms (dyspnea and anxiety) and also a worse prognosis than patients without COPD. However, the prognosis of patients admitted to our setting is poor and many patients with HF and COPD may not receive the assessment and palliative care support they need. Palliative care is necessary in chronic non-oncologic diseases, especially in multipathologic and symptom-intensive patients. This is a clinical care aspect to be improved and evaluated in future research studies

Effectiveness of Intermediate Respiratory Care Units as an Alternative to Intensive Care Units during the COVID-19 Pandemic in Catalonia

Objectives: During the COVID-19 pandemic, the risk of collapse for the health system created great difficulties. We will demonstrate that intermediate respiratory care units (IRCU) provide adequate management of patients with non-invasive respiratory support, which is particularly important for patients with SARS-CoV-2 pneumonia. Methods: A prospective observational study of patients with COVID-19 admitted to the ICU of a tertiary hospital. Sociodemographic data, comorbidities, pharmacological, respiratory support, laboratory and blood gas variables were collected. The overall cost of the unit was subsequently analyzed. Results: 991 patients were admitted, 56 to the IRCU (from a of 81 admitted to the critical care unit). Mean age was 65 years (SD 12.8), Barthel index 75 (SD 8.3), Charlson comorbidity index 3.1 (SD 2.2), HTN 27%, COPD 89% and obesity 24%. A significant relationship (p < 0.05) with higher mortality was noted for the following parameters: fever greater than or equal to 39 degrees C [OR 5.6; 95% CI (1.2-2.7); p = 0.020], protocolized pharmacological treatment [OR 0.3; 95% CI (0.1-0.9); p = 0.023] and IOI [OR 3.7; 95% CI (1.1-12.3); p = 0.025]. NIMV had less of a negative impact [OR 1.8; 95% CI (0.4-8.4); p = 0.423] than IOI. The total cost of the IRCU amounted to euro66,233. The cost per day of stay in the IRCU was euro164 per patient. The total cost avoided was euro214,865. Conclusions: The pandemic has highlighted the importance of IRCUs in facilitating the management of a high patient volume. The treatment carried out in IRCUs is effective and efficient, reducing both admissions to and stays in the ICU

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module

•We report INICC device-associated module data of 50 countries from 2010-2015.•We collected prospective data from 861,284 patients in 703 ICUs for 3,506,562 days.•DA-HAI rates and bacterial resistance were higher in the INICC ICUs than in CDC-NHSN's.•Device utilization ratio in the INICC ICUs was similar to CDC-NHSN's. Background: We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific. Methods: During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days. Results: Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs. Conclusions: Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically