Effect of an educational programme on critical care nurses' competence at two tertiary hospitals in Malawi

BackgroundCritical care specialty deals with the complex needs of critically ill patients. Nurses who provide critical care are expected to possess the appropriate knowledge and skills required for the care of critically ill patients. The aim of this study was to assess the effect of an educational programme on the competence of critical care nurses at two tertiary hospitals in Lilongwe and Blantyre, Malawi.MethodsA quantitative pre- and post-test design was applied. The training programme was delivered to nurses (n = 41) who worked in intensive care and adult high dependency units at two tertiary hospitals. The effect of the training was assessed through participants'' self-assessment of competence on the Intensive and Critical Care Nursing Competence Scale and a list of 10 additional competencies before and after the training.ResultsThe participants'' scores on the Intensive and Critical Care Nursing Competence Scale before the training, M = 608.2, SD = 59.6 increased significantly after the training, M = 684.7, SD = 29.7, p <.0001 (two-tailed). Similarly, there was a significant increase in the participants'' scores on the additional competencies after the training, p <.0001 (two-tailed).ConclusionThe programme could be used for upskilling nurses in critical care settings in Malawi and other developing countries with a similar context.     

Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study

BackgroundTracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi.MethodsThis is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management.ResultsIn our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%.ConclusionTracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.     

Epidemiology of Open Tibia fractures presenting to a tertiary referral centre in Southern Malawi: a retrospective study

BackgroundRoad traffic accidents in Malawi have increased in recent years resulting in a high incidence of trauma seen in the hospitals as well as a high prevalence of musculoskeletal impairment in the community. Open fractures are a common consequence of road traffic accidents and the tibia is the most common long bone open fracture.ObjectiveEpidemiology of open tibia fractures at the largest tertiary level hospital in Malawi and incidence of infections of open fractures managed at the institution.MethodologyThis was a retrospective study of consecutive open tibia fracture patients seen and admitted to Queen Elizabeth Central Hospital''s (QECH) orthopedic department from 1st January 2019 to 31st December 2019. Patients with life-threatening head, chest, or abdominal injuries were excluded as management takes priority over any limb-threatening injury.ResultsThere were 72 open tibia fractures screened, and 60 of these met our entry criteria; 6 patients did not, while 6 patient files were missing. The median age of patients was 36 years, IQR (27–44.75) with Males making up 82%(n=49) of open fractures. Most of the open tibia fractures were caused by road traffic accidents 63%(n=38), followed by assaults 18%(n=11), falls 17%(n=10), and industrial accidents 2%(n=1). 26.7% (n=16) of open tibia fractures developed an infection. We found that patients'' average length of stay was 16. 9(IQR 9.5–31.25) days. Most of the injuries (68.3%, n=41) were moderate to high energy injuries being Gustilo et al. grade II and III open tibia fractures.ConclusionThis study identified that open tibia fractures were common in our hospital and that were often high energy injuries requiring an extended hospital stay to manage. The infection rate noted was higher than that reported on average in lower- and middle-income countries. There is a need to do more robust prospective studies in the area to gather more information.     

The relationship between managed care insurance and use of lower-mortality hospitals for CABG surgery

Context  Explicit information about the quality of coronary artery bypass graft (CABG) surgery has been available for nearly a decade in New York State; however, the extent to which managed care insurance plans direct enrollees to the lowest-mortality CABG surgery hospitals remains unknown. Objective  To compare the proportion of patients with managed care insurance and fee-for-service (FFS) insurance who undergo CABG surgery at lower-mortality hospitals. Design  A retrospective cohort study of CABG surgery discharges from 1993 to 1996, using New York Department of Health databases and multivariate analysis to estimate the use of lower-mortality hospitals by patients with different types of health insurance. Setting  Cardiac surgical centers in New York, of which 14 were classified as lower-mortality hospitals (mean rate, 2.1%) and 17 were classified as higher-mortality hospitals (mean rate, 3.2%). Patients  A total of 58,902 adults older than 17 years who were hospitalized for CABG surgery. Patients were excluded if their CABG surgery was combined with any valve procedure or left ventricular aneurysm resection or if they were younger than 65 years and enrolled in Medicare FFS or Medicare managed care. Main Outcome Measure  Probability of a patient receiving CABG surgery at a lower-mortality hospital. Results  Compared with patients with private FFS insurance (n=18,905), patients with private managed care insurance (n=7169) and Medicare managed care insurance (n=880) were less likely to receive CABG surgery at a lower-mortality hospital (relative risk [RR] of surgery at a lower-mortality hospital compared with patients with private FFS insurance, 0.77; 95% confidence interval [CI], 0.74-0.81; P<.001; and RR, 0.61; 95% CI, 0.54-0.70; P<.001, respectively, after controlling for multiple potential confounding factors). Patients with Medicare FFS insurance used lower-mortality hospitals at rates more similar to those with private FFS insurance (n=31,948; RR, 0.95; 95% CI, 0.91-0.98; P=.004). Conclusions  Patients in New York State with private managed care and Medicare managed care insurance were significantly less likely to use lower-mortality hospitals for CABG surgery compared with patients with private FFS insurance.      

孕前和孕期保健在糖尿病孕妇中的对比研究

目的对比研究孕前和孕期保健在糖尿病妇女妊娠中的作用。方法对2005年9月-2010年9月本社区分娩的106例糖尿病妇女进行调查研究,分析对比孕前和孕期保健对孕妇与新生儿围产期合并症的发生率。结果从孕前进行保健发生感染、羊水过多、妊娠期高血压疾病、早产的孕妇人数小于从孕期开始保健的人数,差异有统计学意义（χ^2=22．85,P〈0．001）。从孕前进行保健发生巨大儿、低血糖、畸形儿的新生儿人数小于从孕期开始保健的人数,差异有统计学意义（χ^2=9．64,P=0．02）。结论加强糖尿病孕妇的孕前保健非常重要,行血糖筛查、早期诊断和治疗糖尿病,并及时有效地控制高血糖是减少围产期合并症、改善母儿预后的重要因素。     

A study of assessment of patient safety climate in tertiary care hospitals

Background

Medical errors are being detected with increasing frequency in healthcare environment, in many cases leading to patient harm. Measurement and improvement of patient safety climate has been identified as a strategic effort towards addressing this vital issue.

Method

Safety Attitude Questionnaire (SAQ), validated by previous research was administered to 300 respondents in three tertiary care hospitals of India, the respondents representing various categories of healthcare workers and variations in safety scale score was analyzed by various statistical tools.

Results

No variation was observed in the Patient Safety Index score among the study hospitals. However, significant variations were observed among different categories of healthcare workers across dimensions of Teamwork, Perception of Management and Stress Recognition. Multiple Regression models identified Teamwork and Perception of Management to have significant correlation with Patient Safety Index Score.

Conclusion

Patient Safety Climate can be effectively assessed and such assessment utilized for focused improvement efforts towards safety in healthcare organizations.     

Routine antenatal HIV testing: the responses and perceptions of pregnant women and the viability of informed consent. A qualitative study

This qualitative cross-sectional survey, undertaken in the antenatal booking clinics of a hospital in central London, explores pregnant women's responses to routine HIV testing, examines their reasons for declining or accepting the test, and assesses how far their responses fulfil standard criteria for informed consent. Of the 32 women interviewed, only 10 participants were prepared for HIV testing at their booking interview. None of the women viewed themselves as being particularly at risk for HIV infection. The minority (n = 6) of the participants who declined testing differed from those who accepted, by interpreting test acceptance as risky behaviour, privileging the negative outcomes of HIV positivity and expressing an inability to cope with these, should they occur. Troublingly, only a minority of women (n = 9) had a broad understanding of the rationale for the test, and none fulfilled the standard criteria for informed consent. This study suggests that, although routine screening combined with professional recommendation may be successful in increasing uptake, this may be at the cost of eroding informed consent. Protecting third parties (notably fetuses) from a preventable disease may outweigh the moral duty of respecting autonomy, enshrined in Western bioethical tradition. Nevertheless, such a policy should be made transparent, debated in the public domain and negotiated with women seeking antenatal care.     

Patients' perception of quality of emergency care in a Nigerian teaching hospital: The influence of patient-provider interactions

BACKGROUND: Attention is rarely given to patients' opinions regarding the quality of care they received, which is an important feedback to healthcare providers, planners and policy makers. AIM: To assess how patients who survived life-threatening/emergency conditions percieved the quality of care they received. METHOD: This prospective study was carried out among adult patients who had received emergency care at the Accident & Emergency (A & E) unit of Olabisi Onabanjo University Teaching Hospital (OOUTH), Sagamu, between March and December 2004 using a semi-structured questionnaire. RESULTS: There were 1129 respondents, 81 males and 48 females. Their mean age was 35.3 years. 62% were treated for surgical, and 37.2% for medical emergencies. The mean duration of stay at A & E was 2.4 days. Although 91% of the respondents regarded available equipments as very adequate, 38.8% perceived the overall quality of care as sub-optimal. Many of the patients were displeased with their interactions with care providers. They longed for urgent improvement in waiting time, speed of issuing drugs, imterpersonal relationship with health workers and attending to emotional distress of emergency victims. They also wished to have free treatment during emergencies CONCLUSION: Majority of the patients who received care in A & E of this tertiary hospital perceived the quality of care received as satisfactory. However, a substantial proportion regarded the quality of care as sub-optimal. Although most thought equipments were adequate, many of them expressed displeasure with their interactions with care providers. To improve patient's satisfaction with emergency care, greater emphasis needs to be placed on enhancing the interpersonal relationships between health workers and patients than is currently done.     

General practice and residential aged care: A qualitative study of barriers to access to care and the role of remuneration

Background

More than 169,000 people live in residential aged care facilities (RACFs). As people age they use health services, particularly general practitioner (GP) services, more frequently but many GPs do not attend patients in RACFs.

Aims

To examine GPs’ perceptions of barriers to providing care to patients in RACFs.

Methods

This study was conducted in June 2014 in the Bayside Medicare Local (BML) region in Victoria, Australia; all participants were drawn from this region. Two focus groups (FGs) were conducted. One was for GPs (n=5) that have a specific interest in practicing in RACFs, the other with RACF staff (n=8) representing public, private, and not-for-profit aged care providers. Results were presented to the Royal Australian College of General Practitioners (RACGP) National Standing Committee for General Practice Advocacy and Support for feedback and validation of the findings against national perspectives of the effect of remuneration on the provision of GP services in RACFs.

Results

Remuneration problems are a barrier to the provision of GP services to patients in RACFs. These problems can be grouped into: direct remuneration, opportunity cost, additional administrative burden, and unremunerated work. GPs’ perceptions of the effects of these problems on willingness to practice in RACFs are described.

Conclusion

Innovative models of remuneration for GPs attending RACFs are needed to ameliorate the problems identified. Such models need to capture and pay for activities that are time consuming but often unremunerated.     

A tale of two cities - oesophageal cancer in Malawi and Scotland

The high incidence of oesophageal cancer in both Scotland and Malawi can be attributed to a combination of environmental and lifestyle factors. The aim of this study is to give a perspective on the comparative epidemiology of oesophageal cancer in these two very different populations (Blantyre, Malawi and Aberdeen, Scotland).     

中医医院医疗质量的监测及医院效益评价研究

通过2001年63家中医医院医疗质量监测的现况调查,对监测中医院的资源配备、经济运营、工作效率、工作效益进行了分析,并对如何发展中医医院提出建议.     

Environmental risk factors for oesophageal cancer in Malawi: A case-control study

Aim

There is a high burden of oesophageal cancer in Malawi with dismal outcomes. It is not known whether environmental factors are associated with oesophageal cancer. Without knowing this critical information, prevention interventions are not possible. The purpose of this analysis was to explore environmental factors associated with oesophageal cancer in the Malawian context.

Methods

A hospital-based case-control study of the association between environmental risk factors and oesophageal cancer was conducted at Kamuzu Central Hospital in Lilongwe, Malawi and Queen Elizabeth Central Hospital in Blantyre, Malawi. Ninety-six persons with squamous cell carcinoma and 180 controls were enrolled and analyzed. These two groups were compared for a range of environmental risk factors, using logistic regression models. Unadjusted and adjusted odds ratios and 95% confidence intervals (CI) were calculated.

Results

Firewood cooking, cigarette smoking, and use of white maize flour all had strong associations with squamous cell carcinoma of the oesophagus, with adjusted odds ratios of 12.6 (95% CI: 4.2–37.7), 5.4 (95% CI: 2.0–15.2) and 6.6 (95% CI: 2.3–19.3), respectively.

Conclusions

Several modifiable risk factors were found to be strongly associated with squamous cell carcinoma. Research is needed to confirm these associations and then determine how to intervene on these modifiable risk factors in the Malawian context.