Acute myocardial infarction at a district hospital in KwaZulu-natal ­ management and outcomes

Acute myocardial infarction (AMI) following ischaemic heart disease (IHD) is associated with increased morbidity and mortality. The condition remains a management challenge in resource-constrained environments. This study analysed the management and outcomes of patients presenting with AMI at a district hospital in KwaZulu-Natal. Methods: A descriptive study that assessed hospital records of all patients diagnosed with AMI over a 2-year period (01 August 2016 to 31 July 2018). Data extracted recorded patient demographics, risk factors, timing of care, therapeutic interventions, follow up with cardiology and mortality of patients. Results: Of the 140 patients who were admitted with AMI, 96 hospital records were analysed. The mean (standard deviation [s.d.]) age of patients was 55.8 (±12.7) years. Smoking (73.5%) and hypertension (63.3%) were the most prevalent risk factors for patients with ST elevation myocardial infarction (STEMI) in contrast to dyslipidaemia (70.2%) and hypertension (68.1%) in patients with non-ST elevation myocardial infarction (NSTEMI). Almost 49.5% of patients arrived at hospital more than 6 h after symptom onset. Three (12.5%) patients received thrombolytic therapy within the recommended 30-min time frame. The mean triage-to-needle time was 183 min ­ range (3; 550). Median time to cardiology appointment was 93 days. The in-hospital mortality of 12 deaths considering 140 admissions was 8.6%. Conclusion: In a resource-constrained environment with multiple systemic challenges, in-hospital mortality is comparable to that in private sector conditions in South Africa. This entrenches the role of the family physician. There is need for more coordinated systems of care for AMI between district hospitals and tertiary referral centres.

COVID-19 and diabetic ketoacidosis: A case series at an urban district hospital in South Africa

Coronavirus disease 2019 (COVID-19) is associated with an increased prevalence and mortality from diabetic ketoacidosis (DKA) globally. With limited access to specialised care, most patients with DKA in South Africa are managed at district hospital level. This study describes the profile of patients admitted to a district hospital in South Africa with DKA and COVID-19 and examines associated risk factors encountered. Methods: This was a case series of all patients presenting to a district hospital with DKA and COVID-19 infection between July 2020 and July 2021. Data extracted included patients' demographic profiles, biochemical results, comorbidities and clinical outcomes. Results: The median age of the 10 patients admitted during the study period was 39 years old (±12), six of whom were male. The hemoglobin A1c (HbA1c) values on admission ranged from 9.7 to 13.8. Five of the patients had pre-existing type 2 diabetes mellitus (DM). Four of the known DM patients were on metformin only, and one was on biphasic insulin. Three patients had other pre-existing comorbidities, two patients with hypertension and one with human immunodeficiency virus (HIV). Three patients demised, two of whom were hypoxic on admission. Conclusion: Diabetic ketoacidosis appears more commonly in COVID-19 infected patients with type 2 DM and at a young age. Suboptimal glycaemic control was associated with DKA, and hypoxia was a strong predictor for mortality. Treatment inertia was evident in the known DM group, who were on monotherapy despite persistent hyperglycaemia. Greater vigilance is required to detect ketosis in type 2 DM and intensify therapy to improve glycaemic control.

Newly implemented community CD4 service in Tshwaragano, Northern Cape province, South Africa, positively impacts result turn-around time

Background: The Northern Cape is South Africa's largest province with an HIV prevalence of 7.1% versus a 13.5% national prevalence. CD4 testing is provided at three of five National Health Laboratory Service district laboratories, each covering a 250 km precinct radius. Districts without a local service report prolonged CD4 turn-around times (TAT).Objective: This study documented the impact of a new CD4 laboratory in Tshwaragano in the remote John Taolo Gaetsewe district of the Northern Cape, South Africa.Methods: CD4 test volumes and TAT (total, pre-analytical, analytical, and post-analytical) data for the Northern Cape province were extracted for June 2018 to October 2019. The percentage of CD4 results within the stipulated 40-h TAT cut-off and the median and 75th percentiles of all TAT parameters were calculated. Pre-implementation, samples collected at Tshwaragano were referred to Kimberley or Upington, Northern Cape, South Africa.Results: Pre-implementation, 95.4% of samples at Tshwaragano were referred to Kimberley for CD4 testing (36.3% of Kimberley's test volumes). Only 7.5% of Tshwaragano's total samples were referred post-implementation. The Tshwaragano laboratory's CD4 median total TAT decreased from 24.7 h pre-implementation to 12 h post-implementation (p = 0.003), with >95.0% of results reported within 40 h. The Kimberley laboratory workload decreased by 29.0%, and testing time significantly decreased from 10 h to 4.3 h.Conclusion: The new Tshwaragano CD4 service significantly decreased local TAT. Upgrading existing community laboratories to include CD4 testing can alleviate provincial service load and improve local access, TAT and efficiency in the centralised reference laboratory

Emergency centre reorganization in preparation to the COVID-19 pandemic: A district hospital's dynamic adaptation response

The COVID-19 global pandemic forced healthcare facilities to put special isolation measures in place to limit nosocomial transmission. Cohorting is such a measure and refers to placing infected patients (or under investigation) together in a designated area. This report describes the physical reorganisation of the emergency centre at Khayelitsha Hospital, a district level hospital in Cape Town, South Africa in preparation to the COVID-19 pandemic. The preparation included the identification of a person under investigation (PUI) room, converting short stay wards into COVID-19 isolation areas, and relocating the paediatric section to an area outside the emergency centre. Finally, we had to divide the emergency centre into a respiratory and non-respiratory side by utilising part of the hospital's main reception. We are positive that the preparation and reorganization of the emergency centre will limit nosocomial transmission during the expected COVID-19 surge. Our experience in adapting to COVID-19 may have useful implications for ECs throughout South Africa and in low-and-middle income countries that are preparing for this pandemic

The experiences of teleradiology end users regarding role extension in a rural district of the North West province: a qualitative analysis

Background: Teleradiology was implemented across South Africa, to provide reporting services to rural healthcare institutes without a radiologist. This is guided by standard operating procedure manuals (SOP) which standardise the quality of services provided. From observation, end users, namely, the radiographer and referring clinician, experience challenges in fulfilling the roles extending beyond the SOP. Aim: To explore the end users' experiences within this context and the impact it has on service delivery. Setting: A rural district in North West province, South Africa. Method: This was a qualitative, exploratory, descriptive study. Focus group discussions were held with radiographers and referring clinicians from the teleradiology site in the North West province. A one-on-one interview was conducted with a private radiologist at the reporting site in Gauteng. An interview guide was used to ask open-ended questions to address the aim of the study. Results: At the teleradiology site, radiographers and referring clinicians are performing extended roles, not described in the teleradiology service-level agreement (SLA) and felt poorly equipped to fulfil these roles. They also felt that the private radiologists needed training on interprofessional collaboration to understand the challenges facing health professionals at these rural sites. Conclusion: SLA's should align with the clinical needs and practices of the district. This should guide the specific training needs of the end users practicing in rural areas, to support their extended roles in the teleradiology setting. Training should be in-house, ongoing and consistent to cater for the influx of health professionals entering the rural setting using teleradiology systems

Knowledge and utilization of non-pneumatic anti-shock garment for the management of postpartum hemorrhage among midwives in government hospitals in Ogun State, Nigeria

Objective: To assess the knowledge and determine the level of utilization of Non-Pneumatic Anti-Shock Garment (NASG) for the management of PPH among Midwives.Method: The study employed a descriptive cross-sectional study design, using a validated self-administered questionnaire. A total of 198 randomly selected midwives across three health facilities in Ogun State participated in the study. A 10-point knowledge scale was used to assess the knowledge of midwives on NASG. Descriptive statistics were used to determine the level of utilization of NASG among midwives, while Chi-square statistics were used to determine the relationship between the dependent and independent variables of interest at p<0.05 level of significance.Results: Most (88.9%) of the respondents were female with a mean age of 40.2±5.6years. Most (48.5%) had a BNS degree. The majority (74.7%) of the respondents were aware of NASG. Close to a half (49.3%) of the respondents had fair knowledge scores, 34.5% had good knowledge scores, while 16.2% had poor knowledge scores. Only 22.7% of the respondents had ever used NASG in the management of PPH; 77.3% never used it before. Also, 67.2% of the respondents reported NASG was not available in their facilities. There was a significant influence of knowledge of NASG on the utilization among midwives (X2=37.151, P<0.05, df=2).Conclusion: This study demonstrated that midwives in healthcare facilities were aware, but did not have good knowledge of NASG. The utilization of the garment for the management of PPH was also very poor, probably due to suboptimal knowledge and non-availability of the garment

Factors influencing risky sexual behaviours of HIV-infected people on first-line antiretroviral therapy in Kigeme District Hospital, Rwanda: A cross-sectional study

INTRODUCTION: Evidence suggests that improved quality of life that follow antiretroviral therapy (ART) may be accompanied by increased sexual activity and risky sexual behaviour. Thus, this study aimed to determine the proportion of HIV infected people on first line ART who were sexually active, the prevalence of risky sexual behaviour defined as unprotected vaginal sex and factors influencing risk sexual behaviour among HIV-infected people on first -line ART in Kigeme District Hospital. METHODS: A cross-sectional study with a quantitative survey method was conducted among 358 HIV infected people on first line ART and an adopted structured questionnaire was used for data collection. STATA version 13 was used for data analysis and binary logistic regression was used to obtain adjusted odd ratio (AOR) with a 95% CI. RESULTS: Findings revealed that 68% of respondents were sexually active in the last 12 months of the interview and the prevalence of risky sexual behaviour among HIV infected people on the first line ART was 38%. Risky sexual behaviour was found to be significantly associated with age range of 30-40 year olds (AOR: 2.468, 95%CI: 1.007-2.046, P=0.048), having sex with HIV-positive partner ( AOR: 2.830, 95%CI: 1.351-5.928, P=0.006) and alcohol use prior to sexual activity (AOR: 2.347, 95%CI: 1.216-4.528, P=0.011). CONCLUSION: The majority of HIV infected people receiving the first-line ART are sexually active and the prevalence of risky sexual behaviour is significant hence effort should be put forth to target this group. Reinforcing behaviour change communication and discouraging alcohol use among HIV infected people receiving the first-line ART is recommended

A comprehensive district-level laboratory intervention after the ebola epidemic in Sierra Leone

Background: The 2014­2016 Ebola outbreak exposed the poor laboratory systems in Sierra Leone. Immense needs were recognised across all areas, from facilities, diagnostic capacity, supplies, trained personnel to quality assurance mechanisms.Objective: We aimed to describe the first year of a comprehensive intervention, which started in 2015, in a public hospital's general laboratory serving a population of over 500 000 in a rural district.Methods: The intervention focused on (1)supporting local authorities and healthcare workers in policy implementation and developing procedures to enhance access to services, (2) addressing gaps by investing in infrastructure, supplies, and equipment, (3) development of quality assurance mechanisms via mentorship, bench-side training, and the introduction of quality control and information systems. All work was performed alongside counterparts from the Ministry of Health and Sanitation.Results: We observed a strong increase in patient visits and inpatient and outpatient testing volumes. Novel techniques and procedures were taken up well by staff, leading to improved and expanded service and safety, laying foundations for further improvements.Conclusion: This comprehensive approach was successful and the results suggest an increase in trust from patients and healthcare workers

Contribution of the Nelson R. Mandela School of Medicine to a socially accoun table health workforce

Background: A socially accountable health professional education curriculum aims to produce fit-for-purpose graduates to work in areas of need. 'Fit-for-purpose' can be assessed by monitoring graduate practice attributes. Aim: The aim of this article was to identify whether graduates of 'fit-for-purpose' programmes are socially accountable. Setting: The setting for this project was all 37 district hospitals in the KwaZulu-Natal province in Durban, South Africa. Methods: We surveyed healthcare professionals working at district hospitals in the KwaZulu-Natal province. We compared four social accountability indicators identified by the Training for Health Network Framework, comparing medical doctors educated at the Nelson R. Mandela School of Medicine (NRMSM) with medical doctors educated at other South African and non-South African medical schools. In addition, we explored medical doctors' characteristics and reasons for leaving or staying at district hospitals. Results: The pursuit of specialisation or skills development were identified as reasons for leaving in the next 5 years. Although one-third of all medical doctors reported an intention to stay, graduates from non-South African schools remained working at a district hospital longer than graduates of NRMSM or other South African schools and they held a majority of leadership positions. Across all schools, graduates who worked at the district hospital longer than 5 years cited remaining close to family and enjoyment of the work and lifestyle as motivating factors.Conclusion: Using a social accountability approach, this research assists in identifying areas of improvement in workforce development. Tracking what medical doctors do and where they work after graduation is important to ensure that medical schools are meeting their social accountability mandate to meet community needs

A self-assessment study of procedural skills of doctors in peri-urban district hospitals of Gauteng, South Africa

Background: Several studies have been carried out on procedural skills of doctors in district hospitals in rural South Africa. However, there is insufficient information about skills of doctors in peri-urban district hospitals. This paper attempts to supplement this vital information. Aim: The aim of the study was to determine self-reported levels of competence in procedural skills of doctors in peri-urban district hospitals and to assess factors influencing this. Setting: The study was undertaken in three district hospitals in two health districts of Gauteng Province. Methods: A cross-sectional descriptive study using a self-administered questionnaire was undertaken in three district hospitals in two health districts of Gauteng Province. The questionnaire assessed procedural skills based on district health service delivery requirements for doctors in district hospitals using a modified skill set developed for family medicine training in South Africa. Results: There was a wide range of self-reported competence and experience among doctors for various skill sets. Doctors were generally more competent for procedures in general surgery, medicine, orthopaedics, obstetrics and gynaecology and paediatrics than anaesthesia, ear, nose and throat and ophthalmology. There were statistically significant associations between age and overall anaesthetic competence (p= 0.03); gender and overall competence in surgery (p= 0.03), orthopaedics (p= 0.02) and urology (p= 0.005); years of experience and overall competence in dermatology skills; current hospital and overall competence in anaesthesia (p= 0.01), obstetrics and gynaecology (p= 0.015) and dermatology skills (p= 0.01). Conclusion: This was one of the first studies to look at self-reported procedural competence of doctors in a peri-urban setting in South Africa. The results highlight the need for regular skills audits, standardised training and updating of skills of doctors in district hospitals

Triage conducted by lay-staff and emergency training reduces paediatric mortality in the emergency department of a rural hospital in Northern Mozambique

Introduction The majority of emergency paediatric death in African countries occur within the first 24 h of admission. A coloured triage system is widely implemented in high-income countries and the emergency triage and assessment treatment (ETAT) is recommended by the World Health Organization, but not put into practice in Mozambique. A retrospective, before and after, mortality analysis was performed using routine patient files from the district hospital between 2014 and 2017. The triage system was implemented in August 2016. Inclusion criteria were children under 15 years of age that entered the emergency centre. Primary outcome was child mortality rate. Secondary outcomes included the percentage agreement between the clinical and non-clinical staff and the duration from triage to first treatment. We used a negative binomial model in STATA 15 to compare mortality rates, and Kappa statistics to estimate the agreement between clinical and non-clinical staff. Results : 4176 admissions were included. The mortality rate ratio (MMR) was 45% lower after the start of the intervention (2016; MRR = 0.55; 0.38, 0.81; p = 0.002), compared to before. To estimate the agreement between non-clinical and clinical staff, 548 (of the 671) patient files were included. The agreement was estimated at 88.7% (Kappa = 0.644; p < 0.001). The median waiting time decreased with urgency of the triage: 2 h33 for 'green'/least serious (IQR 1 h58-3 h30), 21 min for yellow/serious (IQR 0 h10-0 h58) and nine minutes for 'red'/urgent (IQR 2­40 min). Conclusion : In a rural setting with nurse-led clinical care and non-clinician staff working at the triage reception, implementation of a three-coloured triage system was feasible. Triage and ETAT training was associated with a decrease of 45% of paediatric deaths. The impact on mortality, low cost, and ease of the implementation supports scaling this intervention in similar settings

Difficulties of unit managers in selected district hospitals in Cameroon

Background: Being appointed to a managerial position because of one's clinical skills seems to be prestigious, even powerful. However, being a unit manager in a resource-constrained district hospital can be a daunting task. Also, managing a ward unit with no previous training in leadership and management can be very challenging.Objectives: The purpose of this study was to describe the difficulties, in the day-to-day activities, of unit managers in selected Cameroonian district hospitals.Method: A constructionist, descriptive Husserlian phenomenological inquiry was conducted to describe the difficulties of unit managers in two district hospitals. Ten unit managers were selected through a purposive sampling scheme, and then interviewed using semi-structured interviews. Coliazzi's qualitative data analysis method was used for analysis.Results: This study revealed that unit managers looked for assistance because it is not easy to be in their position. Their role implied facing difficulties and making sacrifices for something that is not even worth the trouble. Therefore, as a way to overcome their difficulties, they asked for assistance from the organisation, from their families and from God as strategies to face their difficulties.Conclusion: The difficulties faced by unit managers in the selected district hospitals revealed the need to prepare nurses for managerial positions by ensuring they are trained as managers before commencing employment as a manager

Prevalence and determinants of self-directed referrals amongst patients at hospitals in eThekwini District, KwaZulu-Natal 2015

Background: Non-compliance with designated referral pathways has ramifications such as increased patient waiting time,overburdening of higher levels of care and increasing healthcare costs on patients and the healthcare system. The purposeof this study was to assess the determinants of self-directed referrals amongst patients attending hospitals in the eThekwini district of KwaZulu-Natal.Methods: An analytic, cross-sectional study was conducted at the Medical Outpatient Departments across five district hospitals in eThekwini using interviewer-administered questionnaires. Descriptive statistics were used to determine the proportion and the most frequent factors contributing towards patient self-referral. The likelihood of patients to self-refer was tested using chisquare (X2) and a multivariate regression model.Results: There were 315 patients interviewed with 35% (n = 109/315) having self-referred. The majority (51%; 55/107) of selfreferrals were male and were of African race (74%; n = 80/107). Five institutional factors, namely:availability of medication at the pharmacy (98%); quality of care at the facility (93%); waiting time at facility (92%); services provided (90%); and attitude of healthcare workers (87%), were ranked as the main drivers of self-referral. Multivariate logistic regression established a significant positive association between patient self-referral and male gender (OR 1.73; CI 1.04­2.87, p < 0.05). Age < 39 years (OR 0.96; CI 0.94­0.99, p < 0.05); and patient awareness of a referral letter (OR 0.28; CI 0.09­0.86, p < 0.05) emerged as protective factor against self-referrals.Conclusion: Males patients tend to bypass the referral pathway whilst younger patients and patients who were aware of a referral letter were less likely to bypass the referral system. In addition to addressing the systemic challenges of waiting times, quality of care and availability of medication, a patient-oriented approach that comprises education, encouragement and increased patient awareness is an important strategy to improve referral pathway compliance

Knowledge and practice of pregnant women and health care workers on hepatitis B prevention in the Limbe and Muyuka health districts of the south west region of Cameroon

Introduction: hepatitis B virus (HBV) infection is a major health problem worldwide owing to its high prevalence and significant morbidity and mortality. There are about 2 billion people living with HBV worldwide and over 360 million chronic carriers. The purpose of this study was to assess the knowledge and practices of pregnant women and health care workers in the ANC and maternity units on HBV infection and its transmission.Methods: about 270 women attending ANC and 31 health care workers were selected by convenience sampling. They were evaluated using a structured questionnaire to assess their knowledge and practices on HBV prevention and transmission. Results: pregnant women in the Limbe Health District demonstrated good knowledge but adopted poor practices whereas in the Muyuka Health District, pregnant women demonstrated poor knowledge and adopted poor practices regarding the mode of transmission and prevention of HBV infection. Health care workers in both the Limbe and Muyuka Health Districts however, demonstrated good knowledge and adopted good practices.Conclusion: there was a significant relationship between the knowledge and practice of pregnant women and health care workers on Hepatitis B prevention in the Muyuka Health District (P = 0.0006)

Point-of-care utrasound use over six-month training period in Rwandan district hospitals

Introduction: Point-of-care ultrasound (POCUS) is an effective diagnostic technology in resource-limited settings. There is increasing interest in introducing ultrasound training in such environments, but few reports describing long-term follow-up and impact of a POCUS program in a resource-limited setting. We introduced a POCUS program in Rwanda, and sought to determine the number and type of ultrasounds performed, the impact of a remote quality assurance (QA) program, and the effect of POCUS on patient management. Methods: Seventeen Rwandan physicians underwent a ten-day training course in POCUS in Kigali, Rwanda. Post-course, participants tracked the ultrasounds they performed using a cloud-based storage system, recorded clinical impressions,and received periodic QA with on-site proctoring over a six-month follow-up. Remote QA to evaluate image quality was performed by five emergency ultrasound fellowshiptrained clinicians. Images were graded on a scale of 0­4. (0=no meaningful image, 2= adequate, 4= outstanding). Trainees also documented how POCUS changed clinical management. Results: Over six months, 1158 ultrasounds were performed and logged by fifteen participants at eleven regional hospitals. 590(50.9%) had matched images and interpretations available for review. Abdominal ultrasound was the most frequently performed application (19.7%), followed by liver (14.6%), obstetrics (14.5%), renal (12.4%),and spleen (11%). Across all applications, the mean score was 2.5 (SD± 0.11, 95% confidence interval, 2.39­2.54). Ultrasound result in a management change in 84% of cases. Major changes in management related to medication choice (42.4%), admission (30%), transfer to a higher level of care (28.1%), and performance of procedures (23.3%). Conclusions: During this six-month training program in Rwanda, participants used POCUS for a range of applications. The remote QA process captured 51% of ultrasounds performed. Of scans with QA, the average score was adequate to good. POCUS routinely changed clinical management. This study demonstrates the impact of POCUS in a resource-limited setting