Moving beyond audit: driving system learning using a novel mortality classification system in a tertiary training hospital in Kenya.

Clinical classification systems have proliferated since the APGAR score was introduced in 1953. Numerical scores and classification systems enable qualitative clinical descriptors to be transformed into categorical data, with both clinical utility and ability to provide a common language for learning. The clarity of classification rubrics embedded in a mortality classification system provides the shared basis for discussion and comparison of results. Mortality audits have been long seen as learning tools, but have tended to be siloed within a department and driven by individual learner need. We suggest that the learning needs of the system are also important. Therefore, the ability to learn from small mistakes and problems, rather than just from serious adverse events, remains facilitated.We describe a mortality classification system developed for use in the low-resource context and how it is 'fit for purpose,' able to drive both individual trainee, departmental and system learning. The utility of this classification system is that it addresses the low-resource context, including relevant factors such as limited prehospital emergency care, delayed presentation, and resource constraints. We describe five categories: (1) anticipated death or complication following terminal illness; (2) expected death or complication given clinical situation, despite taking preventive measures; (3) unexpected death or complication, not reasonably preventable; (4) potentially preventable death or complication: quality or systems issues identified and (5) unexpected death or complication resulting from medical intervention. We document how this classification system has driven learning at the individual trainee level, the departmental level, supported cross learning between departments and is being integrated into a comprehensive system-wide learning tool.

Research activity, facilitators and barriers amongst trainee and early-career family physicians in sub-Saharan Africa: A cross-sectional survey.

BACKGROUND:  Primary health care systems in sub-Saharan Africa (SSA) need context-specific evidence to address current challenges. Increased family physician (FP) research activity could help fill this gap. AIM:  To describe the research activity, facilitators and barriers amongst AfriWon Renaissance members. SETTING:  An online programme was designed to improve research activity amongst members of AfriWon Renaissance, an organisation of early-career and trainee FPs in SSA. This article provides a baseline description of their research activity. METHODS:  All AfriWon Renaissance members were invited to participate in an online survey. A content-validated study tool assessed research activity, including participation in research meetings, engagement in research mentorship, number of projects and published articles. Facilitators and barriers were assessed via Likert scales and two open-ended questions. The researchers conducted descriptive statistics using Epi Info 7, a content analysis of open-ended responses and triangulation. RESULTS:  Amongst the 77 respondents, 49 (63.6%) were still in training. Over two-thirds (71.4%) had participated in a research discussion in the past month. Whilst more than half (63.5%) reported having a manuscript under development, only 26 (33.8%) reported a recent publication. Nearly all (94.8%) intend to continue research in their FP careers. The most common facilitators were the institutional requirement to conduct research and having supportive peers and mentors. The most predominant barriers were time constraints and a lack of training on analysis. CONCLUSION:  There is a cohort of committed young FP researchers who would benefit from efforts to address identified barriers and support for their ongoing research activity, in order to increase primary care research outputs in SSA.

Coping with COVID: Developing a Rapid-cycle Frontline Quality-improvement Process to Support Employee Well-being and Drive Institutional Responsiveness in a Tertiary Care Faith-based Hospital in Rural Kenya.

The coronavirus disease 2019 (COVID-19) pandemic has demanded rapid institutional responses to meet the needs of patients and employees in the face of a serious new disease. To support the well-being of frontline staff, a series of debriefing sessions was used to drive a rapid-cycle quality-improvement process. The goals were to confidentially determine personal coping strategies used by staff, provide an opportunity for staff cross-learning, identify what staff needed most, and provide a real-time feedback loop for decision-makers to create rapid changes to support staff safety and coping. Data were collected via sticky notes on flip charts to protect confidentiality. Management reviewed the data daily. Institutional responses to problems identified during debrief sessions were tracked, visualized, addressed, and shared with staff. More than 10% of staff participated over a 2-week period. Feedback influenced institutional decisions to improve staff schedules, transportation, and COVID-19 training.

Pragmatic Recommendations for Safety while Caring for Hospitalized Patients with COVID-19 in Low- and Middle-Income Countries.

Infection prevention and control measures to control the spread of COVID-19 are challenging to implement in many low- and middle-income countries (LMICs). This is compounded by the fact that most recommendations are based on evidence that mainly originates in high-income countries. There are often availability, affordability, and feasibility barriers to applying such recommendations in LMICs, and therefore, there is a need for developing recommendations that are achievable in LMICs. We used a modified version of the GRADE method to select important questions, searched the literature for relevant evidence, and formulated pragmatic recommendations for safety while caring for patients with COVID-19 in LMICs. We selected five questions related to safety, covering minimal requirements for personal protective equipment (PPE), recommendations for extended use and reuse of PPE, restriction on the number of times healthcare workers enter patients' rooms, hand hygiene, and environmental ventilation. We formulated 21 recommendations that are feasible and affordable in LMICs.

Pregnancy in a patient with portal hypertension secondary to liver cirrhosis.

This case report is of a 32-year-old woman of African descent on follow-up for pregnancy in the background of portal hypertension due to liver cirrhosis. She had initially been treated for chronic hepatitis B infection with lamivudine and tenofovir, complicated by portal hypertension and variceal bleeding that thrice required banding. Her pregnancy was uneventful until 31 weeks gestation when she presented with dyspnoea. On examination and investigation, she had oedema, bilateral pleural effusions and ascites. Multidisciplinary discussions involving surgery, anaesthesia, obstetrics, neonatology and medicine were held. A consensus outpatient and inpatient management plan was implemented. At 36 weeks, following non-reassuring fetal cardiotocography, she underwent induction of labour. An assisted vacuum delivery was conducted in a controlled setting. She gave birth to a live female infant who had an APGAR score of 9 at 5 min. Both she and the baby had an uneventful postpartum period.