Effect of low-cost interventions to reduce the incidence of violent events in two public sector tertiary-care emergency departments, Pakistan.

Background: Violence against health care workers has been widely reported in Pakistan. Aims: This study, from September 2019 to April 2020, aimed to determine the effect of low-cost interventions to reduce violent events in two tertiary-care emergency departments in Karachi and Peshawar, Pakistan. Methods: In phase one, a surveillance system was established in each department and information on violent events was recorded for three months. In phase two, low-cost interventions designed to reduce violent events were introduced, e.g. awareness-raising material on violence for patients, training for health care workers and visitor identification cards. Violent events were then recorded for another three months and the percentage difference in number of violent events was calculated. Results: In Karachi, 256 violent events occurred before the intervention and 225 after the intervention, a 12.1% reduction. Physical violence events decreased significantly by 42.9% (P = 0.044). The number of events perpetrated by health care workers decreased by 61.9% (P = 0.016) while those perpetrated by patients decreased only by 5.7% (P = 0.538). In Peshawar, 90 violent events occurred before the intervention and 45 events after, a 50.0% reduction (P = 0.009). The number of events perpetrated by health care workers was the same in both phases. Events perpetrated by patients or their companions decreased significantly by 59.72% (P = 0.001). Conclusion: Violence against health care workers can be reduced significantly by improving their prevention and de-escalation skills. Client educational interventions, supplemented with hospital regulations and patient guidance, can also help reduce the incidence of violent events.

Violence against health care workers in rural areas of Sindh, Pakistan.

OBJECTIVE: To determine the magnitude of violence against healthcare workers in a rural setting, and the consequences of this violence on their personal and professional lives. METHODS: The descriptive, quantitative, cross-sectional study was conducted in 4 rural districts of the Sindh province of Pakistan from February to December 2019, and comprised healthcare workers, including doctors, nurses, support staff and field workers. Data was collected using a structured questionnaire. Data was analysed using SPSS 22. RESULTS: Of the 1622 subjects, 929(57.3%) were males and 693(42.7%) were females. The overall mean age was 35.55+/-10.05 years. The largest cluster was that of doctors 396(24.4%), followed by technicians 202(12.5%). Overall, 522(32.2%) subjects had a professional experience of 1-5 years. Violence at workplace in any form was experienced by 693(42.7%) subjects. Verbal violence had been experienced by 396(24.4%) subjects, while 228(14.1%) had witnessed it. The corresponding numbers for physical violence were 122(7.5%) and 22(1.4%). Verbal violence was more prevalent compared to physical violence (p<0.01). The major effect was that the healthcare workers remained alert 537(33.1%), felt frustrated 524(32.3%) and disturbed 503(31%). Also, 272(16.8%) subjects were planning to migrate or quit the profession. CONCLUSIONS: Violence was found to be a significant issue in rural Sindh.

Assessment of a mass media campaign on giving way to ambulances in five cities of Pakistan.

OBJECTIVE: To determine the contribution of a mass media campaign towards encouraging more vehicles to give way to ambulances, and to identify the factors associated with higher likelihood of giving way to ambulances. METHODS: The three-phase observational study was conducted from December 2017 to March 2018 in Karachi, Lahore, Rawalpindi, Islamabad and Peshawar cities of Pakistan. Six road sites in different areas of each city were selected for observation. The surveys in each city were supervised by academic partners, including APPNA Institute of Public Health, Karachi, University of Health Sciences, Lahore, Al-Nafees Medical College, Rawalpindi and Islamabad, and Khyber Medical University, Peshawar. Three observation surveys were carried out before, during and after the media campaign on right of way for ambulances. Only those ambulances were observed which were rushing through and seeking space. The behaviour of only those vehicles was observed which had the space to change the lane when the space was sought from them. The association of the outcome of vehicles giving way to ambulances immediately or in a few seconds with the campaign was determined using logistic regression analysis. RESULTS: After adjustment for city of observation, timing of the day and type of vehicle, vehicles during and after the campaign were significantly more likely give space to ambulance (p<0.05) compared to cars, buses and vans were significantly less likely to give space (p<0.05). CONCLUSIONS: Media campaign produced better results in encouraging vehicle-owners to give right of way to ambulances to ensure timely medical assistance.

The magnitude and determinants of violence against healthcare workers in Pakistan.

Objectives: To determine the magnitude and determinants of violence against healthcare workers (HCWs) and to identify the predominant types and causes of violence experienced by them. Methodology: A cross-sectional survey based on structured questionnaire adopted from previous surveys and qualitative data was conducted in 4 large cities and 12 districts in 3 provinces of Pakistan. The survey covered 8579 from all cadres of HCWs, including doctors, nurses, technicians, support staff, ambulance workers, vaccinators, lady health visitors, midwives and lady health workers (LHWs). The predictors of overall violence experienced, physical violence experienced and verbal violence experienced were separately analysed for tertiary care hospitals, secondary care hospitals, primary care hospitals and field-level HCWs. Logistic regression was used to compute adjusted ORs with 95% CIs for the association of different factors with the violence experienced. Results: More than one-third (38.4%) reported having experienced any form of violence in the last 6 months. Verbal violence was the most commonly experienced form (33.9%), followed by physical violence (6.6%). The main reasons for physical violence were death of patients (17.6%), serious condition of patients (16.6%) and delay in care (13.4%). Among the different types of field HCWs, emergency vehicle operators were significantly more likely to experience verbal violence compared with LHWs (adjusted OR=1.97; 95% CI 1.31 to 2.94; p=0.001). Among hospital HCWs, those working in private hospitals were significantly less likely to experience physical violence (adjusted OR=0.52; 95% CI 0.38 to 0.71; p=0.001) and verbal violence (adjusted OR=0.57; 95% CI 0.48 to 0.68; p=0.001). Conclusion: Violence against HCWs exists in various forms among all cadres and at different levels of care. The gaps in capacity, resources and policies are evident. Specific strategies need to be adopted for different types of HCWs to protect them against violence.*The study was conducted under the framework of ICRC's Healthcare in Danger Initiative for protection of healthcare against Violence.

Findings from Healthcare in Danger Project: Pakistan security assessment of a public and private tertiary care hospital in Karachi: Gaps and way forward.

OBJECTIVE: To identify and compare security gaps in a public and private tertiary care hospital. METHODS: The study was conducted in January 2016 using a tool adopted from Ingersoll Rand Security Technologies, Occupational Safety and Health Association and findings of baseline research carried out by Health Care in Danger Project at a public and private sector hospital in Karachi. The names of hospitals were kept confidential. Areas assessed included adequacy of workforce, existing institutional mechanisms and campus security. The tool was completed by interviewing administration, security department, and healthcare workers in wards and the emergency departments as well as patients, attendants and through observation visits. RESULTS: The burden of doctors at the private-sector hospital was higher compared to the publicsector hospital (40 versus 22 patients per doctor per day) in the outpatient department. Privatesector hospital scored better than public-sector hospital with regards to compliance to security management standards (68% versus 50%), security perception of staff (90% versus 50%), security staffing (60% versus 50%), and visitor management (80% versus 40%). Campus security was better at private-sector hospital (56% versus 31%). Scores for employee orientation and training were low (30% and 20%), while scores for organisational partnerships were high in both hospitals (80% each). . CONCLUSIONS: Four-pronged strategic framework is recommended that shall comprise restricting access of attendants/visitors/vendors, improving interaction between patients/healthcare workers/guards, mechanisms of reporting and responding to violent events, and maintaining sufficient resources for enhancing and improving security in hospitals.

Effectiveness of training on de-escalation of violence and management of aggressive behavior faced by health care providers in a public sector hospital of Karachi.

BACKGROUND & OBJECTIVE: Considering high burden of violence against healthcare workers in Pakistan APPNA Institute of Public Health developed a training to prevent reactive violence among healthcare providers. The purpose of this training was to equip healthcare providers with skills essential to control aggressive behaviors and prevent verbal and non-verbal violence in workplace settings. This study assesses the effectiveness of training in prevention, de-escalation and management of violence in healthcare settings. METHODS: A quasi-experimental study was conducted in October, 2016 using mixed method concurrent embedded design. The study assessed effectiveness of de-escalation trainings among health care providers working in emergency and gynecology and obstetrics departments of two teaching hospitals in Karachi. Quantitative assessment was done through structured interviews and qualitative through Focus Group Discussions. Healthcare providers` confidence in coping with patient aggression was also measured using a standard validated tool". RESULTS: The overall self-perceived mean score of Confidence in Coping with Patient Aggression Instrument "(CCPAI)" scale was significantly higher in intervention group (Mean= 27.49, SD=3.53) as compared to control group (Mean= 23.92, SD=4.52) (p<0.001). No statistically significant difference was observed between intervention and control groups with regard to frequency of violence faced by HCPs post training and major perpetrators of violence.. CONCLUSION: De-escalation of violence training was effective in improving confidence of healthcare providers in coping with patient aggression.

Higher scrotal uptake ratio of (99m)Tc-MDP on bone scans in newly diagnosed prostate cancer: a reliable indicator of pelvic node metastasis.

OBJECTIVE: Pelvic lymph node dissection (PLND) is the gold standard procedure for nodal staging in prostate cancer (PC) but less commonly used due to its invasiveness. More commonly computerized tomography (CT) and magnetic resonance imaging (MRI) are used although these have limited sensitivities and specificities. The aim of this study was to find out the correlation between higher scrotal uptake ratio (SUR) of (99m)Tc-methylene diphosphonate (MDP) on bone scan and pelvic node metastasis in patients with PC at high risk for nodal metastasis. METHODS: This was a retrospective study which included 68 biopsy proven newly diagnosed PC patients who had bone scan from January 2008 till January 2012. MRI of the pelvis, prostate specific antigen (PSA) and Gleason's score were available in all patients. Whole body bone scan was performed in all patients and SUR was calculated by dividing mean counts over scrotum and soft tissue over lateral aspect of right thigh. PLND was carried out within 2-3 weeks of MRI study in these patients. RESULTS: Mean age of studied males was 71 ± 07 years with a mean PSA level of 65 ± 162 ng/ml. Prostate biopsy revealed adenocarcinoma in all patients with mean Gleason's score 7 ± 1. Mean SUR was 2.786 ± 0.496. MRI was positive for pelvic lymphadenopathy in 32/68 (47 %). PLND revealed evidence of nodal metastasis in 16/68 (24 %) patients. Receiver operating characteristic analysis revealed good diagnostic strength of SUR for nodal metastasis with a cut off value of >2.99 with an area under curve (AUC) 0.708 (95 % CI 0.533-0.847, p value <0.05) and a mean sensitivity of 68.75 % and mean specificity of 80 %. Diagnostic strength of MRI for nodal metastasis was found to be low (AUC 0.566, 95 % CI 0.047-0.657, non-significant p value). No significant correlation was found between SUR and PSA in nodes positive and nodes negative patients. CONCLUSION: We conclude that in newly diagnosed PC patients, higher SUR on bone scan has a high diagnostic accuracy for pelvic node metastasis. Furthermore, a bone scan with a SUR <2.99 and negative for bone metastasis can stratify newly diagnosed PC patients as low risk.

Pulmonary embolism in pregnancy: a diagnostic dilemma.

The diagnosis of PE in pregnancy poses a challenge due to pregnancy-related physiological changes. Missing the PE or wrongly treating a pregnant woman for PE has serious clinical consequences. There has been concern over the use of radiation-based imaging modalities due to risk of teratogenicity and oncogenicity. This review is focused on various diagnostic options and risks of radiation to the fetus and mother from radiation-based procedures.

Recent developments and future prospects of SPECT myocardial perfusion imaging.

Myocardial perfusion SPECT imaging is the most commonly performed functional imaging for assessment of coronary artery disease. High diagnostic accuracy and incremental prognostic value are the major benefits while suboptimal spatial resolution and significant radiation exposure are the main limitations. Its ability to detect hemodynamic significance of lesions seen on multidetector CT angiogram (MDCTA) has paved the path for a successful marriage between anatomical and functional imaging modalities in the form of hybrid SPECT/MDCTA system. In recent years, there have been enormous efforts by industry and academia to develop new SPECT imaging systems with better sensitivity, resolution, compact design and new reconstruction algorithms with ability to improve image quality and resolution. Furthermore, expected arrival of Tc-99m-labeled deoxyglucose in next few years would further strengthen the role of SPECT in imaging hibernating myocardium. In view of these developments, it seems that SPECT would enjoy its pivotal role in spite of major threat to be replaced by fluorine-18-labeled positron emission tomography perfusion and glucose metabolism imaging agents.

Awareness of bird flu amongst young college students.

OBJECTIVE: To assess the awareness among students about the disease, their attitude during the outbreak, along with their perceptions about treatment, and severity of disease. METHODS: A cross sectional study was conducted among 220 intermediate students. The data was collected through a self filled questionnaire after taking verbal consent. The variables included in this study were age, gender and department (medical/non-medical). RESULTS: A total of 220 students participated with mean age of 17 +/- 1 year. There were 132 (61%) males and 84 (39%) females. The students were divided into pre-medical 110 (50%) and non-premedical 110 (50%). About 211 (96%) students said that they had heard about bird flu but only 86 (39%) correctly identified it as a disease of birds and humans both. One hundred and fifty-four (70%) participants said that virus causes it and the most common source of knowledge was media (T.V) by 153 (70%) followed by newspaper 113 (51%) respondents. Flu like symptoms were identified by 77 (35%) and 160 (73%) considered birds to human as the most likely route of transmission. Regarding vaccine, 133 (70%) replied that it is not available and 80 (41%) said that there is a treatment for the disease. About 143 (73%) thought that it is life-threatening. According to 105 (48%) the suitable preventive measure taken by the government would be to kill susceptible chickens. CONCLUSION: The awareness regarding bird flu was quite low among students. As bird flu is a world wide public health problem therefore increasing awareness would be a solution to avoid its spread and complications.