Implementing recommendations arising from confidential enquiries into maternal deaths

Implementing recommendations is a complex process involving all levels of health care. Effecting change in the health system can be broadly divided into four areas: policy, administration, clinical practice and training. Changes at the policy level require advocacy by lobby groups, as these changes are mainly political in nature. Changes at administrative level require a diversion of resources, and a clear policy framework must be in place within which the health administrator can work. Changes to clinical practice refer mainly changes in protocols of managing patients. The essential elements to change clinical practice include on-site, face-to-face teaching by a senior clinician; ineffective methods are lectures and memorandums on guidelines for practice posted to clinicians. Training refers to ensuring there are appropriate curricula for healthcare workers. Recommendations should also be phrased in such a way that targets can be established. These targets should be measurable and then be measured.     

Office Falloposcopy; a Tertiary Level Assessment for Planning the Management of Infertile Women

Summary: Thirty-nine women underwent Falloposcopic examination utilizing the linear eversion catheter. Indications for examination included bilateral and unilateral proximal and distal tubal occlusive disease, assessing the residual Fallopian tube after salpingectomy for ectopic pregnancy, and unexplained infertility. Seventy-three Fallopian tubes were available for examination, of which 72 (98.6%) were successfully cannulated. Sixty-eight ampullas were successfully visualized (94.4%). The mean duration of the examination was 24.7 minutes. Where proximal tubal disease was not suspected, 30.3% of oviducts were found to have a proximal lesion and 57.5% were found to have distal intratubal disease. Management was changed in 24 women (61.5%) on the basis of Falloposcopic information. These data demonstrate the clinical value of Falloposcopy.     

Peripheral pulmonary lesions: ultrasonography and ultrasonically guided aspiration biopsy

Twenty-five patients, each of whom had peripheral intrathoracic lesions that were smaller than 5.0 X 5.0 cm in size and not diagnosed by conventional methods, underwent real-time sonography and ultrasonically guided aspiration biopsy. The lesions included 18 nodules, two infiltrates, and five cavitary lesions. Sonography showed homogeneous hypoechoic or isoechoic density with well-defined margins in 16 of the nodules, and heterogeneous echogenicity with irregular margins in infiltrates. The cavitary lesions showed a hyperechoic ring with a central sonolucent area. Biopsy specimens were successfully obtained by percutaneous aspiration under ultrasound guidance in 24 (96%) of the patients, and a positive diagnosis was established in 21 (84%) by cytology and/or histology. All 17 malignant lesions were diagnosed by aspiration biopsy, while only four of seven benign lesions were diagnosed by this method. Two patients (8%) experienced minimal pneumothorax after aspiration biopsy. We conclude that real-time sonography, including ultrasonically guided aspiration biopsy, is a useful and safe method for examination of peripheral intrathoracic lesions and has a high diagnostic yield.     

Saving children--an audit system to assess under-5 health care.

OBJECTIVE: To develop and pilot an audit system usable by medical officers in peripheral hospitals for deaths of children under 5 years to: (i) identify and classify all causes of deaths; and (ii) to identify substandard care and missed opportunities for intervention and to classify these as modifiable factors. SETTING: The four public sector hospitals in Mafikeng health region in North West province. METHOD: An action research methodology was used. The system for classifying under-5 deaths was based on the International Classification of Diseases 10 (ICD-10), but modified for practical application in peripheral hospitals. Each death was analysed at a mortality meeting and factors related to the family, administration or actions or omissions by health care workers that could have contributed to the death were recorded. These factors were later grouped and categorised. During the last month of the pilot participating health care workers evaluated the audit system and completed a semi-structured questionnaire. STUDY PERIOD: 1 November 2000-31 October 2001. RESULTS: Two hundred and thirty-nine under-5 deaths occurred and were discussed during 61 mortality meetings. A workable system to identify and classify causes of deaths and modifiable factors occurring within the health system was developed and tested. A simple, user-friendly one-page data sheet encompassing the whole audit was developed. Overall the health care workers were positive about the mortality meetings and were confident that the classification systems developed could be applied in other peripheral hospitals. CONCLUSION: The audit system (called the Under-5 Health Care Problem Identification Programme (U5PIP)), was piloted under normal service conditions and is usable and acceptable for peripheral hospitals.     

Measuring implementation progress in kangaroo mother care

Aim: To describe the development and testing of a monitoring model with quantitative indicators or progress markers that could measure the progress of individual hospitals in the implementation of kangaroo mother care (KMC). Methods: Three qualitative data sets in the larger research programme on the implementation of KMC of the MRC Research Unit for Maternal and Infant Health Care Strategies in South Africa were used to develop a progress-monitoring model and an accompanying instrument. Results: The model was conceptualized around three phases (pre-implementation, implementation and institutionalization) and six constructs depicting progress (awareness, adopting the concept, mobilization of resources, evidence of practice, evidence of routine and integration, sustainable practice). For each construct, indicators were developed for which data could be collected by means of the monitoring instrument used in a walk-through visit to a hospital. The instrument has been tested in 65 hospitals.

Conclusion: The progress-monitoring model enables the quantification of individual hospitals' progress in the process of implementing KMC and an objective measurement of the effectiveness of different outreach strategies. The model also has potential to be adapted for measuring progress in other innovative healthcare interventions on a large scale.     

What does cerebral oximetry measure?

Editor—We feel that the recent paper by Yoshitani andcolleagues¹ raises important issues. They demonstrated that,in patients undergoing elective hip arthroplasty, normovolaemichaemodilution caused no change in jugular bulb saturations () but decreased cerebral saturations () when measured with a cerebral oximeter (INVOS 4100S). Two explanationswere offered for the unexpected disparity in readings. First,they postulated that subtle changes     

Are deaths due to prematurity avoidable in developing countries?

Our aim was to assess the potential for reducing the perinatal mortality rate (PNMR) related to spontaneous preterm delivery. Data from 44 Perinatal Problem Identification Program sentinel sites around South Africa were used. In each perinatal death the primary cause as well as missed opportunities and substandard care were discussed and allocated. 3045 perinatal deaths in 78,343 births of > or = 1000 g were analysed. There were 518 perinatal deaths (17%) whose primary obstetric cause of death was due to spontaneous preterm labour (PNMR 7.48/1000 births). The most common avoidable factors were delay in seeking help during labour (14.7%), lack of neonatal facilities (10.0%), lack of transport (7.3%) and inappropriate response to the presence of premature rupture membranes (4.6%). Few perinatal deaths could be ascribed to poor antenatal or intrapartum management of spontaneous preterm labour. The vast majority of spontaneous preterm births could not be prevented within the health institutions. Prevention of deaths due to prematurity outside of metropolitan areas will rely on the neonatal care being adapted to reduced resources.     

Cryptorchidism: A general surgical perspective

Background The treatment of cryptorchidism has changed, with surgery now advocated before the age of two years. Delayed treatment affects fertility, malignant potential and psychological stress. Aims To assess the pattern of referral of cryptorchid patients to a surgical clinic, management and follow-up. Methods A four-year review of 114 cryptorchid patients examined age at presentation, waiting time, timing of surgery and length of follow-up. Results The mean age at presentation to the surgical clinic was 6.7 years (neonatal to 71). The mean age at orchidopexy was 5.6 years. Seventy per cent had a surgical procedure within eight weeks of presentation to a surgeon. Seven per cent were kept under surveillance until a maximum age of three years before orchidopexy was considered. Only 29% proceeded to surgery before the age of two. Seventeen were referred to a paediatric urology unit for further management. Conclusions Orchidopexy seems prudent between one and two years of age. Only one-quarter of patients underwent early orchidopexy. It is vital that it is detected early, by paediatricians at birth or the general practitioners (GPs) at the six-week check up. Prompt referral to a surgeon with a paediatric interest is essential in order to permit surveillance or surgery.