Evaluation of lay health workers' needs to effectively support anti-tuberculosis treatment adherence in Malawi.

OBJECTIVE: To identify barriers and facilitators to efforts by lay health workers (LHWs) to support anti-tuberculosis treatment adherence in Malawi to inform the design of a knowledge translation intervention for improving adherence. DESIGN: Qualitative study utilizing focus groups and interviews conducted with LHWs providing tuberculosis (TB) care in Zomba District, Malawi. RESULTS: Participants identified lack of knowledge, both general (understanding of TB and its treatment) and job-specific (understanding of tasks such as completion of treatment forms), as the key barrier to LHWs in their role as adherence supporters. Lack of knowledge among LHWs providing TB care was reported to lead to a lack of confidence, conflicting messages given to patients, poor interactions with patients and errors in documentation. In addition to lack of knowledge, a number of system barriers were identified as limiting LHWs' ability to function optimally, including a lack of physical resources, workload, communication delays and ineffective guardians. CONCLUSION: Our findings suggest a gap between LHW knowledge and their responsibilities as adherence supporters. The results have informed the development of an educational outreach intervention and point-of-care tool, to be evaluated in a randomized trial in Zomba District.

La extracción de un hemograma antes de la valoración médica retrasa la administración de antibióticos en los pacientes con fiebre neutropénica en urgencias / Complete blood counts testing before physician assessment delays antibiotics in Emergency Febrile Neutropenia patients

Objetivo: La fiebre neutropénica (FN) se asocia a una alta mortalidad y requiere un tratamiento antibiótico precoz. Los procedimientos en urgencias, como las pautas preestablecidas de extracción de analíticas en el triaje, pueden disminuir los retrasos. Se evalua si el disponer de un hemograma con anterioridad a la primera valoración médica se asocia con una reducción del tiempo puerta-antibiótico. Método: Se revisaron los datos de 83 pacientes con FN ingresados en un hospital terciario durante 11 meses. El tiempo puerta-antibiótico se calculó como aquél correspondiente entre el momento del triaje y el de la administración del tratamiento. El principal factor de predicción fue la disponibilidad de los resultados del hemograma antes de la visita médica. Resultados: Se incluyó 72 pacientes [36% varones, edad de 58 (DE 14) años], todos clasificados con categorías altas de gravedad (I, II ó III) de triaje. El 50% tuvieron los resultados disponibles del hemograma cuando fueron valorados por primera vez por el urgenciólogo; y en ellos fue mayor el de tiempo puerta antibiótico que en los que no tuvieron un hemograma disponible (224 vs 83 minutos, p < 0,05). El 90% de los pacientes fueron diagnosticados de FN en urgencias y el 93% fueron tratados con antibióticos intravenosos. En un análisis de regresión logística, la valoración médica previa a los resultados del hemograma se asoció con un tiempo puerta-antibiótico más corto(-84 minutos; p = 0,051), mientras que los casos atendidos en fin de semana se asociaron con un mayor tiempo puerta-antibiótico (+151 minutos, p = 0,002).Conclusión: El tiempo puerta-antibiótico es un indicador factible de la calidad en la atención de los pacientes con FN. La mayoría de los pacientes son diagnosticados y tratados en urgencias. Los hallazgos del estudio no sugieren que disponer de los resultados de un hemograma en el momento de la primera valoración médica reduzca el tiempo puerta-antibiótico (AU)

Objective: Febrile neutropenia (FN) has high mortality and requires prompt antibiotic therapy. Emergency Department(ED) processes, such as standing orders for blood tests at triage, may reduce delays. We evaluated whether having complete blood counts (CBC) available prior to first physician assessment was associated with shorter door-to-antibiotic(DTA) time. Methods: Electronic and chart data was reviewed on 83 FN patients admitted to a tertiary care center over 11 months. DTA time was calculated from triage to delivery of drug. The main predictor was CBC result available before physician encounter. Results: Among 72 patients included, 36% were male, with a mean age of 58±14. All were given high acuity triagecodes, 50% had CBC results available when first assessed by the ED physician; their mean DTA time was longer than those who did not have a CBC available (224 min vs 83, p < 0.05). Although 90% of patients were diagnosed as “FN” in the ED, 93% were treated with IV antibiotics. In multivariable regression analysis, seeing a physician before CBC results was associated with shorter DTA time (–84 min, p = 0.0514), while weekend cases were associated with a longer DTAtime (+151 min, p = 0.0023).Conclusion: DTA time is a feasible measure of quality of care for FN patients. Most patients are diagnosed and treated inED. Our findings do not suggest that having a CBC result available at the first physician assessment reduces DTA time (AU)

Emergency department overcrowding following systematic hospital restructuring: trends at twenty hospitals over ten years.

OBJECTIVE: Hospital restructuring often results in fewer inpatient beds, increased ambulatory services, and closures of hospitals or emergency departments (EDs). The authors sought to determine the impact of systematic hospital restructuring on ED overcrowding. METHODS: Time series analyses of average monthly overcrowding for EDs in Toronto, Ontario, Canada, from 1991 and 2000 (n = 20 hospitals, 120 months) were conducted. Autoregression models evaluated the rate of increase of overcrowding before and during systematic restructuring. A secondary analysis included total ED visits, patient age, and sex distribution as covariates. Seasonality was assessed by means of spectral analysis. RESULTS: Severe and moderate overcrowding averaged 3% and 14% of the time each month, respectively, over the whole period. Before restructuring (n = 74 months), severe and moderate overcrowding averaged 0.5% and 9% per month, respectively; during restructuring (n = 46 months), the monthly averages were 6% and 23%, respectively. Neither severe nor moderate overcrowding was increasing before restructuring. During restructuring, however, both increased significantly (severe 0.2% per month [p < 0.0001]; moderate 0.5% per month [p < 0.0001]). Similar results were found after controlling for ED utilization. Female gender independently predicted increased overcrowding; older age predicted reduced moderate overcrowding; number of total visits was not a predictor. Spectral analysis revealed significant seasonality in overcrowding. CONCLUSIONS: Hospital restructuring was associated with increased ED overcrowding, even after controlling for utilization and patient demographics. Restructuring should proceed slowly to allow time for monitoring of its effects and modification of the process, because the impact of incremental reductions in hospital resources may be magnified as maximum operating capacity is approached.

Problems for clinical judgement: 4. Surviving in the report card era.

Health care report cards involve comparisons of health care systems, hospitals or clinicians on performance measures. They are going to be an important feature of medical care in Canada in the new millennium as patients demand more information about their medical care. Although many clinicians are aware of this growing trend, they may not be prepared for all of its implications. In this article, we provide some historical background on health care report cards and describe a number of strategies to help clinicians survive and thrive in the report card era. We offer a number of tips ranging from knowing your outcomes first to proactively getting involved in developing report cards.

Problems for clinical judgement: 3. Thinking clearly in an emergency.

The resuscitation of a patient in extremis is frequently characterized by chaos and disorganization, and is one of the most stressful situations in medicine. We reviewed selected studies from the fields of anesthesia, emergency medicine and critical care that address the process of responding to a critically ill patient. Individual clinicians can improve their performance by increased exposure to emergencies during training and by the incorporation of teamwork, communication and crisis resource management principles into existing critical care courses. Team performance may be enhanced by assessing personality factors when selecting personnel for high-stress areas, explicit assignment of roles, ensuring a common "culture" in the team and routine debriefings. Over-reliance on technology and instinct at the expense of systematic responses should be avoided. Better training and teamwork may allow for clearer thinking in emergencies, so that knowledge can be translated into effective action and better patient outcomes.

Problems for clinical judgement: 1. Eliciting an insightful history of present illness.

This article presents the results of a review of studies of psychology that describe how ordinary human reasoning may lead patients to provide an unreliable history of present illness. Patients make errors because of mistakes in comprehension, recall, evaluation and expression. Comprehension of a question changes depending on ambiguities in the language used and conversational norms. Recall fails through the forgetting of relevant information and through automatic shortcuts to memory. Evaluation can be mistaken because of shifting social comparisons and faulty personal beliefs. Expression is influenced by moods and ignoble failures. We suggest that an awareness of how people report current symptoms and events is an important clinical skill that can be enhanced by knowledge of selected studies in psychology. These insights might help clinicians avoid mistakes when eliciting a patient's history of present illness.

Problems for clinical judgement: 2. Obtaining a reliable past medical history.

Ordinary human reasoning may lead patients to provide an unreliable history of past experiences because of errors in comprehension, recall, evaluation and expression. Comprehension of a question may change depending on the definition of periods of time and prior questions. Recall fails through the loss of relevant information, the fabrication of misinformation and distracting cues. Evaluations may be mistaken because of the "halo effect" and a reluctance to change personal beliefs. Expression is influenced by social culture and the environment. These errors can also occur when patients report a history of present illness, but they tend to be more prominent with experiences that are more remote. An awareness of these specific human fallibilities might help clinicians avoid some errors when eliciting a patient's past medical history.

Complex emergencies: expected and unexpected consequences.

Complex emergencies emerged as a new type of disaster following the end of the Cold War, and have become increasingly common in recent years. Human activity including civil strife, war, and political repression often coexist with and contribute to natural phenomena such as famine. They frequently result in high mortality, population displacement, and the disruption of civil society and its infrastructure. This article reviews the context of recent complex emergencies, and their expected health consequences, such as diarrhea, measles, malnutrition and outbreaks of infectious disease, and the disruption of mechanisms of disease control and surveillance. However, the complex nature of these emergencies also may have unexpected consequences, such as hindering understanding of their causes or limiting the attention paid to them by the public. This paper discusses the context and consequences of complex emergencies from the health standpoint, and explores some of their unexpected effects.

Rape in war: the humanitarian response.

Women and children are vulnerable to sexual violence in times of conflict, and the risk persists even after they have escaped the conflict area. The impact of rape goes far beyond the immediate effects of the physical attack and has long-lasting consequences. We describe the humanitarian community's response to sexual violence and rape in times of war and civil unrest by drawing on the experiences of Médecins Sans Frontières/Doctors Without Borders and other humanitarian agencies. Health care workers must have a keen awareness of the problem and be prepared to respond appropriately. This requires a comprehensive intervention protocol, including antibiotic prophylaxis, emergency contraception, referral for psychological support, and proper documentation and reporting procedures. Preventing widespread sexual violence requires increasing the security in refugee camps. It also requires speaking out and holding states accountable when violations of international law occur. The challenge is to remain alert to these often hidden, but extremely destructive, crimes in the midst of a chaotic emergency relief setting.

Continuous electrocardiographic monitoring and cardiac arrest outcomes in 8,932 telemetry ward patients.

OBJECTIVE: To estimate the benefit of routine electrocardiographic (ECG) telemetry monitoring on in-hospital cardiac arrest survival. METHODS: In a tertiary care hospital, all telemetry ward admissions and cardiac arrests occurring over a five-year period were reviewed. Ward location and survival to discharge were determined for all patients outside of critical care areas. RESULTS: During the study period, 8,932 patients were admitted to the telemetry ward, and 20 suffered cardiac arrest (0.2%; 95% CI = 0.1 to 0.3). Telemetry monitors signaled the onset of cardiac arrest in only 56% (95% CI = 30 to 80) of monitored arrests. Three patients survived to discharge, and in two of these three patients the arrest onset was signaled by the monitor. This yields a monitor-signaled survival rate among telemetry ward patients of 0.02% (95% CI = 0 to 0.05). All survivors suffered significant arrhythmias prior to their cardiac arrests. CONCLUSIONS: Cardiac arrest is an uncommon event among telemetry ward patients, and monitor-signaled survivors are extremely rare. Routine telemetry offers little cardiac arrest survival benefit to most monitored patients, and a more selective policy for telemetry use might safely avoid ECG monitoring for many patients.

Lumbar puncture first: an alternative model for the investigation of lone acute sudden headache.

Subarachnoid hemorrhage (SAH) is a diagnosis often considered in patients presenting to the ED with acute sudden headaches, but with normal physical examinations. Standard of care today is for these patients to be investigated by noncontrast CT scan followed by lumbar puncture (LP) for negative CTs. However, given that most investigated patients have benign headaches, most of the CT and LP results are normal. The authors studied, by means of a theoretical analysis, the impact of an alternative diagnostic model, in which LP would be the first (and, in most cases, only) diagnostic test for patients suspected of SAH who met lone acute sudden headache (LASH) criteria. Given reasonable assumptions, for every 100 patients investigated, the "LP-first" model would result in 79 to 83 fewer CT scans and only seven to 11 additional LPs, as compared with traditional strategies. Among ED headache patients meeting LASH criteria, the authors believe use of this model could result in more efficient use of resources, minimal additional morbidity, and equal diagnostic accuracy for SAH.