Rozprawy doktorskie na temat „Critical care medicine – Case studies”

Social media are dynamic tools that have allowed virtual socialization and dialogue to emerge on the Internet. Although the term is often used synonymously with social networking and web 2.0, social media have penetrated intra-personal and professional communication extensively and their use has become essentially tacit knowledge among teenagers, and increasingly in the general population. To date, the value of social media to health professionals as a tool for clinical activity and in public health has not been extensively studied. Blogs, Facebook, Twitter, Wikipedia, YouTube, Flickr, Mashups and Second Life are no longer obscure words in the vocabularies of highly technical people. These spaces are starting to replace face-to-face interaction in a large majority of populations and institutions. Healthcare has not been isolated from this trend. The evidence base for the use of social media is rising exponentially, with applications in medical education, collaboration, surveillance, clinical trials, public health, and health services research. However, the comprehensive documentation of how, where and why these tools are affecting health(care) is not well documented. This thesis provides a comprehensive review of the impact of social media in medicine and health(care). Chapter 1 provides an overview of the conceptual and theoretical frameworks, along with the assumptions, that guide the use of social media in the health domain. Chapter 2 synthesizes the what, where, when, how and why social media are being adopted, structured according to the different functionalities of social media. These include blogs, microblogs, social networking, professional and thematic networking, wikis, media sharing tools, mashups, collaborative filtering/bookmarking and other social media (e.g., Second Life). Chapter 2 also discusses a series of clinical implications and recommendations for stakeholders wishing to engage these dynamic spaces. Chapter 3 reviews three recent administrative and judicial cases that have emerged from the inappropriate use of social media and Chapter 4 concludes with the main implications of and significance of the findings. Further research is clearly required to solidify the evidence on the use of social media in health care and to explore and document its economic, clinical, governance and tactical impact and utility.

This study is the first to analyze news coverage of a hegemonic struggle over a crisis that threatened to close a Southern safety net hospital. Such closure could have left indigent, African American men and women without health care access. The study utilizes critical discourse analysis to focus on news portrayals of patients and the struggle over whether the hospital would continue to be governed by a majority-Black, public board of directors or a nonprofit, private board recommended by a majority-White civic group. Results indicate that newspaper coverage privileged the elite, White view, while stereotypically representing indigent, Black patients as problematic. Coverage legitimized privatizing the hospital’s board through a neoliberal discourse that also portrayed its majority-Black board as incompetent.

This research examines the impact and consequences of inspection by the Commission for Social Care Inspection (CSCI). The study begins with a Systematic Review (SR) of existing literature that is divided into effectiveness and process questions. The results of this review show there is no international literature on the effectiveness of inspection at improving residential care for older people. There is also very little process literature. The second part of the research uses a multi-site case study approach with a longitudinal element, to qualitatively examine the impact of inspection in relation to the quality of care provided by residential care homes for older people. Four CSCI inspectors from four different inspection offices across England took part in the study. The case studies show inspection struggled to induce quality improvements in services and had little direct impact on residents. A ‘culture of ageism’ existed within the services and this influenced both provision and residents expectations of care. Provision in all four case studies was still dominated by institutional routine and a lack of service user empowerment. In this context despite clear evidence regarding the value of outcomes focused care this had, by enlarge, not filtered through to the services in this study and there was still a tendency to focus on outputs without relating these to service user outcomes. I argue that the complexity of residential care, which depends upon an interaction between environment, care home management, staff, residents, their relatives, and the government inspectorate means that the most successful method of quality improvement comes through partnership and negotiation between the these groups. My findings have shown that it is very rarely one group who is decisive in determining an improvement in quality and that change must come about through negotiation. Although inspection must incorporate a notion of ‘assessment’ that is standardised and measurable, it should also encompass professional judgement and actively seek to include elements of user-expertise. I argue that despite rhetoric that advocates this approach the inspection regime is hamstrung by a particular form of management values and practice. Constant ‘modernisation’ of the inspectorate has further emphasised a model of inspection that sees care as a series of discrete events, where each issue is clearly defined and decisions are taken by inspectors who choose between a prescribed set of judgement criteria. To this extent inspection is increasingly focused on audit. I raise the question whether in the changing landscape of inspection the CSCI has marginalised inspectors and risks losing a very valuable method of effecting change.

After decades of global intervention to conquer diseases, healthcare in many countries is still lacking. Assessments of medical laboratories in developing countries today find poor infrastructure conditions with no standardized processes or quality assurance to guarantee accurate results and enable quality healthcare. Bringing healthcare programs in developing countries up to international standards remains a challenge.

Currently, there is a scarcity of scientific research related to the determinants of success in implementing quality management systems (QMS). There has been little research dedicated to identifying the critical success factors for medical laboratories striving to improve the accuracy and reliability of their testing services in developing countries.

In over nine years of research, the author realized there was a need for incorporating Critical Success Factor (CFS) methodology into laboratory modernization efforts. This time frame included CDC sponsored trips to several African countries and collaborating with the Vietnam Administration for Medical Services/Ministry of Health (VAMS), Centers for Disease Control-Vietnam (CDC-vn) and seven universities to build laboratory capacity and initiate laboratory improvements to meet national and international laboratory standards. In 2017, VAMS approved a proposed study to identify CSFs in four laboratories in Vietnam.

The research question this study sought to answer was "What are the top five critical success factors for successful implementation of QMS into laboratories in Vietnam?" with an outcome of improved accuracy and reliability of testing results. This study utilized both qualitative and quantitative research methods employing principles of descriptive research. A demographic survey, semi-structured interview, content analysis, and benchmarking were utilized to identify the top five CSFs and barriers. Content analysis was employed to review CSF definitions and categorize all 220 listed CSFs into ten comprehensive and mutually exhaustive categories. Two research assistants assisted the researcher place each CSF into one of the ten categories. Rigorous and non-rigorous methods measured interrater reliability with the categorization of CSFs. Cohen Kappa values were > 0.85 indicating excellent reliability and accuracy between the assistants and the researcher. Chi-square values were all > 0.05 (p < 0.05) indicating demographic variables did not statistically impact findings.

Qualitative responses were gathered through personal interviews, a demographic survey, and benchmarking. Using a stratified convenience sampling, participants represented four levels of stakeholders: laboratory staff, laboratory managers, hospital administrators, and clinicians utilizing laboratory services.

Data from this study found the top five CSFs were: staff knowledge of QMS, laboratory management leadership knowledge and skills, staff commitment to the QMS change process, mentorship, and hospital administration support. In addition to determining the top five CSFs, the study revealed information about encountered or perceived barriers to successful QMS implementation. The participants in this study identified lack of staff knowledge on QMS, lack of financial support from the hospital administration, ineffective laboratory manager leadership knowledge and skills, lack of laboratory infrastructure, and lack of sufficient resources.

The study’s findings add to the body of knowledge in strengthening medical laboratory services and may serve as a basis for continued research in this area of health care. Local, national, and international partners may use this information to tailor training materials and activities to better meet the needs of participating laboratories across Vietnam.

The demands on health and social care organisations require professions to work more collaboratively. During pre-registration training, health care and social work students learn within practice settings, supported by practice mentors. These settings are rich learning environments to experience interprofessional working (IPW) and for students to learn together through interprofessional practice learning (IPPL). There is, however, evidence that students' experiences of both are varied or limited. The value placed on IPW, and IPPL, is therefore of interest. This thesis will investigate practice mentors' attitudes to IPW and IPPL, and explore their perspectives of the enablers and barriers to these occurring in practice settings. A mixed-methods case study approach was used to measure the attitudes of practice mentors from health and social work, and to identify enablers and barriers to IPW, and IPPL for students. Online surveys and semi-structured face to face interviews were carried out with a range of professions within one Scottish health board and associated local authority. Results showed that attitudes to IPW, and IPPL for students were generally positive. Attitudes were not significantly affected by governing body, gender, area of work, years of experience, or prior experience of IPE. IPW was perceived to be enabled by shared processes and policies, IPPL for staff, effective communication, established teams, and shared processes and policies. Proximity to other professions and shared spaces encouraged informal communication and positive interprofessional relationships. Regular structured IPPL opportunities for students were limited. However, where opportunities did occur, this was linked to areas where practice mentors perceived that there was a strong interprofessional team identity. Although attitudes to IPW, and IPPL for students are positive, further work is needed to identify systems for improving IPW, to strengthen professions' identity as interprofessional teams, and to increase IPPL opportunities for students.

The purpose of this thesis is to explore the institutionally shaped response to the introduction of the national guidelines on the Swedish regional health policy arena. The thesis consists of two case studies. Adapting a qualitative approach, the data is based on individual interviews and these were analysed thematically. The first paper explores the response by four Swedish regional health authorities to the introduction of the National Guidelines for Cardiac Care, while the second paper aims to broaden the understanding of how the national guidelines are used for strategic purposes among politicians. As illustrated in this thesis, organizations will respond, adjust and react to external pressure according to conditions shaped by the institutional context. Key findings here are that the national guidelines are a complex policy instrument that, beyond being able to be used in an instrumental fashion by the medical managment, can also serve a legitimizing function for political decision-makers. The goals of the national guidelines, i.e. equal and efficient care, and the uncertainty about who, among multiple stakeholders, is responsible for the guidelines in the regional health authority, is a source of ambiguity and potential conflict. Those who are potentially responsible represent different rationales – a political rationale and a scientific rationale. The dominating scientific rationale of the national guidelines can create instability, when pushing towards the use of explicit priority-setting. Priority-setting in the institutional setting of a regional health authority has strong elements of becoming “wicked problems” since the dilemma of prioritization remains regardless of ambitions to apply a “technocratic fix”. A wicked problem is characterized by high complexity and being persistently hard to solve (Williams et al. 2012). A recurring dilemma is that priority-setting still contains many wicked problems, as social values and political considerations remain important parts of the policy process. One weakness of the national guidelines, identified in this thesis, is that the guidelines discuss each service area separately, and thereby reinforce a silo mentality in the Swedish health policy arena. To sum up, the national guidelines create a multifaceted and complex response in the Swedish health policy arena where different rationalities collide, and where conflicts appear and are dealt with within the regional health authorities.

This study examines two groups -international and domestic students at Portland State University (PSU) - in terms of their motivations to seek university-health services, and their satisfaction with university-health services. The Theory of Motivated Information Management (W. A. Afifi & Weiner, 2004) served as the foundation for this study to examine the preferences of students in terms of the ways they seek information about their health concerns. Differences in international and domestic students' anxiety, efficacy, and satisfaction with physicians were supported. International students reported more anxiety than domestic students. Domestic students reported being more efficacious than international students when talking to a medical provider about a current medical issue. Also, international students reported higher satisfaction with a medical provider at their last university health services visit. First, subjects were asked if they currently have a medical concern for which they might consider consulting a physician at PSU health services. If this scenario applied, subjects were asked to rate a variety of possible, theoretically informed motivations for seeking medical information by consulting a physician, to test the Theory of Motivated Information Management. Second, subjects were asked if they have previously consulted a physician at PSU health services. If this scenario applied, subjects were asked to provide satisfaction ratings of the physician and staff. The results contribute to the understanding of information-seeking processes and support the theory's effectiveness in this situation, explaining where international and domestic students are significantly different in regard to their responses.

Abstract Amidst the worst disaster to impact a major U.S. city in one hundred years, New Orleans’ main trauma and safety net medical center, the Reverend Avery C. Alexander Charity Hospital, was permanently closed. Charity’s administrative operator, Louisiana State University (LSU), ordered an end to its attempted reopening by its workers and U.S. military personnel in the weeks following the August 29, 2005 storm. Drawing upon rigorous review of literature and an exhaustive analysis of primary and secondary data, this case study found that Charity Hospital was closed as a result of disaster capitalism. LSU, backed by Louisiana state officials, took advantage of the mass internal displacement of New Orleans’ populace in the aftermath of Hurricane Katrina in an attempt to abandon Charity Hospital’s iconic but neglected facility and to supplant its original safety net mission serving the poor and uninsured for its neoliberal transformation to favor LSU’s academic medical enterprise.

Text in English
The purpose of this study was to develop strategies to overcome the challenges in the management of large intensive care units (ICUs). Qualitative, research was conducted to explore and describe the challenges and needs experienced by the ICU managers and critical care nurses in the management of large ICUs. Data was collected through interviews. The study was conducted in two phases, that is, Phases I and II which involved compilation of evidence in preparation for development of the strategies and development of the strategies respectively. Two groups of critical care nurses participated in the steps of data collection in Phase I of the study. The unit managers participated in Phase I step 1 which was individual interviews and the critical care nurses not in the management role participated in Phase I, step 2 which was focus group interviews. Data was analysed using the descriptive analysis method of Tesch (1990). The study has highlighted the challenges and needs in the management of large ICUs, through seven themes that emerged from the findings. Ten strategies were developed to overcome the challenges and address the identified needs. The strategies have been presented as a contribution to literature.
Health Studies
D. Litt. et Phil. (Health Studies)

A following study on vancomycin demonstrated the differing pharmacokinetics during the course of a septic insult, day 2 pharmacokinetics differing from day 7.
An important study showed that some septic patients with "normal" serum creatinines can have very high creatinine clearances. It follows that drugs which are renally excreted will have high clearances and illustrates why many of the above patients had low serum levels of antibiotic, a reason why some ICU patients require different dosing to ward patients.
Due to the required fluid loading and inotropic use in septic patients, creatinine clearances and drug clearances are often raised. This results in low serum concentrations at the end of a standard dosing interval.
My beta-lactam antibiotic work has repeatedly demonstrated low serum levels at the end of the standard dosing interval. In view of beta-lactam time-dependent kill characteristics we designed a continuous infusion protocol which we validated in a follow-up paper.
The inflammatory response of infections involves endothelial damage and capillary permeability. With associated fluid shifts of severe sepsis and treatment thereof, the volume of distribution (Vd) of antibiotics that distribute into the extracellular space (aminoglycosides, glycopeptides) is high. Peak serum levels for these antibiotics are therefore lower than those found in non-critically ill and in normal volunteers. It is noteworthy that this change in Vd is not apparent with drugs that have good tissue penetration (e.g. ciprofloxacin).
This thesis is a compilation of 11 of my prospectively designed studies plus extracts from 5 published reviews, focusing on pharmacokinetic (PK) aspects of antibiotics in ICU patients, all published in internationally peer-reviewed journals.
Two large PK studies on ciprofloxacin (a drug that has excellent tissue penetration) designed to address possible PK differences over time, could not demonstrate this difference in adults nor in two groups of paediatric patients where differences in body water are significant.
Two papers investigated the pharmacokinetics of amicakin in adult and paediatric patients documenting the benefit of extended interval dosing.
We automatically assume that antibiotic prescribing data, collated from healthy volunteers and not so ill patients, can be transcribed into the Intensive Care Unit. This is not so.
Jeffrey Lipman.
"April 2005."
Source: Dissertation Abstracts International, Volume: 68-03, Section: B, page: 1548.
Thesis (M.D.)--Chinese University of Hong Kong, 2005.
Includes bibliographical references (p. 235-254).
Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web.
Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [200-] System requirements: Adobe Acrobat Reader. Available via World Wide Web.
School code: 1307.

This descriptive case study examines the use of medical simulation technology in the three-year Thompson Rivers University respiratory therapy training program. Qualitative analysis of data gathered from 78 participants through interviews, observations, and discussion groups reveal a wide variety of low- intermediate- and high-fidelity technologies used for education and evaluation. Deliberate practice is the predominant learning theory informing the use of simulation for safe and ethical training in competencies that would otherwise pose significant risk to patients. Recommendations include enhancements of the existing technology with psychological and environmental fidelity, and for optimal curriculum placement of high-fidelity simulators at hospital sites for student development of critical thinking and team training. Further research into learning with high-fidelity simulation specifically within the context of a student respiratory therapist as an embedded hospital team member is needed. Keywords: respiratory therapy, patient simulation, critical thinking, learning, critical care, deliberate practice

Submitted in fulfillment of the requirements for the Degree in Masters of Technology in Nursing, Durban University of Technology, Durban, South Africa, 2015.
Background The current health care system in South Africa and its diverse settings of health care delivery system require a nurse who can make decisions, think critically, solve problems and work effectively in a team. Traditional nursing education teaching strategies have over the years relied on didactic and often passive approaches to learning. In pursuit of quality, academics and students must be continually engaged in a process of finding opportunities for improving the teaching and learning process. Purpose of the study The purpose of this study was to evaluate the structure and the process in case based learning at the University of Technology. Methodology This study is qualitative in nature, governed by an interpretive paradigm. This is a case study, which enabled the researcher to merge student interview data with records in order to gain insight into the activities and details of case based learning as practised at the University of Technology under study. Most importantly, the case study method was deemed appropriate for the current study, since case-based learning as a pedagogical approach (and a case) cannot be abstracted from its context for the purposes of study. Case based learning is evaluated in its context namely, the undergraduate nursing programme, using the Donabedian framework of structure, process and product. Results The study recorded that students were positive towards case based learning though some identified dynamics of working in groups as demerits of case based learning. The structures that are in place in the programme and the CBL processes are adequate and support CBL. There are however areas that need attention such as the qualification of the programme coordinator, the size of the class-rooms and the service of the computer laboratory. Conclusion The study found that apart from a few minor discrepancies, case based learning is sufficiently implemented, and experienced as invaluable by students, at the University of Technology under study.

In the industrialised world, premature birth has been recognised as one of the most significant perinatal health issues (Kramer, Platt et al. 1998). In Australia 8.1% of babies are born before 37 weeks gestation (Laws, Abeywardana et al. 2007). Premature babies often have prolonged stays in Neonatal Intensive Care Units (NICUs) and can suffer from a number of different conditions during their stay. Some of these conditions have been shown to exhibit certain variations in their physiological parameters that can indicate the onset of such conditions, before it can be detected by other means. Medical monitoring equipment produces large masses of data, which makes analysing this data manually impossible. Adding to the complexity of the large datasets is the nature of physiological monitoring data – the data is multidimensional, where it is not only changes in individual dimensions that are significant, but sometimes simultaneous changes in several dimensions. As the time-series produced by the monitoring equipment is temporal, there is a need for clinical research frameworks that enables both the dimensionality and temporal behaviour to be preserved during data mining. The aim of this research is to extend previous research that proposed a framework to support analysis and trend detection in historical data from Neonatal Intensive Care Unit (NICU) patients. The extensions contribute to fundamental data mining framework research through the integration of temporal abstraction and support of null hypothesis testing within the data mining processes. The application of this new data mining approach is the analysis of level shifts and trends in historical temporal data and to cross correlate data mining findings across multiple data streams for multiple neonatal intensive care patients in an attempt to discover new hypotheses indicative of the onset of some condition. These hypotheses can then be evaluated and defined as rules to be applied in the monitoring of neonates in real-time to enable early detection of possible onset of conditions. This can assist in faster decision making which in turn may avoid conditions developing into serious problems where treatment may be futile. This research employs a constructive research method. In this research, the problem is the inability of current data mining frameworks to completely support clinical research in multidimensional temporal data. This research has resulted in the design of a temporal abstraction multidimensional data mining (TAMDDM) framework suitable for clinical research in multidimensional temporal time series data. The framework is demonstrated through a case study with neonatal intensive care monitoring data.

Poor health care delivery in rural communities is a major problem facing the health sector in Namibia. Patients who visit rural communities often wait on queues for several hours every day before they can be examined by a medical practitioner. This is detrimental to the health care process and impacts negatively on the efficiency and effectiveness of the sector. Mobile phones can however be employed as tools to improve work processes in such hospitals and as a result improve health care delivery in rural communities. The purpose of this study was to investigate the health care services provided to patients at Outpatient Departments (OPDs) in rural hospitals through the use of data collection instruments such as interviews, questionnaires, document analysis, expert validation and photographs in order to compile a Mobile Health Service Framework (MHSF) to improve healthcare delivery processes in OPDs. From an interpretive paradigm perspective, the qualitative design was used together with a case study approach. Three hospitals in rural communities were used as case studies. These were Okuryangava Hospital, Katutura Hospital and Khomasdal Hospital. Interviews were conducted and questionnaires distributed to the participants. The findings revealed that there is a high concentration of mobile phone usage in rural communities and there is a high usage of the SMS feature on such mobile phones.
Computing
M. Sc. (Computing)

RESUMO: Enquadramento teórico - Os estudos epidemiológicos demonstram que apesar de todo o progresso científico, muitas pessoas continuam sem acesso aos Serviços de Saúde Mental (SSM) e que, em muitos casos, os cuidados não têm a qualidade suficiente. A experiência de vários países mostra que os processos de implementação de modelos de intervenção terapêutica, como é o da Gestão de Cuidados, são lentos e complexos, não dependendo somente do grau de efectividade ou da complexidade das práticas a implementar. O Modelo de Gestão de Cuidados (MGC), é definido como uma prática baseada na evidência, utilizada para ajudar os doentes nos seus processos de recuperação. As estratégias para implementar práticas baseadas na evidência são críticas para a melhoria dos serviços. Existem, apesar de toda a evidência, muitas barreiras à implementação. Ao constatarmos que as práticas validadas pela ciência estão longe de estar claramente disseminadas nos serviços de saúde mental, fundamentamos a necessidade de utilizar metodologia de implementação que, além da efectividade das práticas, permita uma efectividade da implementação. Para responder às necessidades de formação e no âmbito da implementação do Plano Nacional de Saúde Mental, foram formados, em Portugal, 170 profissionais de saúde mental provenientes de serviços públicos e do sector social, de todas as regiões de Portugal Continental. Considerando que estes profissionais adquiriram competências específicas no MGC, através de um programa de formação nacional idêntico para todos os serviços de saúde mental, investigámos o grau de implementação deste modelo, bem como os facilitadores e as barreiras à sua correcta implementação. Existem vários estudos internacionais sobre as barreiras e os facilitadores à implementação de práticas baseadas na evidência, embora a maior parte desses estudos seja baseado em entrevistas semi-estruturadas a profissionais. Por outro lado, não existem, em Portugal, estudos sobre as barreiras e os facilitadores à implementação de práticas de saúde mental. Objectivos 1. Estimar o grau da implementação do MGC nos serviços de saúde mental portugueses 2. Caracterizar as regiões onde a implementação do MGC tenha ocorrido em maior grau. 3. Identificar os factores facilitadores e as barreiras à implementação do MGC, entre as regiõesde saúde do país. 4. Explorar as relações entre a fidelidade da implementação, as barreiras e os facilitadores da implementação, a cultura organizacional e as características dos serviços de saúde mental. Metodologia Estudo observacional, transversal e descritivo, com características exploratórias. População: profissionais dos serviços de saúde mental públicos e do sector social que frequentaram o Programa Nacional de Formação em Saúde Mental Comunitária no curso “Cuidados Integrados e Recuperação”, da Coordenação Nacional para a Saúde Mental / Ministério da Saúde, entre Outubro de 2008 e Dezembro de 2009, (n=71). Avaliação Fidelidade de implementação do Modelo de Gestão de Cuidados - IMR-S (Illness Management and Recovery Scale); Qualidade das guidelines utilizadas na implementação do Modelo de Gestão de Cuidados - AGREE II-PT (Appraisal of Guidelines, for Research and Evaluation); Avaliação das Barreiras e Facilitadores à implementação do MGC - BaFAI (Barriers and Facilitators Assessment Instrument); Avaliação da Cultura Organizacional dos serviços de saúde mental - CVF-I (Competing Values Framework Instrument). Análise Estatística Para a descrição dos dados foram aplicados métodos de estatística descritiva. Para a comparação de subgrupos foram utilizados os testes de Mann Whitney e Kruskall-Wallis. Para a investigação de associações foram utilizados os métodos de correlação de Spearman e a Regressão Múltipla. O tratamento e análise dos dados foram realizados utilizando o programa estatístico IBM SPSS Statistics® para Mac/Apple® nas versões 19 e 20. Resultados Serviços: A articulação com os cuidados de saúde primários existe na maioria dos serviços (56.34%) e 77.46% dos serviços têm autonomia para definir os cuidados a prestar. A maioria dos serviços (63.38%) realiza duas ou mais reuniões clínicas por mês e a quase totalidade (95.77%) recebe estagiários e/ou internos. A área da investigação tem níveis considerados baixos, quando comparados com outros países da Europa, tanto para a globalidade das áreas de investigação (25.35%), como para as áreas psicossociais (22.54%). Considerando componentes fundamentais para a implementação de modelos de gestão de cuidados, os resultados nacionais indicam que 66.20% dos serviços fazem registos em processo clínico único. As percentagens de utilização de planos individuais de cuidados são globalmente baixas (46.48%). Por seu turno, a utilização de guidelines, nos serviços do país, tem uma percentagem média nacional de 57.75%. Profissionais: São, na sua maioria, do sexo feminino (69.01%), com idades entre os 25 e os 56 anos (média 38.9, ± 7.41). Pertencem, maioritariamente, aos grupos profissionais da enfermagem (23.94%) e da psicologia (49.30%). A formação dos profissionais é de nível superior em todos os grupos, com uma percentagem total de licenciados de 80.3%, tendo os restantes uma formação ao nível do mestrado. Apesar dos valores baixos (17%) de formação prévia em modelos de gestão de cuidados, 39% dos profissionais indicou utilizar algumas vertentes destes modelos na sua prática. Apesar de 97,18% dos profissionais ter participado em dois ou mais encontros científicos, num período de dois anos, apenas 38.03% apresentou alguma comunicação científica no mesmo intervalo. Guideline: Os resultados da avaliação da guideline do MGC indicaram percentagens mais altas, quanto à qualidade do seu desenvolvimento, nos Domínios 1 (Objectivo e finalidade, com 72.2%) e 4 (Clareza de Apresentação, 77.7%). O Domínio 5 (Aplicabilidade) foi pontuado no limite inferior do desenvolvimento com qualidade suficiente (54.1%), ao passo que a guideline obteve uma pontuação negativa nos Domínios 2 (Envolvimento das partes interessadas, com 41.6%) e 3 (Rigor do Desenvolvimento, com 28.1%). Adicionalmente não foi possível às avaliadoras cotar o Domínio 6 (Independência editorial), por ausência de referências neste contexto. A guideline teve uma avaliação global positiva (66%), com recomendação de aceitação com modificações. Cultura Organizacional: O perfil de liderança com maior frequência nos serviços de saúde mental portugueses foi o de Mentor (45.61%). As percentagens mais baixas pertenceram aos perfis Monitor e Inovador (3.51%). Na perspectiva da cultura organizacional dos serviços, apontuação mais alta foi a da Cultura das Relações Humanas (74.07%). A estratégia de liderança, com predomínio em todas as regiões, foi a estratégia de Flexibilidade (66.10%). Os resultados mostram que a única associação positivamente significativa com o grau da implementação do MGC é a do perfil Produtor, com um peso específico de 14.55% na prevalência dos perfis de liderança nos serviços de saúde mental portugueses. Barreiras: As barreiras à implementação da prática do MGC, identificadas pelos profissionais dos serviços de saúde mental, com percentagens mais altas nos totais do país, foram: o tempo (57.7%), o conhecimento sobre o modelo e a motivação (40.8%), a colaboração dos outros profissionais (33.7%), o número de contactos reduzidos com os doentes (35.2%), as insuficiências do ponto de vista dos espaços (70.4%) e dos instrumentos disponíveis (69%) para implementar o MGC. Existiu uma variação entre as regiões de saúde do país. Os resultados mostram que houve uma correlação negativa, de forma significativa, entre a implementação do MGC e as barreiras: da resistência à utilização de protocolos, do formato da prática, da necessidade de mais treino e da não cooperação dos profissionais. Foram encontradas diferenças estatisticamente significativas entre as barreiras à implementação e as características dos serviços, dos profissionais e da cultura organizacional. Implementação: A média nacional da fidelidade de implementação do MGC (41.48) teve valores aproximados aos de estudos similares. Na pontuação por regiões, a implementação com maior fidelidade ocorreu no Alentejo. Se considerarmos a implementação com fidelidade esta ocorreu em 57.75% dos serviços e uma boa implementação em 15.49%. Os métodos de regressão permitiram confirmar a capacidade preditiva das barreiras e da cultura organizacional quanto à fidelidade da implementação do MGC. Discussão: No universo das hipóteses inicialmente colocadas foi possível verificar a variação da implementação do MGC entre as regiões do país. O estudo permitiu, adicionalmente, concluir pela existência de denominadores comuns de maior sucesso da implementação do MGC. Foi ainda possível verificar uma relação significativa, existente entre o grau de implementação e as dimensões das barreiras, a cultura organizacional e os recursos dos SSM (aqui definidos pelas características dos serviços e dos profissionais). De uma forma mais conclusiva podemos afirmar que existem outros factores, que não estão relacionados com a avaliação restrita dos recursos financeiros ou humanos, associados à qualidade da implementação de práticas baseadas na evidência, como o MGC. Exemplo disso são os achados referentes à região de saúde do Alentejo, onde a distância dos grandes centros urbanos e as conhecidas dificuldades de acessibilidade, combinadas com os problemas conhecidos da falta de recursos, não impediram que fosse a região com os valores mais altos da fidelidade de implementação. Conclusões: Foram encontradas inúmeras barreiras à implementação do MGC. Existem barreiras diferentes entre regiões, que resultam das características dos serviços, dos profissionais e da cultura organizacional. Para existir implementação é necessária a consideração de metodologias próprias que vão para além dos tradicionais programas de formação. As práticas baseadas na evidência, amplamente defendidas, exigem implementações baseadas na evidência.-------------ABSTRACT: Introduction - Several epidemiological studies show that, despite all scientific progress, many people still continue to have no access to mental health services and in many situations the quality of care is poor. The experiences of several countries show that progress towards case management implementation is slow and complex, depending not only from the degree of effectiveness or the complexity of the practice. Case management is defined as an evidence-based practice used to help patients in the recovery process. Strategies to implement evidence-based practices are critical to services improvement. There are many barriers to their implementation, despite all available evidence. Realising that practices of proved scientific value are far from being clearly implemented, justifies the need to use implementation methodologies that, beyond practice effectiveness, allow implementation effectiveness. To answer training needs and in the framework of the National Mental Health Plan implementation, 170 mental health (MH) professionals from portuguese public and private sectors were trained. Considering that case management skills were acquired, as a result of this training programme, we decided to study the degree of implementation in the services.Barriers and facilitators to the implementation were studied as well. There are several studies related with barriers and facilitators to the implementation of evidence-based practices, but most of them use semi-structured interviews with professionals. Additionally, there are no studies in Portugal related with barriers and facilitators to the implementation of mental health practices. Objectives1. Estimate the degree of case management implementation in Portuguese MH Services. 2.Describe regions where implementation occurred with higher fidelity degree. 3. Identify barriers and facilitators to case management implementation across country regions. 4. Explore the relationships between implementation, barriers and facilitators, organisational culture and services characteristics. Methodology - Cross sectional, descriptive study. Assessments - Implementation fidelity - IMR-S (Illness Management and Recovery Scale); Guideline quality - AGREE II-PT (Appraisal of Guidelines, for Research and Evaluation); Barriers and facilitators assessment - BaFAI (Barriers and Facilitators Assessment Instrument); Organisational culture assessment - CVF-I (Competing Values Framework Instrument). Statistical analysis - Descriptives and cross-tabs. Subgroups comparison: Mann-Witney and Kruskall-Wallis. Associations between variables were calculated using Spearman correlation's and Multiple Regression. Results - Services: Liaison with primary care is done in most services (56.34%) and 77.46% have autonomy to determine care. Most services have regular clinical meetings and almost all give internship training (95.77%). Research activity is low compared with other European countries, for both general and psychosocial research. Considering key components for the case management implementation, 66.20% of all services use single clinical records. The use of individual care plans is globally low (46.48%) and there is a use of guidelines in 57.75% of services. Human Resources: most are women (69.01%), with age ranging from 25-56 (average 39.9, SD 7.41). The majority are psychologists (49.30%) and nurses (23.94%). All have a university degree, 19.7% have a masters degree and 83% didn’t have any case management training before the above mentioned national training. Despite the low levels of preceding case management training, 39% have used model components in day-to-day practice and although 97.18% of the workforce have attended scientific meetings in the last 2 years, only 38.03% presented communications in the same period. Guideline: Results show that higher scores were obtained in Domain 1. Scope and Purpose (72.2.%),and Domain 4. Clarity of presentation (77.7%). Domain 5. pplicability scored near low boundary (54.1%) and negative scores were found in Domain 2. Stakeholder Involvement (41.6%) and Domain 3. Rigour of Development (28.1%). Global score was 66% and the guideline was recommended with modifications. Organisational Culture: The most frequent leadership profile was the Mentor profile (45.61%). Lower scores belonged to Innovator and Monitor profiles (3.51%). On the organisational culture overall, higher scores were found in the Human Relations culture (74.07%). The higher leadership strategy was the strategy of flexibility (66.10%). The results additionally showed that the only leadership profile associated with case management implementation was the Producer profile, representing 14.55% of all leadership profiles in the country.Barriers: The barriers identified by MH professionals, with high percentages, were: lack of time (57.7%), knowledge and motivation (40.8%), other colleagues cooperation (33.7%), low number of contacts with patients (35.2%), lack of facilities (70.4%) and lack of instruments (69%) to implement case management, varying across regions. Results show that there was a negative correlation between implementation and the following barriers: using protocols, practice format, need for more training and lack of cooperation from colleagues. Additionally, statistical differences were found between barriers to implementation and: services characteristics, workforce characteristics, organisational culture. Implementation: The national average results of case management implementation fidelity was (41.48), close to values found in similar studies. In the regional scores South Region Alentejo had the highest implementation score. If we look at minimum scores to assume implementation fidelity, these occurred in 57.75% of services and a good implementation occurred in 15.49% of these. Regression methods allowed to confirm that implementation score prediction was possible using the combination of barriers and organisational culture scores. Discussion - Considering the initial study hypotheses, it was possible to confirm the variation of case management implementation across country regions. Additionally, we could conclude that common denominators exist when successful implementation occurred. It was possible to observe a significant relationship between implementation degree and the dimensions of barriers, organisational culture and services resources (defined as professionals and services characteristics). In a more conclusive way, we can say that there are factors, other than financial and human resources, that are associated with evidence based practices implementation like case management. An example is the Alentejo region, were the distance from urban centres, and the known difficulties associated with accessibility, plus the lack of financial and human resources, have not impeded the regional higher score on implementation. Conclusions: Case management implementation had several barriers to implementation. There are different barriers across country regions, resulting from organisational culture, services and professionals characteristics. To reach implementation it is necessary to consider specific methodologies that go beyond traditional training programs and evident practices, widely promoted. Evidence-based practices require evidence-based implementations.