Original article
Development of a virtual tool for monitoring quality of care in acute myocardial infarction via the internet
Desenvolvimento de um sistema para monitoramento da qualidade do atendimento ao infarto agudo do miocárdio via WEB
Marcelo B. Rivas
, Francisco Viacava, Fabio N. Gonçalves, Hegláucio S. Barros, Rodrigo S. Moreira
Corresponding author
Laboratório de Informações em Saúde (LIS), Instituto de Comunicação e Informação Científica e Tecnológica em Saúde (ICICT), Fundação oswaldo Cruz, Rio de Janeiro, Brazil
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Rivas, Francisco Viacava, Fabio N. Gonçalves, Hegláucio S. Barros, Rodrigo S. Moreira" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Marcelo B." "apellidos" => "Rivas" "email" => array:1 [ 0 => "mbsrivas@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Francisco" "apellidos" => "Viacava" ] 2 => array:2 [ "nombre" => "Fabio N." "apellidos" => "Gonçalves" ] 3 => array:2 [ "nombre" => "Hegláucio S." "apellidos" => "Barros" ] 4 => array:2 [ "nombre" => "Rodrigo S." "apellidos" => "Moreira" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Laboratório de Informações em Saúde (LIS), Instituto de Comunicação e Informação Científica e Tecnológica em Saúde (ICICT), Fundação oswaldo Cruz, Rio de Janeiro, Brazil" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Desenvolvimento de um sistema para monitoramento da qualidade do atendimento ao infarto agudo do miocárdio via WEB" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Measurement of quality indicators is now used to monitor performance at various stages of hospital care.</p><p id="par0010" class="elsevierStylePara elsevierViewall">For ST-elevation myocardial infarction (STEMI), which accounts for 30–47% of cases of myocardial infarction (MI),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> reperfusion should be initiated within 12<span class="elsevierStyleHsp" style=""></span>hours of symptom onset, and has a greater impact on mortality reduction if performed within 3<span class="elsevierStyleHsp" style=""></span>hours.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Various countries assess performance measures in the treatment of STEMI,<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a> based on indicators published in the guidelines.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The Myocardial Ischaemia National Audit Project is a database of quality indicators of treatment of MI in England and Wales. Four-monthly reports are published for the purpose of assessing outcomes and quality of care. Sustained improvements in fibrinolysis and secondary prevention have been observed since its implementation.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The Medicare Quality Monitoring System, run by the US government, provides information on hospital performance including data on legislation, costs, and morbidity and mortality rates, which is then analyzed and used in the Hospital Compare initiative. This provides performance indicators for the treatment of particular conditions (for example mortality from pneumonia, door-to-balloon times, and aspirin prescription rates in MI).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The US National Registry of Myocardial Infarction, including over two million cases of MI since 1990, demonstrated that at least one in five patients did not receive all the recommended therapies. A 37% reduction in annual mortality in these patients between 1990 and 2006 has been attributed to improved adherence to guidelines.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Despite the growing number of studies on quality of health care in Brazil, most hospitals do not routinely measure such variables, although some, such as Hospital Albert Einstein in São Paulo and Hospital Pró-Cardíaco in Rio de Janeiro, provide up-to-date information on their indicators that can be freely consulted on the internet.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Methods</span><p id="par0040" class="elsevierStylePara elsevierViewall">In the first stage of the project critical elements in the treatment of STEMI were identified and indicators were formulated following analysis of the US and Brazilian clinical protocols and based on the available evidence. A panel of specialists was formed to discuss controversial points in the guidelines on the in-hospital treatment of STEMI and to standardize indications and contraindications for therapeutic strategies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the second stage, a pilot study was performed aimed at exploring the possibility of obtaining these indicators retrospectively from information in the medical records of patients admitted with a diagnosis of STEMI in a teaching hospital. Analysis of the pilot study showed significant gaps in the recording of contraindications to recommended therapies.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the latest phase, a virtual tool was developed for the prospective collection of data in real time, using a client/server platform so that various hospitals could access the Fiocruz server, where the data are processed and the indicators are automatically generated.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Hospitals that according to the national health institutions register provided emergency cardiological treatment were selected to participate in the project; these included institutions with the necessary catheterization facilities to perform primary angioplasty, as well as those using solely fibrinolytics as reperfusion therapy.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Ten hospitals in the municipality of Rio de Janeiro that met the required conditions were invited to a meeting at which the aims of the project were presented. Information on the institutions and the physicians responsible for entering data into the system were recorded via the site <a href="http://www.qualiiam.cict.fiocruz.br/">www.qualiiam.cict.fiocruz.br</a>, which generates passwords for participants.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Each hospital developed its own method of collecting data from medical records, which were then entered on an electronic form without patients being identified. All patients were aged 18 or over. The criteria used for a diagnosis of STEMI were characteristic elevation and gradual decline of troponin or more rapid increase and fall in creatine kinase MB (CK-MB), together with at least one of the following criteria: (a) ischemic symptoms; (b) electrocardiographic alterations indicative of ischemia (ST-segment elevation or depression or new-onset left bundle branch block); (c) pathological Q waves on the electrocardiogram; or (d) evidence on imaging studies of loss of myocardial viability or of wall motion abnormalities.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,14,15</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The electronic form developed to enter data into the system consists of fields defined on the basis of clinical protocols for the first 24<span class="elsevierStyleHsp" style=""></span>hours of STEMI treatment. The first section is for recording data related to hospital admission, including date and time of admission, gender, age, and time of symptom onset, funding source, hospital department that made the diagnosis of STEMI and information on treatment and previous medication. This is followed by four sections on administration of recommended drugs in the first 24<span class="elsevierStyleHsp" style=""></span>hours: (i) aspirin/clopidogrel; (ii) beta-blockers; (iii) angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs); and (iv) fibrinolytics. Data on percutaneous coronary intervention (PCI) are recorded in the final section.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In the sections on medical therapy, the following information is required: date, time and dosage of the prescription and administration of each drug, and all contraindications as stipulated in the clinical protocols. In the section on PCI, the date and time of balloon inflation are recorded. Justification must be provided in cases where no reperfusion method was employed.</p><p id="par0080" class="elsevierStylePara elsevierViewall">In order to ensure uniformity in the definition of variables, a glossary of terms has been developed that can be accessed via an icon in the data collection form.</p><p id="par0085" class="elsevierStylePara elsevierViewall">All fields on the electronic form must be completed. The system detects inconsistencies in the date and time of admission and in the administration of medical therapy, which are essential elements for the calculation of indicators.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Following the pilot study, in which the lack of data on contraindications made it difficult to identify the justification for non-use of recommended therapies, further options were added to all relevant fields: “NH” (when the drug was not available), “A” (absence of information in the medical record) and “Other” (free text field to record any other problems encountered).</p><p id="par0095" class="elsevierStylePara elsevierViewall">Once completed, the electronic form is sent via the internet to the server, where the indicators are calculated in real time.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Carrying out data processing and calculation of indicators was the responsibility of the Health Information Laboratory of the Institute for Scientific and Technological Communication and Information of the Oswaldo Cruz Foundation (Fiocruz), where the server is located. The calculation of performance indicators for STEMI treatment took account of contraindications and indications for treatment in the first 24<span class="elsevierStyleHsp" style=""></span>hours of hospitalization. These items were considered mandatory for inclusion of patients in the study. In cases where precise data were not available, the information was flagged as incomplete.</p><p id="par0105" class="elsevierStylePara elsevierViewall">In calculating the indicators, the numerator was taken as the number of cases without contraindication that received a particular drug and the denominator was taken as the number of cases without contraindication. Patients who had received a drug before hospital admission were excluded from the calculation for that drug. Thus, the number of patients considered in the indicators for different therapeutic procedures may vary.</p><p id="par0110" class="elsevierStylePara elsevierViewall">When calculating the indicator for administration of ACE inhibitors or ARBs, the denominator takes account of both the absence of contraindications and the fact that these drugs are not indicated in all cases of STEMI. According to the review of guidelines by the panel of specialists, ACE inhibitors and ARBs have a higher level recommendation in patients with hypertension, diabetes or clinical or echocardiographic signs of left ventricular systolic dysfunction. Based on these characteristics, the indicator was calculated only in cases in which these drugs were indicated and there were no contraindications to their use.</p><p id="par0115" class="elsevierStylePara elsevierViewall">At the same time, a tool was developed to access the results of the indicators via the internet, so that representatives of the participating hospitals could generate reports in real time that would include the number of patients considered in calculating each indicator, reference values recommended by the protocols, and the mean of the results obtained by all the hospitals in the system, while maintaining the confidentiality of each institution's data. Using passwords generated by the system, representatives can consult the site at <a href="http://www.qualiiam.cict.fiocruz.br/indicadores.php">www.qualiiam.cict.fiocruz.br/indicadores.php</a> to access the results for the following indicators:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">percentage of patients without contraindication for aspirin who received the drug within 24<span class="elsevierStyleHsp" style=""></span>hours of hospital admission;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">percentage of patients without contraindication for beta-blockers who received the drugs within 24<span class="elsevierStyleHsp" style=""></span>hours of hospital admission;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">percentage of patients with left ventricular systolic dysfunction and without contraindications for ACE inhibitors or ARBs who received one of these drugs within 24<span class="elsevierStyleHsp" style=""></span>hours of hospital admission;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">percentage of patients without contraindication for fibrinolysis who received fibrinolytics within 24<span class="elsevierStyleHsp" style=""></span>hours of hospital admission;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">percentage of patients who received fibrinolytics within 30<span class="elsevierStyleHsp" style=""></span>min of hospital admission;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">percentage of patients who underwent angioplasty with balloon inflation within 90<span class="elsevierStyleHsp" style=""></span>min of hospital admission;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">mean time (min) between hospital admission and the administration of fibrinolytics (door-to-needle time);</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">mean time (min) between hospital admission and angioplasty balloon inflation (door-to-balloon time).</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0160" class="elsevierStylePara elsevierViewall">Of the 10 institutions invited to participate in the project, five (two public and three private) agreed. After 18 months 124 cases of STEMI had been entered into the system, the number of patients differing between hospitals (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7; B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14; C<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16; D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>44; and E<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>43). The mean age of those included was 63.6 years and 69.2% were male.</p><p id="par0165" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results for the indicators calculated for the five hospitals in the municipality of Rio de Janeiro between October 2008 and October 2010.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">The best performance was seen in the administration of aspirin (94.6%). ACE inhibitors or ARBs were prescribed in 76% of patients with indication, excluding those who presented contraindications. Beta-blockers were used in 82.5% of the 80 patients without contraindication.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The percentage of patients without contraindication to fibrinolytics who received these agents was 68.4% (n<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>29). In no case was door-to-needle time less than 30<span class="elsevierStyleHsp" style=""></span>min; the mean was 122<span class="elsevierStyleHsp" style=""></span>min and the longest door-to-needle time was 392<span class="elsevierStyleHsp" style=""></span>min after hospital admission.</p><p id="par0180" class="elsevierStylePara elsevierViewall">In three of the 14 cases in which fibrinolysis was not performed the reason given was delay in in-hospital diagnosis of STEMI, the diagnosis only being confirmed over 12<span class="elsevierStyleHsp" style=""></span>hours after symptom onset. Four other patients arrived at the hospital more than 12<span class="elsevierStyleHsp" style=""></span>hours after symptom onset, and there was thus no indication for fibrinolysis.</p><p id="par0185" class="elsevierStylePara elsevierViewall">All 74 patients admitted to hospitals with catheterization facilities underwent primary PCI. Mean door-to-balloon time was 161<span class="elsevierStyleHsp" style=""></span>min, ranging between 30 and 900<span class="elsevierStyleHsp" style=""></span>min. In only 28% of patients undergoing PCI was the door-to-balloon time less than 90<span class="elsevierStyleHsp" style=""></span>min as recommended.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0190" class="elsevierStylePara elsevierViewall">The development of a virtual tool for real-time calculation and analysis of the main quality indicators related to initial treatment of STEMI has provided valuable information on hospital performance, data that can be used to monitor and improve quality of care.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Most patients were male and in the seventh decade of life, as is found in the main registries of acute coronary events.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,16</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">The data on medical therapy (aspirin, ACE inhibitors/ARBs and beta-blockers) within 24<span class="elsevierStyleHsp" style=""></span>hours of admission showed better adherence to guidelines than in other studies.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,16</span></a> This is probably due to the fact that in the present study patients with contraindications were not included when calculating the indicators, which appears not to have been the case in other studies. In any event, there is room for improvement in the initial treatment of patients admitted with STEMI, in terms of both prompt diagnosis and drug therapy, since the guidelines recommend that the latter should be administered within 24<span class="elsevierStyleHsp" style=""></span>hours of admission in 100% of eligible patients.</p><p id="par0205" class="elsevierStylePara elsevierViewall">The number of patients included in the denominator for calculating each indicator varied depending on the contraindications for each drug or procedure assessed. Aspirin had the lowest denominator, and besides contraindications such as bleeding events and allergy, the main reason for the lower number of patients eligible for this indicator was the fact that many were already medicated with aspirin on arrival, since early administration significantly reduces morbidity and mortality in cases of suspected MI. These patients were given aspirin in ambulances or in medical centers with no facilities for fibrinolysis, were routinely taking aspirin for pre-existing risk factors (for example, diabetes or peripheral arterial disease), or were self-medicated in view of symptoms suggestive of MI.</p><p id="par0210" class="elsevierStylePara elsevierViewall">With regard to fibrinolysis in the present study, no institution achieved a door-to-needle time (the time elapsed between hospital admission and the start of intravenous infusion of fibrinolytics) of less than 30<span class="elsevierStyleHsp" style=""></span>min, as recommended in the guidelines. Hospitals with large volumes of patients may have longer waiting times before observation and performance of an ECG, resulting in delays in the diagnosis of STEMI. Current guidelines recommend an ECG within 10<span class="elsevierStyleHsp" style=""></span>min in cases of suspected MI.</p><p id="par0215" class="elsevierStylePara elsevierViewall">As regards primary PCI, the guidelines recommended a maximum door-to-balloon time (the time elapsed between hospital admission and balloon inflation inside the infarct-related artery) of 90<span class="elsevierStyleHsp" style=""></span>min. This goal was achieved in less than 30% of patients undergoing PCI in our study, demonstrating that there is room for improvement in this process. Besides the factors mentioned above that may delay a diagnosis of STEMI, the availability of a catheterization laboratory and an interventional cardiology team can also affect door-to-balloon times.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Furthermore, over 30% of patients admitted to institutions without facilities for angioplasty received no reperfusion therapy at all, even when there were no relative or absolute contraindications. Overcoming this situation is a challenge for health systems around the world, particularly in developing countries.</p><p id="par0225" class="elsevierStylePara elsevierViewall">In the US, the American College of Cardiology (ACC) has launched the D2B (door-to-balloon) program,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> which focuses on strategies to reduce waiting times for patients with chest pain, streamline the process of diagnosing STEMI, and improve the timeliness of coronary reperfusion.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The fact that no patients admitted to hospitals with facilities for PCI underwent fibrinolytic therapy may be due to the superiority of mechanical reperfusion, especially when performed within 90<span class="elsevierStyleHsp" style=""></span>min of hospital admission.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">Assessing outcomes of health care entails a series of steps, including definition of variables, development of appropriate methodology and processing of the data obtained. An advantage of the present project is the requirement to complete all the fields on the form, even when information is lacking from the medical record. This minimizes loss of data due to non-completion and enables identification of variables that are frequently missing from medical records, providing opportunities for improvement.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusion</span><p id="par0240" class="elsevierStylePara elsevierViewall">The system presented is a viable tool for monitoring performance in the treatment of STEMI, with updating of variables in real time.</p><p id="par0245" class="elsevierStylePara elsevierViewall">The low level of adherence and of effective participation of institutions treating STEMI in terms of uploading and consulting information online in real time represents a challenge for implementation of the system.</p><p id="par0250" class="elsevierStylePara elsevierViewall">The results obtained suggest that improvements are needed in the quality of care in MI, especially regarding the excessive delays in the use of reperfusion therapies. The tool was designed as a management aid to monitor the performance of individual hospitals and critical elements will vary between institutions. However, the small sample size limits any in-depth analysis.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Analysis of these indicators in the future in health services with different levels of complexity may help to assess the impact of online reporting on the development of better treatment practices.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflict of interest</span><p id="par0260" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres176186" "titulo" => array:6 [ 0 => "Abstract" 1 => "Background" 2 => "Objective" 3 => "Methods" 4 => "Results" 5 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec164562" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres176187" "titulo" => array:6 [ 0 => "Resumo" 1 => "Fundamento" 2 => "Objetivo" 3 => "Métodos" 4 => "Resultados" 5 => "Conclusão" ] ] 3 => array:2 [ "identificador" => "xpalclavsec164563" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-03-17" "fechaAceptado" => "2011-12-15" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec164562" "palabras" => array:5 [ 0 => "Quality indicators in health care" 1 => "Myocardial infarction" 2 => "Emergency medicine" 3 => "Guidelines" 4 => "Health management" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec164563" "palabras" => array:5 [ 0 => "Indicadores de qualidade em assistência à saúde" 1 => "Infarto do miocárdio" 2 => "Medicina de emergência" 3 => "Diretrizes" 4 => "Gestão em saúde" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Measurement of quality indicators contributes to monitoring the performance of initial treatment of ST-elevated myocardial infarction (STEMI).</p> <span class="elsevierStyleSectionTitle">Objective</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To develop a virtual tool to calculate performance indicators of initial treatment of STEMI online via the internet.</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">We identified critical elements of the therapeutic process and formulated indicators in a retrospective pilot study, and developed a virtual tool for prospective data collection on initial treatment of STEMI. Rio de Janeiro hospitals with emergency care units were selected and invited to participate in the project. Online reports were developed to be accessed at <span class="elsevierStyleInterRef" href="http://www.qualiiam.icict.fiocruz.br/indicadores.php">www.qualiiam.icict.fiocruz.br/indicadores.php</span> and analyzed.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Five hospitals agreed to participate in the project and monitored treatment of different numbers of patients with a diagnosis of STEMI (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7, B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14, C<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16, D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>44 and E<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>43). Aspirin was administered in 94.6% of cases, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 76.1% and beta-blockers in 82.5%; 68.4% of patients with no contraindication received fibrinolysis. In no case was door-to-needle time less than 30<span class="elsevierStyleHsp" style=""></span>min, and mean time was 122<span class="elsevierStyleHsp" style=""></span>min. All patients admitted to hospitals with catheterization facilities underwent primary angioplasty; mean door-to-balloon time in these patients was 161<span class="elsevierStyleHsp" style=""></span>min; in only 28% was it less than 90<span class="elsevierStyleHsp" style=""></span>min.</p> <span class="elsevierStyleSectionTitle">Conclusion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The system can be used as a tool to monitor the performance of initial treatment of patients with STEMI. Analysis of these indicators in the future may help to evaluate the contribution of online reporting to the development of better treatment practices.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span class="elsevierStyleSectionTitle">Fundamento</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A mensuração de indicadores de qualidade contribui para monitoramento do desempenho do tratamento do Infarto Agudo do Miocárdio com Supradesnivelamento do Segmento ST (IAMCSST).</p> <span class="elsevierStyleSectionTitle">Objetivo</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Desenvolver uma ferramenta virtual para calcular indicadores de desempenho através de informações enviadas via WEB.</p> <span class="elsevierStyleSectionTitle">Métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Identificação de pontos críticos no processo terapêutico e formulação de indicadores avaliados em retrospetivo estudo piloto. Desenvolvimento de ferramenta virtual para coleta prospetiva dos dados relacionados com o atendimento inicial ao IAMCSST. Seleção e convocação dos hospitais para cadastro no sistema e exposição do projeto. Utilização do sítio <span class="elsevierStyleInterRef" href="http://www.qualiiam.cict.fiocruz.br/indicadores.php">www.qualiiam.cict.fiocruz.br/indicadores.php</span> para acesso aos relatórios dos indicadores em tempo real.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Houve variação no número de pacientes cadastrados por cada hospital (A<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>7; B<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14; C<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16; D<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>44; E<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>43). AAS foi administrado em 94,6% dos casos. A administração do IECA/BRA ocorreu em 76,1% dos pacientes. A administração de betabloqueadores ocorreu em 82,5%. 68,4% dos pacientes sem contra-indicação a fibrinolítico recebeu o fármaco. Em nenhum caso o tempo porta agulha foi inferior a 30<span class="elsevierStyleHsp" style=""></span>min. A média obtida foi 122<span class="elsevierStyleHsp" style=""></span>min. Todos os pacientes admitidos nos hospitais com hemodinâmica foram submetidos à angioplastia primária. A média obtida para tempo porta-balão foi 161<span class="elsevierStyleHsp" style=""></span>min. Em apenas 28% destes pacientes o tempo porta balão foi menor do que 90<span class="elsevierStyleHsp" style=""></span>min.</p> <span class="elsevierStyleSectionTitle">Conclusão</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">O sistema pode ser usado como ferramenta de gestão para monitoramento dos indicadores de <span class="elsevierStyleItalic">performance</span> no atendimento inicial ao IAM. Análises futuras destes indicadores poderão contribuir para avaliar o impacto destes relatórios sobre a incorporação de melhores práticas assistenciais.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Rivas, M. Desenvolvimento de um sistema para monitoramento da qualidade do atendimento ao infarto agudo do miocárdio via WEB. Rev Port Cardiol 2012. <span class="elsevierStyleInterRef" href="doi:10.1016/j.repc.2011.12.017">doi:10.1016/j.repc.2011.12.017</span>.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">ACE: angiotensin-converting enzyme; ARBs: angiotensin receptor blockers; SD: standard deviation.</p>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Indicators \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommended \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percentage of patients without contraindication who received aspirin within 24<span class="elsevierStyleHsp" style=""></span>hours of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percentage of patients without contraindication who received beta-blockers within 24<span class="elsevierStyleHsp" style=""></span>hours of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">82.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percentage of patients with left ventricular systolic dysfunction and no contraindications who received ACE inhibitors or ARBs within 24<span class="elsevierStyleHsp" style=""></span>hours of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percentage of patients without contraindication who received fibrinolytics within 24<span class="elsevierStyleHsp" style=""></span>hours of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percentage of patients who received fibrinolytics within 30<span class="elsevierStyleHsp" style=""></span>min of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.2% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Percentage of patients who underwent angioplasty with balloon inflation within 90<span class="elsevierStyleHsp" style=""></span>min of admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab268769.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Indicators \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Max \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">n \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Recommended \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean time (min) between admission and administration of fibrinolytic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">122 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">88 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">392 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><30<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mean time (min) between admission and balloon inflation in angioplasty \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">161 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">137.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">900 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">74 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><90<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab268768.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Performance indicators for initial 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| Year/Month | Html | Total | |
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| 2023 November | 46 | 29 | 75 |
| 2023 October | 24 | 14 | 38 |
| 2023 September | 22 | 23 | 45 |
| 2023 August | 30 | 18 | 48 |
| 2023 July | 26 | 8 | 34 |
| 2023 June | 36 | 14 | 50 |
| 2023 May | 41 | 28 | 69 |
| 2023 April | 24 | 6 | 30 |
| 2023 March | 49 | 16 | 65 |
| 2023 February | 41 | 23 | 64 |
| 2023 January | 24 | 14 | 38 |
| 2022 December | 40 | 21 | 61 |
| 2022 November | 50 | 29 | 79 |
| 2022 October | 31 | 28 | 59 |
| 2022 September | 20 | 30 | 50 |
| 2022 August | 30 | 28 | 58 |
| 2022 July | 26 | 40 | 66 |
| 2022 June | 25 | 27 | 52 |
| 2022 May | 24 | 28 | 52 |
| 2022 April | 32 | 35 | 67 |
| 2022 March | 28 | 41 | 69 |
| 2022 February | 26 | 33 | 59 |
| 2022 January | 26 | 28 | 54 |
| 2021 December | 15 | 33 | 48 |
| 2021 November | 40 | 34 | 74 |
| 2021 October | 32 | 50 | 82 |
| 2021 September | 20 | 25 | 45 |
| 2021 August | 28 | 36 | 64 |
| 2021 July | 28 | 30 | 58 |
| 2021 June | 25 | 17 | 42 |
| 2021 May | 25 | 47 | 72 |
| 2021 April | 39 | 40 | 79 |
| 2021 March | 51 | 20 | 71 |
| 2021 February | 48 | 17 | 65 |
| 2021 January | 28 | 9 | 37 |
| 2020 December | 45 | 9 | 54 |
| 2020 November | 32 | 15 | 47 |
| 2020 October | 17 | 14 | 31 |
| 2020 September | 69 | 16 | 85 |
| 2020 August | 17 | 6 | 23 |
| 2020 July | 43 | 10 | 53 |
| 2020 June | 41 | 10 | 51 |
| 2020 May | 37 | 4 | 41 |
| 2020 April | 28 | 10 | 38 |
| 2020 March | 36 | 6 | 42 |
| 2020 February | 34 | 25 | 59 |
| 2020 January | 27 | 6 | 33 |
| 2019 December | 23 | 4 | 27 |
| 2019 November | 25 | 4 | 29 |
| 2019 October | 32 | 7 | 39 |
| 2019 September | 14 | 6 | 20 |
| 2019 August | 35 | 5 | 40 |
| 2019 July | 41 | 7 | 48 |
| 2019 June | 27 | 10 | 37 |
| 2019 May | 44 | 5 | 49 |
| 2019 April | 17 | 12 | 29 |
| 2019 March | 19 | 10 | 29 |
| 2019 February | 36 | 8 | 44 |
| 2019 January | 24 | 5 | 29 |
| 2018 December | 45 | 10 | 55 |
| 2018 November | 49 | 10 | 59 |
| 2018 October | 80 | 12 | 92 |
| 2018 September | 37 | 11 | 48 |
| 2018 August | 35 | 4 | 39 |
| 2018 July | 15 | 8 | 23 |
| 2018 June | 45 | 1 | 46 |
| 2018 May | 31 | 7 | 38 |
| 2018 April | 64 | 1 | 65 |
| 2018 March | 47 | 7 | 54 |
| 2018 February | 35 | 7 | 42 |
| 2018 January | 32 | 11 | 43 |
| 2017 December | 49 | 12 | 61 |
| 2017 November | 62 | 13 | 75 |
| 2017 October | 59 | 11 | 70 |
| 2017 September | 50 | 11 | 61 |
| 2017 August | 53 | 15 | 68 |
| 2017 July | 47 | 20 | 67 |
| 2017 June | 48 | 6 | 54 |
| 2017 May | 39 | 8 | 47 |
| 2017 April | 38 | 4 | 42 |
| 2017 March | 48 | 10 | 58 |
| 2017 February | 35 | 6 | 41 |
| 2017 January | 30 | 4 | 34 |
| 2016 December | 37 | 16 | 53 |
| 2016 November | 30 | 9 | 39 |
| 2016 October | 48 | 4 | 52 |
| 2016 September | 21 | 8 | 29 |
| 2016 August | 4 | 3 | 7 |
| 2016 July | 12 | 10 | 22 |
| 2016 June | 6 | 5 | 11 |
| 2016 May | 8 | 9 | 17 |
| 2016 April | 24 | 3 | 27 |
| 2016 March | 64 | 15 | 79 |
| 2016 February | 65 | 17 | 82 |
| 2016 January | 46 | 7 | 53 |
| 2015 December | 49 | 9 | 58 |
| 2015 November | 46 | 10 | 56 |
| 2015 October | 45 | 9 | 54 |
| 2015 September | 41 | 7 | 48 |
| 2015 August | 52 | 14 | 66 |
| 2015 July | 22 | 9 | 31 |
| 2015 June | 27 | 7 | 34 |
| 2015 May | 38 | 10 | 48 |
| 2015 April | 47 | 12 | 59 |
| 2015 March | 43 | 2 | 45 |
| 2015 February | 29 | 8 | 37 |
| 2015 January | 51 | 12 | 63 |
| 2014 December | 39 | 6 | 45 |
| 2014 November | 39 | 9 | 48 |
| 2014 October | 55 | 9 | 64 |
| 2014 September | 52 | 9 | 61 |
| 2014 August | 39 | 13 | 52 |
| 2014 July | 49 | 16 | 65 |
| 2014 June | 39 | 11 | 50 |
| 2014 May | 31 | 6 | 37 |
| 2014 April | 33 | 10 | 43 |
| 2014 March | 34 | 13 | 47 |
| 2014 February | 46 | 14 | 60 |
| 2014 January | 38 | 22 | 60 |
| 2013 December | 47 | 12 | 59 |
| 2013 November | 46 | 14 | 60 |
| 2013 October | 46 | 13 | 59 |
| 2013 September | 45 | 13 | 58 |
| 2013 August | 55 | 26 | 81 |
| 2013 July | 63 | 18 | 81 |
| 2013 June | 76 | 14 | 90 |
| 2013 May | 51 | 21 | 72 |
| 2013 April | 55 | 26 | 81 |
| 2013 March | 55 | 17 | 72 |
| 2013 February | 59 | 22 | 81 |
| 2013 January | 71 | 19 | 90 |
| 2012 December | 51 | 12 | 63 |
| 2012 November | 59 | 24 | 83 |
| 2012 October | 32 | 10 | 42 |
| 2012 September | 18 | 5 | 23 |
Show all
