Patient Satisfaction with the Outpatient Department Services at a Tertiary Care Hospital in Northern India and Root Cause Analysis of the Lowest-Scoring Attribute using Fishbone Diagram.

BACKGROUND: Assessing patients' satisfaction is an easy and cost-effective method of evaluating the outpatient services provided by health-care institutions. OBJECTIVES: The objectives of this study were to determine patient satisfaction among patients attending various outpatient departments (OPDs) at a tertiary care hospital and the factors affecting their satisfaction. MATERIALS AND METHODS: A cross-sectional study was conducted among patients attending various OPDs at a tertiary care hospital in Faridabad. Exit face-to-face interviews were conducted for 334 patients above 18 years of age who availed OPD services followed by pharmacy services. Information regarding sociodemography, rating of satisfaction with various attributes of OPD services on a 5-point Likert scale, and reasons for dissatisfaction was collected. Data were analyzed using SPSS version 22. Root cause analysis for the lowest-scoring attribute was done using fishbone diagram. RESULTS: About 64% of the patients were satisfied with the OPD services. "Attitude and communication of doctors" was the prime contributor to patient satisfaction. "Promptness at medicine distribution counter" was the attribute that scored lowest followed by "waiting time at the registration counter." The mean waiting time for registration was 38.2 min, for consultation with doctor 41.3 min, for collection of samples 49.6 min, and for drug dispensing 61 min. CONCLUSION: The issues related to pharmacy services need to be promptly acknowledged and addressed.

Economic Hardships in Managing COVID-19 Patients in the Intensive Care Unit: A Retrospective Observational Study at a Tertiary Care Hospital in North India.

BACKGROUND: The information on healthcare expenditure is crucial to know the impact of the pandemic on public health budgets, thereby correctly managing the ongoing crisis and preparing for subsequent waves. OBJECTIVE: To estimate the length of stay and cost incurred on COVID-19 patients who died in the ICU. METHODS: It is a record-based descriptive study conducted on 76 deceased COVID-19 patients admitted to the ICU of a dedicated COVID-19 hospital (DCH) between April and October 2020. Central Government Health Services (CGHS) package rate list, Delhi-NCR, was used as a reference for the cost of the ICU bed, ventilator, investigations, and procedures. RESULTS: The median duration of stay in the hospital was 12 days, and in the ICU, it was eight days. The median total cost of managing the patient was 91,235.6 INR; of this, the median total cost for ICU stay per patient was 6,904 INR. The major proportion of total expenses was contributed by personal protective equipment (PPE) kits, an average of 11,091.33 INR per month. The median cost of stay in the ICU, on the ventilator, in the ward, and mean cost of investigations were higher among those with associated co-morbidities. CONCLUSION: Most elderly male with co-morbidities lost their battle after ventilator support in the ICU. Patients with co-morbidities and severe disease not only have a long duration of hospitalization and poor survival rate but also fetch an economic burden close to one lakh on the institute.

Application of a Negative Intrauterine Pressure Suction Device for Prophylactic Management of Atonic Postpartum Hemorrhage: A Quality Improvement Study.

BACKGROUND: Postpartum hemorrhage (PPH) is the leading cause of maternal mortality worldwide. PPH-preventing interventions need to be prioritized and can be integrated with conventional methods of PPH prevention. The introduction of negative intrauterine pressure using a suction cannula can be one of the cheapest modalities to decrease PPH secondary to uterine atonicity. This method has brought a renaissance to practical obstetrics in low-middle income countries (LMIC), where the cost and availability of uterotonics are major health issues. METHODS: It was a prospective quality improvement (QI) study conducted in the labor and delivery wards of a tertiary care medical institute and teaching center over the duration of one year. We aimed to assess the decrease in the incidence of atonic PPH with a negative intrauterine pressure suction device (NIPSD) integrated with active management of the third stage of labor (AMTSL) in the prevention of atonic PPH following normal vaginal delivery in low-risk antenatal women. In the initial six months, routine AMTSL was instituted for all consenting women (group 1). In the next six months, NIPSD was integrated with AMTSL (group 2). Data pertaining to the amount of blood loss, the incidence of primary PPH, uterine tone, fall in hemoglobin and hematocrit levels post-delivery, need for blood transfusion, and doctor and patient satisfaction were tabulated for all patients. RESULTS: A total of 1324 consenting women were eligible for enrollment during the study time frame. In the initial six months (baseline period, group 1), 715 participants were subjected to routine AMTSL in the third stage of labor. During the intervention phase (group 2), 609 parturient women were recruited. There was no significant difference in baseline parameters between the two groups. With the introduction of NIPSD to routine AMTSL, there was a significant decrease in the average volume of blood loss during vaginal delivery (group 1 = 389.45+65.42 ml, group 2 = 216.66+34.27 ml; p-value = 0.012). The incidence of atonic PPH was reduced by more than 75% (group 1 = 13 women, group 2 = 3 women; p-value = 0.001) after the introduction of NIPSD complementing routine AMTSL. The introduction of NIPSD has also been instrumental in reducing the cost burden on patient and hospital expenditures. The net benefit of its introduction resulted in a reduction of the overall cost burden of blood transfusions by around 70%. CONCLUSION: PPH is a public health problem, and measures to reduce PPH must be implemented to decrease this health burden. In countries with low resources, complementing routine AMTSL with NIPSD can be instrumental in decreasing the incidence of PPH. Considering its cost-effectiveness and reusability, LMIC can adopt NIPSD as a routine measure in all vaginal deliveries.

Gender differences in genotypic distribution of endothelin-1 gene and endothelin receptor A gene in pulmonary hypertension associated with rheumatic mitral valve disease.

INTRODUCTION: The female gender is a risk factor for idiopathic pulmonary arterial hypertension. However, it is unknown whether females with rheumatic mitral valve disease are more predisposed to develop pulmonary hypertension compared to males. AIM: We aimed to investigate whether there was a difference in genotypic distribution of endothelin-1 (ET-1) and endothelin receptor A (ETA) genes between female and male patients of pulmonary hypertension associated with rheumatic mitral valve disease (PH-MVD). METHODS: We compared prevalence of ET-1 gene (Lys198Asn) and ETA gene (His323His) polymorphisms according to gender in 123 PH-MVD subjects and 123 healthy controls. RESULTS: The presence of mutant Asn/Asn and either mutant Asn/Asn or heterozygous Lys/Asn genotypes of Lys198Asn polymorphism when compared to Lys/Lys in females showed significant association with higher risk (odds ratio [OR] 4.5; p =0.007 and OR 2.39; p =0.02, respectively). The presence of heterozygous C/T and either mutant T/T or heterozygous C/T genotypes of His323His polymorphism when compared to wild C/C genotype in females showed a significant association with higher risk (OR 1.96; p =0.047 and OR 2.26; p =0.01, respectively). No significant difference was seen in genotypic frequencies in males between PH-MVD subjects and controls. Logistic regression analysis showed that mutant genotype Asn/Asn (p =0.007) and heterozygous genotype Lys/Asn of Lys198Asn polymorphism (p =0.018) were independent predictors of development of PH in females. CONCLUSIONS: ET-1 and ETA gene polymorphisms were more prevalent in females than males in PH-MVD signifying that females with rheumatic heart disease may be more susceptible to develop PH.

Mortality analysis of COVID-19 cases during the second wave and its comparison with the first wave: A hospital-based study.

Objectives: This study was undertaken to determine the characteristics of COVID-19 deaths during the second wave and to compare these characteristics with the mortality during the first wave in a dedicated COVID hospital (DCH). Study Design: It was a hospital record-based descriptive study. Methodology: The study was conducted in a tertiary care COVID hospital, using a standard death audit proforma. The data were analyzed to know various demographic characteristics and factors related to mortality during the second wave from March to June 2021. The findings were compared with the mortality data during the first wave from April to July 2020 at the same hospital. Results: A total of 264 deaths occurred at the center during the study period with a mortality rate of 22.8%. Male cases were more in number, the age group was 21-70 years, the highest number of mortality was seen in the mid of the study period, duration of stay was five days on average and common causes of death were pneumonia alone or with acute respiratory distress syndrome with sepsis. In comparison to the first wave, the mortality rate was four times higher, the age group was younger and opportunistic infections viz. mucormycosis and aspergillosis were present during the second wave. Conclusion: The mortality rate was significantly higher and the younger age groups were involved during the second wave, with opportunistic fungal infections due to the use of immunomodulators.

Are numbers deceptive? Is death auditing a solution for death analysis, among the COVID-19 deceased?: A study from a dedicated COVID-19 hospital in Faridabad, Haryana.

BACKGROUND: COVID-19 pandemic has havocked the entire world and India has not been spared. The focus is not only on the containment but on the reduction in mortality also. The objective of the study was to know the trend of COVID-19 deaths in a 510-bedded dedicated COVID-19 hospital and to determine the cause of death and various factors associated with these deaths. METHOD: A descriptive study was conducted in a COVID-dedicated hospital setting to analyze deaths occurring during April--July, 2020 using a standard death audit proforma. RESULTS: A total number of 95 COVID-19 patients died in ICU. The mortality rate among ICU patients varied from 24.6% to 52.9%. Most of the cases were referred from other hospitals. About 64% of the deceased was admitted in severe condition and 34% of cases were referred on ventilator support. The week-wise trend revealed a positive association between the number of deaths and the number of referred cases as well as the number of patients received on ventilator support and in severe condition. About one-third of cases were late in seeking treatment at health centers with the same weekly trend. Being unaware of the condition (1%) and the stigma associated with the disease (32%) were the reasons behind it. Common direct causes of death were pneumonia (73%), pneumonia complicated with sepsis (16%), and acute respiratory disease syndrome (ARDS) (7%). CONCLUSION: High case fatality rate in the ICU of a referral COVID-dedicated hospital is mainly because of the admission of patients in severe conditions.