The cost of time: A randomised, controlled trial to assess the economic impact of upfront, point-of-care blood tests in the Emergency Centre

Introduction Time and cost constraints abound in the Emergency Centre (EC). These resource-constraints are further magnified in low- and middle-income countries (LMIC). Almost half of all patients presenting to the EC require laboratory tests. Unfortunately, access to laboratory services in LMIC is commonly inadequate. Point-of-Care (POC) tests may assist to avert this shortcoming. The aims of this study were to evaluate the cost effectiveness of upfront POC blood tests performed prior to doctor assessment compared to the standard EC workflow.Methods A secondary analysis was performed on data from a prospective, randomised, controlled trial where patients with abdominal/chest symptoms or generalised body pain/weakness followed either the normal EC workflow pathway or one of two enhanced workflow pathways with POC tests (i-STAT with and without a complete blood count (CBC)) prior to doctor evaluation. The incremental cost effectiveness ratio (ICER) was used to perform the cost effectiveness analysis.Results :There were 248 patients enrolled in the study. The use of the two upfront, POC test pathways significantly exceeded the primary outcome measure of a 20% reduction in treatment time. In the i-STAT + CBC group, the 31 min. time-saving translated into cost-saving of US$14.96 per patient (IECR 0.27) whereas the 21 min. time-saving in the i-STAT only group only had an additional net cost of US$3.11 per patient (IECR 0.90).Conclusion Upfront, POC blood tests can be utilised in the resource-constrained EC to manage patients more efficiently by saving time. This time-saving can, in fact, be more cost effective than traditional EC workflow making it an economically viable option for implementation in LMIC

The role of diffusion-weighted and fluid attenuated inversion recovery magnetic resonance imaging in diagnosis and timing of acute ischemic stroke

Background: Ischemic stroke causes serious long-term disability and a great number of economic losses. Thrombolytic therapy is used only if the time of stroke onset was <4.5 hours. However, new categories such as wake-up and day un-witnessed strokes, patients unable to tell exact time of last seen well. The importance of study is to use diffusion weighted/Fluid attenuated inversion recovery (DWI/FLAIR) mismatch as a radiological marker which can help to identify patients with lacunar and non-lacunar stroke within 4.5 hours of onset and use it to determine whether patients with unknown onset stroke qualify for thrombolytic therapy or not. Patients and methods: prospective cohort study was conducted on 72 patients with known time of symptoms onset, imaged within 24 hours from stroke onset. Patients underwent the admission Computed tomography CT and magnetic resonance scans (DWI and FLAIR only) with time gap was no longer than one hour. The presences of lesions in the neuroradiological modalities were assessed in correlation with the duration of the stroke.Results: The time from stroke onsetto neuroimaging was significantly shorter with ischemic lesions visible in DWI/FLAIR mismatch group when compared to other modalities. The DWI/FLAIR was characterized by global specificity 100%, sensitivity 91.9%, PPV 100% and NPV 92.1%. It succeeded to diagnose 12 patients with lacunar stroke before 4.5 hours from the stroke onset.Conclusion: The presence of acute ischemic lesions only in DWI/FLAIR mismatch group can help to identify both lacunar and non-lacunar stroke patients who are within 4.5 hours' time window for intravenous thrombolysis

Delay to diagnosis and breast cancer stage in an urban South African breast clinic

Background. Breast cancer is the most common cancer in women in many low- and middle-income countries, and often presents at an advanced stage that affects prognosis irrespective of the care available. Although patient-related delay is commonly cited, the reasons for delay and the relationship of delay to stage are still poorly documented, especially in Africa. Objectives. To identify where patient-related socioeconomic delays occur and how these relate to stage at presentation. Methods. Consecutive women with a new breast cancer diagnosis were prospectively invited to complete a questionnaire on their socioeconomic characteristics and ability to access care. Clinical stage at presentation was documented. Results. Over 14 months, 252 women completed the questionnaire (response rate 71.6%). Their median age was 55 years (interquartile range 44 - 65), with 26.5% aged <45 years. Stage at presentation was stage 1 in 15.5% of patients, stage 2 in 28.5% and stage 3 in 56.0%. Almost a third of the patients (30.4%) presented with a T4 tumour (6.1% inflammatory). Total delay in presenting to the breast clinic was significantly associated with locally advanced stage at presentation (p=0.021). Average delay differed between early stage (1.5 months) and locally advanced (2.5 months), and most delay occurred between acknowledging a breast symptom and seeking care. The least delay was between attending a health service and presenting at the open-access breast clinic, with 75.0% presenting within 1 month. Factors associated with delay were difficulties with transport, low level of education and fear of missing appointments due to work. Conclusions. Most women delayed in seeking breast care. Facilitating direct access to specialist breast clinics may reduce delays in presentation and improve time to diagnosis and care

The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town

Introduction:Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa.Methods:The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients' folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher's Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant.Results:The majority of patients were 19­44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09).Discussion:Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate.African relevance

The association between hospital arrival time, transport method, prehospital time intervals, and in-hospital mortality in trauma patients presenting to Khayelitsha Hospital, Cape Town

Introduction:Trauma is a leading cause of unnatural death and disability in South Africa. The aim of the study was to determine whether method of transport, hospital arrival time or prehospital transport time intervals were associated with in-hospital mortality among trauma patients presenting to Khayelitsha Hospital, a district-level hospital on the outskirts of Cape Town, South Africa.Methods:The Khayelitsha Hospital Emergency Centre database was retrospectively analysed for trauma-related patients presenting to the resuscitation area between 1 November 2014 and 30 April 2015. Missing data and additional variables were collected by means of a chart review. Eligible patients' folders were scrutinised for hospital arrival time, transport time intervals, transport method and in-hospital mortality. Descriptive statistics were presented for all variables. Categorical data were analysed using the Fisher's Exact test and Chi-square, continuous data by logistic regression and the Mann Whitney test. A confidence interval of 95% was used to describe variance and a p-value of <0.05 was deemed significant.Results:The majority of patients were 19­44 year old males (n = 427, 80.3%) and penetrating trauma the most frequent mechanism of injury (n = 343, 64.5%). In total, 258 (48.5%) patients arrived with their own transport, 254 (47.7%) by ambulance and 20 (3.8%) by the police service. The arrival of trauma patients peaked during the weekend, and was especially noticeable between midnight and six a.m. In-hospital mortality (n = 18, 3.4%) was not significantly affected by transport method (p = 0.26), hospital arrival time (p = 0.22) or prehospital transport time intervals (all p-values >0.09). Discussion:Method of transport, hospital arrival time and prehospital transport time intervals did not have a substantially measurable effect on in-hospital mortality. More studies with larger samples are suggested due to the small event rate

Evaluation du temps de transit colique par l'utilisation des marqueurs radio-opaques chez le noir africain

Contexte. La constipation est l'un des motifs les plus frequents en consultation de pathologie digestive en Cote d'Ivoire. L'exploration de la constipation releve de plusieurs methodes. Parmi celles-ci; la mesure du temps de transit colique par l'utilisation de marqueurs radio-opaques constitue une alternative interessante pour nos pays. Elle permet de quantifier le ralentissement colique; d'en preciser la nature et le siege. Le but de ce travail etait d'etablir les normes du temps de transit colique chez l'africain sain et chez le sujet africain presentant une constipation quelqu'en soit le type. Patients et methodes. Le temps de transit a ete etudie chez 60 sujets de race noire des deux sexes et ages de plus de 18 ans dont 30 presentaient une constipation chronique idiopathique et 30 etaient consideres comme etant des sujets sains. Le recrutement des patients a ete fait dans les services de consultation externes de gastro-enterologie des CHU de Yopougon et de Cocody. Resultats. 50% des sujets constipes avaient un TTC normal. Chez les femmes; le TTC des sujets sains etaient de 28 H pour le colon droit; 22 H pour le colon gauche; 22 H pour le rectosigmoide et 44 H pour l'ensemble du colon. Chez les hommes; ces valeurs etaient de 34 H pour le colon droit; 26 H pour le colon gauche; 44 H pour le rectosigmoide et 64 H pour l'ensemble du colon. Les TTC moyens dans les differents segments du colon etaient plus long chez les femmes constipees que chez les hommes constipes; exception faite du segment rectosigmoidien ou le TTC etait plus long chez les hommes constipes que chez les femmes constipees. Conclusion. La mesure du TTC avait permis d'etablir des normes chez les sujets sains africains; de mesurer le TTC chez les sujets africains constipes et de confirmer l'importance de la constipation a TTC normal

Reduction of Client Waiting Time Using Task Shifting in an Antiretroviral Clinic at Specialist Hospital Bauchi; Nigeria

Aiming to assess the impact of the intervention in reducing the patients' waiting time in the clinic; two surveys were conducted before and after task shifting intervention in an anti-retroviral (ARV) clinic at the Specialist Hospital; Bauchi; Nigeria in November 2008 and April 2009; respectively. Before the task shifting; six nurses from the clinic were trained on integrated management of adolescent and adult illness; as well as on the principle and guidelines for the anti-retroviral therapy; after which their schedule in the clinic was broadened to include seeing HIV patients presenting for routine refill and follow-up visits. In this study; fifty-six and sixty patients; respectively out of 186 and 202 who attended the clinic on the days of the pre- and post-intervention surveys; were randomly sampled. Data on patients' sex; age and marital status; whether patient a first timer or follow up visitor and the time spent in the clinic on that day as well as the number and composition of staff and equipment in the clinic was collected. The difference in waiting time spent between the first group before task shifting and second group after task shifting was statistically analyzed and significance tested using unpaired t- test. There was a reduction in the average waiting time for patients attending the clinic from 6.48 h before task shifting to 4.35 h after task shifting. The difference of mean was -2.13 h; with 95CI: -2.44:-1.82 hours and the test of significance by unpaired t-test P0.0001

Timing of Spontaneous Birth and the Risk of Adverse Perinatal Outcome

The study aspired to assess the impact of time of birth on spontaneous onset of labour and delivery. A retrospective descriptive study was conducted from the Empangeni Hospital delivery registry on 9;397 infant births between January to December 2005; weighing more than 1;000 g. Logistic regression; adjusting for birth weight and for gender was used to estimate the relationship between spontaneous birth and timing of birth. A higher proportion of births (59) occurred between 10h00 and 22h00 of the day. Estimating the hourly births; we found that the daytime peak is 5.3and occurred at 10h00 while the night-time peak is 4.9and occurred at 20h00. Maternal age was significantly associated with the timing of spontaneous births (p 0.05). A higher proportion of preterm babies was born during the day (6.4) and early night (3.4) compared to late night births (1.6). There were significant differences between multiple births and low birth weight infants born during the day (1.1; 6.9) and night (0.8; 6.3). However; low birth weight babies were born mostly during early night rather than late night (4vs. 2.3; p 0.05). Adverse pregnancy outcome; measured by estimating the perinatal mortality rate; was the same for day and night and was equally distributed between early and late night. Timing of birth of infants did not influence the negative outcomes of pregnancy among this study population

Patients' response to waiting time in an out-patient pharmacy in Nigeria

PURPOSE : To identify the dispensing procedure at a pharmacy; investigate the possible operational problems that may lead to excessive patient waiting times as prescriptions are filled and to examine patient disposition to perceived delays at the pharmacy. METHODS : The study was carried out in a 574-bed university teaching hospital in Ile - Ife; Nigeria. The subjects were out-patients who gave their consent to participate in the study. Data were collected using the techniques of workflow analysis and time study in observing the dispensing process. A validated questionnaire was administered on the out-patients to measure their responses to waiting in the pharmacy as well as their level of satisfaction with pharmaceutical services rendered. RESULTS: The workflow analysis revealed considerable delay in the dispensing procedure as a result of extended process components. The total waiting time for a dispensing process averaged 17.09 min; and 89.5 percent of this was due to delay components. Specifically; the major delay components included patient queues for billing prescription sheets and subsequent payment to the cashier. Operational problems identified included patients' indirect access to dispensing pharmacist and the tortuous procedure for prescription billing and payments. Generally; patients were not satisfied with undue delay caused by the dispensing procedure at the pharmacy. CONCLUSION: Most of the patient waiting time in the hospital studied can be accounted for by delay components of the dispensing procedure. Attempts should therefore be made to reduce the time on these components of the dispensing process so that more time could be devoted to counseling while reducing the total time spent by the patient in having their prescriptions sheets filled

"Devenir des gastrectomises pour cancer gastrique en chirurgie ""B"" a l'hopital du Point ""G"" - Bamako"

"En 10 ans; les auteurs ont collige 177 cas de cancers gastriques sur lesquels 53; soit 29;9 pour cent ont pu beneficier d'une resection (curative ou palliative). Le taux de resection a visee curative a ete de 19;7 pour cent et celui de resection a visee palliative de 10;2 pour cent. Il ressort de ces chiffres que les taux d'operabilite et de resecabilite en chirurgie ""B"" sont nettement inferieurs a ceux des pays developpes. Par contre pour les patients ayant pu beneficier d'une resection curative; le taux de survie a 5 ans est de 28 pour cent; chiffre comparable a ceux des series occidentales. Les auteurs recommandent un diagnostic precoce des cancers gastriques."