How do patients perceive and expect quality of surgery, diagnostics, and emergency services in tertiary care hospitals? an evidence of gap analysis from Pakistan

Objectives: Service quality is one of the important gears to appraise services and determine the gray areas that need improvement. In countries with a resource-poor health system, the first step of measuring quality is yet to be taken. This study seeks to inform policy makers in developing contextual service quality models by identifying service quality gaps in tertiary care teaching hospitals using patients' perspective. Methods: A cross-sectional study was performed using multistage cluster sampling, and a modified version of the SERVQUAL [SERV-service, QUAL-quality] instrument was administered to determine patient's expectations and perceptions. A total of 817 completed questionnaires were obtained from patients and/or their attendants using convenience sampling

Results: Data analysis revealed statistically significant negative quality gaps between expectations and perceptions of tangibility, reliability, empathy, assurance, responsiveness, and communication. The difference in mean expectation and perception for responsiveness across the sexes was significant [p < 0.003;p < 0.037, respectively] as well as in perception of communication [p < 0.026]. Other dimensions and overall hospital expected and perceived quality were independent of sex. Educational status showed significant difference in expectation and perception in responsiveness [p < 0.005], but the perception of each dimension was significantly different in different educational categories [assurance:p < 0.001; empathy:p < 0.001; reliability:p < 0.001; tangibility:p < 0.001; responsiveness:p < 0.001; communication:p < 0.001; and for overall service quality:p < 0.001]. Age and service departments showed no relationship with any of the perceived or expected dimension of service quality of hospitals

Conclusions: Tertiary care hospitals failed to meet patients' expectations in all major areas of service quality, posing a question of how hospitals implement and evaluate their quality assurance policy

Use of antibiotics within the integrated management of childhood illness [IMCI]: guidelines in pediatric outpatient settings

Background: The success of standardized measures for disease classification and treatment has led disease-specific approaches led WHO and UNICEF to incorporate them into a set of guidelines for the integrated management of childhood illness [IMCI], which includes modules or subsets of guidelines for the recognition and management of children with acute respiratory infections, diarrhea, measles, malaria and other febrile illness, and malnutrition

Objective: To assess the use of antibiotics within the IMCI Guidelines in Pediatric Outpatient Settings of Jinnah Hospital

Methodology: It was a cross-sectional study conducted at Pediatrics OPD Jinnah Hospital from May 1, 2014 - August 21, 2014. The 150 children and their parents / accompanying person fulfilling the inclusion criteria after consultation from pediatric consultation were interviewed regarding their disease status and prescription by the doctor regarding antibiotics and other conditions. All the information was entered in a structured questionnaire. The samples were collected by non-probability / purposive sampling technique

Results: Among 150 children included in study mean age of children was 36 months SD 20.42 months. 60% were male and 40% female. Presenting complaints among children were, 75.0% presented fever, 26.4% had loose motions, 22.3% has vomiting, 20.3% had cough. 12.8% presented with abdominal pain. Among those who received antibiotics, 10% received third generation cephalosporin [ceftriaxone, cefexime], 10.7% penicillin's [mostly amoxicillin and piperacillin], and 4% ciprofloxacin. 30% received combination of 2 or 3 antibiotics [14.7% combination of ceftriaxone and amikacin [aminoglycoside], According to IMCI guidelines 34% were not appropriately treated, 20.7% received antibiotics when they should not and 13.3% did not received antibiotics when they should have

Conclusion: Their low adherence to integrated management of childhood illness [IMCI] recommendations for prescription of antibiotics in routine outpatient settings the study shows highly prevalent use of third generation cephalosporins

Faculty development ---- looking through different lenses

To understand how the faculty and students perceive the needs, barriers and possible solutions for instructional, professional and organizational development of faculty in context of a medical school. Mixed method sequential study. Shaikh Khalifa Bin Zayed Al-Nahyan Medical College [SKZMC] Lahore from September 2013 to March 2014. Five-point Likert scale, focus group discussions [FGDs] and in-depth, face-to-face interviews [IDI] were used to collect data. Using convenience sampling, 2lfaculty members for Likert scale forms,lO for FGD and 12 for ID1 were selected along with93 students for Likert scale and20 students for 2 FGDs. Scale data summarized using mean +/- SD and categorized using median score. Thematic analysis was done on interview and focus group data and findings were triangulated. Triangulation showed lack of motivation, poor time management, deficiencies in curriculum understanding and alignment with instruction and assessment, unawareness of innovative instruction and assessment tools, lack of feedback use and reflection, poor learning environment, and almost no rewards and recogrution of excellence in teaching. Weak institutional leadership and unsupportive administration were impediments too. Enhanced motivation by incentives, rewards and institutional support along with a robust faculty development program, training faculty and improving instructional, professional and organizational structure were identified as context specific solutions to address the needs and barriers. Innovative instructional training, development of research, leadership and scholarship, with organizational restructuring and support, are the main elements for faculty development in this specific context

Managing small intestinal obstruction: a Sheikh Zayed Hospital experience

Managing intestinal obstruction continuous to challenge surgeons all over the World. Between January 2001 to December, 2004, 54 patients with maw to female ratio of 1.8:1 and mean age of 51 presented with small bowel obstruction. They were divided in to two groups; group A and B. Group A comprised of 30 patients [55%] and were managed conservatively. Whereas group B had 24 patients [44%] who required surgery. Conservative management was observed for 12 to 36 hours and beyond this time patients were explored in the face of deterioration. In group a, 83% patients had history of previous surgery whereas 17% patients had no prior surgical intervention. In group B 38% patients had abdominal surgery in the past whereas 62% had no previous surgical intervention. Predominant symptoms of bowel obstruction were abdominal pain, [100%] constipation [60%] and vomiting [48%]. Common causes of obstruction were post-operative adhesions 38% [n=7] obstructed hernias 25% [n=6] ileoceacal tuberculosis 21% [n=3] intestinal ischemia 8% [n=2] and ceacal carcinoma 8% [n=2]. Two patients died to septicemia, subsequent to anastomotic leak. We conclude that adhesive bowel disease and obstructive external hernias are the commonest causes of small bowel obstruction. A good clinical acumen and repeated clinical examinations are necessary to avoid the stage of bowel gangrene while managing small intestinal obstruction

Transduodenal Sphincteroplasty - still an effective biliary drainage procedure in the Laparoscopic era

With the advent of interventional endoscopic procedures and with growing experience with laparoscopic surgery, the indications for open biliary procedures have become limited. This prospective study reviews the changing trends in the indications of transduodenal sphincteroplasty and presents the short-term and long-term outcomes of this procedure in the present minimally invasive surgical era. Transduodenal sphincteroplasty was performed for various benign obstructive biliary pathologies. Various parameters recorded were the demographic data, indications for surgery, early and late complications and long-term outcome of the procedure. The changing trend in the current indications of the procedure was reviewed. Results of transduodenal sphincteroplasty on 49 consecutive patients over 9 years period are presented. Mean age was 48.4 years with male to female ratio of 1:3.4. Twenty-six [53.0%] patients presented with obstructive jaundice and 36.7% had cholangitis. Common indications of surgery included multiple common duct calculi [44.8%], impacted ampullary stones [36.6%] and ampullary stenosis [10.2%]. Overall hospital morbidity was 12.2% with zero mortality. After a mean follow up of 9.3 years, 95.9% patients had "good" or "fair" and 4.1% reported "poor" results. Most of the biliary pathologies may be dealt with laparoscopic and endoscopic procedures; open drainage procedures may still be indicated in selected patients. Transduodenal sphincteroplasty remains an effective biliary drainage procedure with acceptable morbidity and mortality. The procedure should be regarded as an essential in the general surgical knowledge and training