Gender differences in factors associated with prehospital delay among acute coronary syndrome patients in Pakistan.

PURPOSE: To identify gender differences in prehospital delay time (PDT) and its associated factors among acute coronary syndrome (ACS) patients. DESIGN: Descriptive cross-sectional comparative study. METHODS: This study was conducted among 249 ACS patients at two tertiary care hospitals of a large metropolitan city of Pakistan. Data were collected through the modified Response to Symptoms Questionnaire. RESULTS: The median PDT of women was found to be 7 hours, compared to 3.5 hours among men (p = .001). Results of the regression analysis indicated that most women delayed because of social factors, such as attendants' responses to their symptoms (p = .002), and because they were worried about expenses required for the treatment (p = .002); yet, most men delayed owing to individual factors, such as waiting for symptoms to subside (p< .001), and not recognizing the symptoms as being cardiac related (p< .001). Having anxiety and lack of knowledge about symptoms was associated with extended PDT among both genders. CONCLUSION: Women delayed longer than men in seeking treatment for their ACS symptoms. Different factors were associated with PDT in women and men. This study may provide important insights for designing interventional studies to reduce PDT in Pakistani ACS patients.

Validity and reliability testing: Urdu translated modified Response to Symptoms Questionnaire.

OBJECTIVE: To determine validity and reliability of the Urdu translated, modified "Response to symptoms questionnaire" (RSQ) among acute coronary syndrome (ACS) patients in Karachi. STUDY DESIGN: A qualitative, tool validation study. PLACE AND DURATION OF STUDY: Two tertiary care hospitals in Karachi, the Aga Khan University Hospital, Karachi and the Karachi Institute of Heart Diseases, from December 2010 to April 2011. METHODOLOGY: After making certain modifications, the original tool in English was translated into Urdu. Next, five cardiology experts evaluated the tool for its content and face validity. Test retest and inter rater reliabilities were computed for the RSQ using 5% of the total sample size of the parent study. RESULTS: Sufficient conceptual and semantic equivalence was found between the Urdu and English versions of the modified RSQ. Content validity index was calculated to be 1 for both relevance and linguistic clarity. Test retest and inter rater reliabilities were calculated to be 95.9% and K = 0.97, respectively. CONCLUSION: The Urdu translated modified RSQ has sufficiently acceptable content validity, test retest and inter rater reliability; hence, it should be used by the researchers for the evaluation of factors associated with pre-hospital delay among Urdu speaking ACS patient populations.

Self-glucose monitoring and glycaemic control at a tertiary care university hospital, Karachi, Pakistan.

OBJECTIVE: To explore the association between Self Monitoring of Blood Glucose (SMBG) levels and improved glycemic control (HbA1c level) among type 2 diabetic patients, receiving oral hypoglycaemic agents and insulin, and to ascertain the factors influencing SMBG. METHOD: Using Comparative cross sectional study design five hundred Type 2 diabetes patients through convenient sampling between 30-70 years were interviewed through a structured questionnaire in year 2006 and 2007 at AKUH Ambulatory setting. These 500 subjects were divided as 250 in case (doing SMBG) and 250 in control (not doing SMBG) groups. RESULTS: We identified that HbA1c value was maintained at good and fair levels in case (56%) as compared to controls (p=0.002). There was a high association of SMBG with education level, as graduate and above were monitoring SMBG at high level as evident by (p=0.005). Furthermore, there was a high association of SMBG with duration of diabetes as subjects having diabetics more than 5 years were monitoring their blood glucose level at frequent intervals (p=0.001). In case, 96.8% subjects had knowledge about the target of fasting and random blood glucose in comparison to 91.6% subjects in controls. The frequency of blood sugar checking varied among all subjects in case group such as 55% checked their blood sugar occasionally, 26% monitored daily, and 13% twice a day and 3% checked their blood sugar before and after each meal. CONCLUSION: Self-monitoring of blood glucose levels was associated with clinically and statistically better glycaemic control regardless of diabetes type or therapy. Therefore, healthcare personnel must increase awareness on the importance of SMBG and strongly promote this practice among diabetic patients.

Impact of infection control activities on the rate of needle stick injuries at a tertiary care hospital of Pakistan over a period of six years: an observational study.

BACKGROUND: Accidental exposure to blood and body fluids is frequent among health care workers. They are at high risk of nosocomial transmission of blood borne pathogens due to injuries caused by used sharps. We are reporting impact of surveillance and educational program on the rate of needle stick injuries among health care workers at a tertiary care hospital in Pakistan. METHODS: At Aga Khan University Hospital sharp injuries are reported to infection control office. To reduce these incidents a quality improvement project was inducted in the year 2005. Health care workers were educated; surveillance data from 2002 to 2007 was analyzed and compared with various risk factors. RESULTS: During study period 1382 incidents were reported. Junior doctors sustained highest number of injuries (n = 394; 28.5%) followed by registered nurses (n = 283; 20.4%). Highest number of incidents was reported during blood collection (19%). An increasing trend was observed in the pre intervention years (2002-04). However noticeable fall was noted in the post intervention period that is in year 2006 and 2007. Major decline was noted among nurses (from 13 to 5 NSI/100 FTE/year). By relating and comparing the rates with various activities directly linked with the use of syringes a significant reduction in incidents were found including; hospital admissions (p-value 0.01), surgeries and procedures performed (p = 0.01), specimens collected in the laboratory (p = 0.001) and patients visits in clinics (p = 0.01). CONCLUSION: We report significant reduction in needle stick injuries especially during post intervention study period. This is being achieved by constant emphasis on improving awareness by regular educational sessions, implemented as a quality improvement project.

A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan.

INTRODUCTION: Administering medication is one of the high risk areas for any health professional. It is a multidisciplinary process, which begins with the doctor's prescription, followed by review and provision by a pharmacist, and ends with preparation and administration by a nurse. Several studies have highlighted a high medication incident rate at several healthcare institutions. METHODS: Our study design was exploratory and evaluative and used methodological triangulation. Sample size was of two types. First, a convenient sample of 1000 medication dosages to estimate the medication error (95% CI). We took another sample from subjects involved in medication usage processes such as physicians, nurses, pharmacists, and patients. Two sets of instruments were designed via extensive literature review: a medication tracking error form and a focus group interview questionnaire. RESULTS: Our study findings revealed 100% compliance with a computerized physician order entry (CPOE) system by physicians, nurses, and pharmacists. The main error rate was 5.5% and pharmacists contributed an higher error rate of 2.6% followed by nurses (1.1%) and physicians (1%). Major areas for improvement in error rates were identified: delay in medication delivery, lab results reviewed electronically before prescription, dispension, and administration.

Utilization of King's interacting systems framework and theory of goal attainment with new multidisciplinary model: clinical pathway.

BACKGROUND: The critical role of research in nursing practice is the application of nursing theories to discover new knowledge. This study uses King's interacting systems framework and theory of goal attainment to investigate the effectiveness of implementing clinical pathways for patients undergoing transurethral resection of prostate (TURP) at Aga Khan University Hospital (AKUH), Pakistan. OBJECTIVE: To assess the impact of the implementation of a clinical pathway for the surgical procedure of TURP on clinical quality, cost, and patient and staff satisfaction. STUDY DESIGN: Quasi-experimental, non-equivalent control group study design using clinical pathway intervention. SETTING: Aga Khan University Hospital (AKUH). SUBJECTS: The study population consisted of a convenience sample of patients undergoing surgery for TURP (control and experimental) and health team members (nurses, physicians and others). STUDY FINDINGS: Findings showed a significant difference in variances and outcomes as a result of TURP clinical pathway intervention. The clinical pathway significantly improved all twelve nursing and physician related variances and outcomes, such as: complete documentation; delayed consultation; delayed education; and other variances. Clinical pathway intervention also significantly reduced hospital related variances, and post-operative problems such as electrolyte imbalance, phlebitis, constipation, and urinary tract infection (UTI). The findings also showed significant improvement in patient and staff satisfaction, however no significant difference was observed in patient, hospital and financial related variances. The current investigation identified that successful implementation of integrated clinical pathways can help health professionals, managers and administrators to meet one of their biggest challenges in making optimal use of limited resources while delivering high quality and timely care.

A university-sponsored home health nursing program in Karachi, Pakistan.

This article describes a university-sponsored home health nursing program in a large urban center in Pakistan and details the essential elements needed in implementing such a program in a developing country. Compared to in-hospital treatment, home healthcare reduced hospital stay from 12.8 days to 3.9 days, and resulted in a net savings of Pakistani rupees (PRs) 5,374,135 (USD 89,569). A cost-effective home treatment program in a resource-limited country can be successfully implemented by using the hospital pharmacy as the central point for the preparation and distribution of medications and specialty nursing services.

Registered nurses perception of work satisfaction at a Tertiary Care University Hospital.

Hospitals are facing serious challenges to provide high quality care with current nursing shortages. Nursing shortages are of major concern for Nursing Management, clinicians and administrators as they lead to impact on quality of care. Under-stressed, frustrated and demoralized nurses give rise to concern for hospital Nursing Management in providing quality care according to set standards. A descriptive qualitative research design was used to explore the registered nurses' perceptions regarding the high turnover rates among nurses at a Tertiary Care University Hospital. Data was collected from nurses working at various speciality areas, which were: Critical Care, Medical and Surgical Care, Ambulatory Care, Maternal/Child and Emergency departments. A convenience sample of 45 registered nurses from nine subspecialty groups was selected for a focus group interview and five focus groups were selected for a study population. Findings of exit interviews (from 1 September 2001 to 28 February 2002) were also included in the data analysis. These exit interviews of RNs were conducted by Nurse Recruiter at the time of their resignations. The data analysis showed that the most dissatisfying factors at work and within the work setting were identified as: high workload, stress associated with high workload, biased Nursing Management, lack of appreciation and monetary incentives, finally a rigid attitude of Nursing Management. However, the most satisfying factors were: working with an internationally reputable organization, patients' positive feedback and availability of required material or equipment. The study participants recommended that nursing retention could be improved at the Tertiary Care University Hospital by launching the following strategies by Nursing Management: reducing workload by adequate nurse-patient ratios according to international standards, promoting respect of nurses in front of patients and other staff, rewards and recognition of nurses, simplifying nursing documentation, increasing recreational activities for nurses and empowering nurses and Nursing Management group.

The impact on Asian health care systems of nursing migration.

Nurses are precious resource in every corner of the world and hospitals are facing serious challenges in providing high quality care with current nursing shortages. While the shortage of nurses is a worldwide issue, impacting currently more on under developed countries, little literature is available on this aspect of the issue. Lots of job opportunities are available for nurses in western countries, advertised on a daily basis, that attract nurses and result in major nursing migration from Asian countries to the western world.

Defining the cultural milieu for implementing faculty practice in Pakistan.

Faculty practice can promote a collaborative partnership mutually beneficial to both nursing education and service. However, little is known about its implementation in developing countries. The purpose of this study was to explore the potential for introducing faculty practice within the cultural milieu of Karachi, Pakistan. Focus groups of nursing faculty, staff and students were conducted in various settings: government, semigovernment and private institutions to elicit the data. Data analysis revealed that a more comprehensive definition of faculty practice is needed that will provide the foundation for a culturally acceptable model of faculty practice in Pakistan. Hierarchy dominates the current cultural milieu and must be addressed before faculty practice can be implemented.