What presents to a rural district emergency department: a case mix

Background: There is little information available on the range of conditions presenting to generalist run rural district hospital emergency departments (EDs) which are the first point of acute care for many South Africans. Aim: This study aims to assess the range of acute presentations as well as the types of procedures required by patients in a rural district hospital context. Setting: Zithulele is a 147-bed district hospital in rural Eastern Cape. Methods: This is a cross-sectional study assessing all patients presenting to the Zithulele hospital emergency department from 01 October 2015 to 31 December 2015. Data collected included the triage acuity using the South African Triage Scale system, patient demographics, diagnosis, outcome and procedures performed. Diagnoses were coded retrospectively according to the international statistical classification of diseases and related health problems version 10 (ICD 10). Results: Of the 4 002 patients presenting to the ED during the study period, 2% were triaged as emergencies and 45% as non-urgent. The most common diagnostic categories were injuries, infections and respiratory illnesses respectively. Diagnoses from all broad categories of the ICD-10 were represented. 67% of patients required no procedure. Diagnostic procedures (n = 877) were more prevalent than therapeutic procedures (n = 377). Only 2.4% of patients were transferred to a referral centre acutely. Conclusion: Patients with conditions from all categories of the ICD-10 present for management at rural district hospitals. Healthcare professionals working in this setting need to independently diagnose and manage a wide range of ED presentations and execute an assortment of procedures

Laboratoires médicaux et qualité des soins: la partie la plus négligée au niveau des hôpitaux ruraux de la République Démocratique du Congo

Introduction: la qualité des soins est essentielle pour sauver des vies humaines de différentes maladies. Cependant, un diagnostic inapproprié ne peut en aucun cas aboutir à une prise en charge correcte des patients ainsi qu'à des soins de qualité. Nous avons effectué une analyse descriptive transversale dans trois laboratoires des hôpitaux généraux en République Démocratique du Congo.Méthodes: une équipe d'experts nationaux dans le domaine des laboratoires avait conduit l'enquête au niveau de trois laboratoires cliniques des hôpitaux généraux de la République Démocratique du Congo. Des observations, visites et entretiens structurés à l´aide d'un questionnaire ont été utilisées pour évaluer la performance de ces laboratoires cliniques. Nous avons également utilisé un guide d'évaluation développé au niveau national pour l'évaluation des laboratoires.Résultats: les laboratoires cliniques des hôpitaux généraux visités ont présenté de nombreux déficits notamment en ce qui concerne les infrastructures, la formation de base et continue des personnels, les équipements, la supervision et le contrôle de qualité. Le plateau technique de ces laboratoires n'était pas adapté pour répondre aux besoins de la population en ce qui concerne les maladies fréquemment rencontrées dans ces zones. Nous avons également noté que, ces laboratoires sont peu ou presque pas accompagnés et qu'il n'y avait aucune équipe de coordination dédiée à la supervision et évaluation des laboratoires au niveau de l'hôpital, voire même au niveau de la zone de santé. En plus, les techniciens de ses différents laboratoires n'ont pas été supervisés pendant de nombreuses années.Conclusion: les laboratoires cliniques doivent être améliorés pour permettre un diagnostic adéquat de différentes maladies. Cette amélioration doit s'appuyer sur les maladies locales. Au sein du système, il est important de consacrer plus d'attention aux laboratoires cliniques. Un plaidoyer pour cette composante négligée du système de santé est nécessaire, car cette situation pourrait être la même dans de nombreux pays en voie de développement

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

Clinical profile and outcome of hyperglycaemic emergencies at a rural hospital in southern Nigeria

We have documented the clinical pattern of hyperglycaemic emergencies (HGEs) and predictors of outcome at a tertiary hospital in a rural setting in Nigeria. In a 2-year retrospective review, we identified 88 patients with HGEs. Fifty-four (61%) were females, and mean age was 55 years. Forty-seven (53%) had hyperglycaemic hyperosmolar states (HHS), 34 (39%) had diabetic ketoacidosis (DKA), and 7 (8%) had a mixed type of HGE. The commonest precipitating factor was infection and was seen in 39 (44.3%) patients; 28 (32%) were newly diagnosed with diabetes. The mortality rate overall was 34% and the case fatality rate of DKA, HHS, and mixed-type HGE was 23%, 38%, and 57% respectively. Elevated urea was a predictor of poor outcome; while age, gender, and the presence of chronic diabetes complications were not predictors of outcome. We conclude that the mortality rate in HGEs is high, and that elevated urea is a predictor of poor outcome.Effective diabetes education, prompt recognition of symptoms, and treatment of metabolic derangements in HGEs may reduce morbidity and mortality

Management of severe acute malnutrition in children under 5 years through the lens of health care workers in two rural South African hospitals

Background: Despite the widespread implementation of the World Health Organization (WHO) guidelines for the management of severe malnutrition in South Africa, poor treatment outcomes for children under 5 years are still observed in some hospitals, particularly in rural areas.Objective: To explore health care workers' perceptions about upstream and proximal factors contributing to poor treatment outcomes for severe acute malnutrition in two district hospitals in South Africa.Methods: An explorative descriptive qualitative study was conducted. Four focus group discussions were held with 33 hospital staff (senior clinical and management staff, and junior clinical staff) using interview guide questions developed based on the findings from an epidemiological study that was conducted in the same hospitals. Qualitative data were analysed using the framework analysis.Findings: Most respondents believed that critical illness, which was related to early and high case fatality rates on admission, was linked to a web of factors including preference for traditional medicine over conventional care, gross negligence of the child at household level, misdiagnosis of severe malnutrition at the first point of care, lack of specialised skills to deal with complex presentations, shortage of patient beds in the hospital and policies to discharge patients before optimal recovery. The majority believed that the WHO guidelines were effective and relatively simple to implement, but that they do not make much difference among severe acute malnutrition cases that are admitted in a critical condition. Poor management of cases was linked to the lack of continuity in training of rotating clinicians, sporadic shortages of therapeutic resources, inadequate staffing levels after normal working hours and some organisational and system-wide challenges beyond the immediate control of clinicians.Conclusion: Findings from this study suggest that effective management of paediatric severe acute malnutrition in the study setting is affected by a multiplicity of factors that manifest at different levels of the health system and the community. A verificatory study is encouraged to collaborate these findings

The management of diabetic ketoacidosis at a rural regional hospital in KwaZulu-Natal

Background: Diabetic ketoacidosis (DKA) is a biochemical triad of hyperglycaemia, ketoacidosis and ketonaemia and one of the potentially life-threatening acute metabolic complications of diabetes mellitus. This study aimed at describing the clinical profile of patients presenting with DKA to a busy rural regional hospital in KwaZulu-Natal. Methods: A retrospective review of clinical notes of patients presenting with DKA to the Emergency Department was performed over a 10-month period. Data included patients' demographic profile, clinical presentation, precipitating factors, comorbidities, biochemical profile, length of hospital stay and outcome.Results: One hundred and five black South African patients above the age of 12 years were included in the study. Sixty-four (60.95%) patients had type 1 diabetes mellitus (T1DM) and 41 (39.05%) patients had type 2 diabetes mellitus (T2DM). Patients with T2DM were significantly older than those with T1DM (52.1 ± 12.4 years vs. 24.4 ± 9.5 years, p < 0.0001). The acute precipitant was identified in 68 (64.76%) cases with the commonest precipitant in T1DM patients being poor adherence to treatment, whereas in T2DM, the most common precipitant was infection. Nausea and vomiting were the most common presenting symptoms with the majority of patients presenting with non-specific symptoms. Fifty-seven (54.29%) cases had pre-existing comorbidities, with higher prevalence in T2DM than T1DM patients. Glycated haemoglobin was severely elevated in the majority of patients. Patients remained hospitalised for an average of 8.9 ± 7.5 days. The mortality rate was 17.14%, and 12 of the 18 deaths occurred in patients with T2DM.Conclusion: The prevalence of DKA was higher in patients with T1DM and those with pre-existing comorbidities. The mortality rate remains alarmingly high in older patients with T2DM

Professional nurses' perception of their clinical teaching role at a rural hospital in Lesotho

Background. Nursing education institutions in Lesotho face an increasing number of enrolments owing to a high demand for professional nurses to work in the community. Enrolments have doubled during the last 3 years; without an increase in teaching resources or staff. Professional nurses in the wards are expected to mentor students and teach the clinical elements of nursing while continuing with their day-to-day clinical duties. Furthermore; professional nurses in Lesotho have not been trained for this clinical teaching role. Objective. To explore the perceptions of professional nurses with regard to their clinical teaching role in the development of competent nurses. Methods. A qualitative study was undertaken at a rural hospital in Lesotho. Data were gathered by conducting semi-structured interviews with professional nurses. Interview transcripts were coded and emerging themes identified. Data saturation was reached after eight interview transcripts were analysed. Results. Four themes representing the perceptions of the professional nurses emerged in the analysis: (i) the clinical teaching role; (ii) the complexities of clinical teaching; (iii) learners have their issues; and (iv) making it work. Conclusion. Professional nurses understand and appreciate their educational role in the development of competent nurses. This clinical teaching role is performed in difficult circumstances; including administrative challenges; limited resources and staff shortages; while maintaining clinical responsibilities. Despite these challenges; the nurses have remained resilient and solution focused. Nursing education institutions should re-orientate professional nurses with regard to current trends and principles of nursing education to enhance their clinical teaching role

Insuffisance renale aigue compliquant un paludisme grave a plasmodium falciparum: prise en charge dans un milieu peu equipe

Les auteurs rapportent un cas d'insuffisance renale aigue classe F selon le critere RIFLE compliquant un paludisme grave chez un enfant de 7 ans; de sexe masculin; pris en charge dans un milieu logistiquement pauvre. La goutte epaisse etait positive avec une Hyperparasitemie a plasmodium falciparum; l'uremie a 143 mg/dl et la creatininemie a 5;0mg/dl. Par manque de dialyse; l'association furosemide a forte dose et dopamine a dose dopaminergique avait permis de controler la surcharge hydrosodee en attendant la resolution de l'insuffisance renale

Tuberculosis and lactic acidosis as causes of death in adult patients from a regional hospital in Johannesburg

Background: Tuberculosis and adverse effects have been shown to affect both the quality of life and the survival of patients on antiretroviral treatment. This study sought to investigate the causes of death in a sample of adult HIV-infected patients on antiretroviral treatment at Thembisa Hospital, Johannesburg, South Africa. Methods: A retrospective study was conducted by examining the charts of 498 adult patients treated from January 2004 to December 2006 at the antiretroviral clinic of a regional hospital in Johannesburg. A data collection form was used to collate both sociodemographic and clinical data. Results: The majority of the patients were female (71.7%) with a mean age of 37.7 ± 11.6 years, and in the age group of 18­77 years. The greater number of the patients was South African citizens, with only 2.2% citizens of other Southern African countries. At baseline, 29.9% had been on anti-tuberculosis treatment. Most of the patients had been prescribed the regimen comprising stavudine, lamivudine, and nevirapine or efavirenz; two of them (0.4%) were on the second line regimen made of zidovudine, didanosine, and lopinavir­ritonavir. At least one side effect was documented in 82.1% of patients; the ten most documented side effects were skin rashes (62.9%), peripheral neuropathy (48.4%), headaches (38.2%), chest pain(21.9%), coughing (21.7%), anaemia (21.5%), diarrhoea (19.3%), vomiting (16.7%), dizziness (15.3%), and lactic acidosis (11.2%). A mortality rate of 3.6% was recorded during the 2-year study period. Although the cause of death was undetermined in 11.1% of patients, 50.0% and 38.9% of deaths respectively were a consequence of tuberculosis and lactic acidosis. Conclusions: In addition to tuberculosis, side effects in particular, lactic acidosis was the other main cause of death in patients treated at the study site. These findings suggest that patients on regimens containing drugs that cause lactic acidosis should be closely monitored when the first complaints suggesting lactic acidosis are reported or noticed

Review of tetanus admissions to a rural Ugandan hospital

Tetanus; which can be eliminated through an effective immunization programme; remains a significant cause of morbidity and mortality in Uganda with a high case fatality rate. This study was carried out in St Francis Hospital Buluba (SFHB) after observing that the hospital was registering an abnormally high number of tetanus patients. Its aim was to retrospectively establish the socio-demographic characteristics of the patients and determine the case-fatality rate among tetanus patients admitted between 2005- 2008. Records of all patients registered and treated for tetanus up to the time of death or discharge on the Medical and Pediatric wards were evaluated. Case notes of 71 patients were retrieved and analyzed for clinical characteristics. During the three-year period under study; 163 patients (0.65of all admissions) were managed for tetanus. Analysis was done for only 154 (94.5) patients because records of the others lacked basic data. The majority of the patients (67) were males and most were young (81were below 13 years of age). Forty two percent (42) came from areas outside Mayuge district. The registered case-fatality rate was 47; with mortality being highest in the extremes of age. This paper recommends scaling up and sustaining immunization service to the whole population. Presentation of an immunization certificate should be made compulsory for all children joining school at all levels. Finally; programmes that help the population to access booster doses later in life should also be implemented

Prevention of postpartum hemorrhage: options for home births in rural Ethiopia

This paper sought to determine the safety and feasibility of home-based prophylaxis of postpartum hemorrhage (PPH) with misoprostol, including assessment of the need for referrals and additional interventions. In rural Tigray, Ethiopia, traditional birth attendants (TBAs) in intervention areas were trained to administer 600mcg of oral misoprostol. In non-intervention areas women were referred to the nearest health facility. Of the 966 vaginal deliveries attended by TBAs, only 8.9% of those who took misoprostol prophylactically (n=485) needed additional intervention due to excessive bleeding compared to 18.9% of those who did not take misoprostol (n=481).The experience of symptoms among those who used misoprostol can be considered of minor relevance and self-contained. This study found that prophylactic use of misoprostol in home births is a safe and feasible intervention. Community health care workers trained in its use can correctly and effectively administer misoprostol and be a champion in reducing PPH morbidity and mortality (Afr J Reprod Health 2009; 13[2]:87-95)