Bed Head Tickets Research Articles

Exploring Clinical Documentation Practices among Healthcare Staff: A Clinical Audit of National Hospital Galle, Sri Lanka

Introduction: Valid and trustworthy clinical documentation improves patient outcomes, boosts hospital data accuracy, and enhances reflective action to improve healthcare service quality and safety. In Sri Lanka, the bedhead ticket (BHT) is the legal documentation record for inpatients. In 2022, the Ministry of Health (MoH) issued new rules for the correct maintenance of BHTs.Objective: This clinical audit's objective was to assess the in-patient clinical documenting practices at National Hospital Galle (NHG), Sri Lanka.Methodology: A total of 384 randomly selected BHTs from the record room, which belonged to patients who received inward care from April 2023 to September 2023, were included in this clinical audit. A checklist and a marking scheme were prepared according to MoH guidelines and filled out after going through each BHT.Results: The level of completeness of the first page was good in 96% of BHTs. Maintenance of continuation sheets was average in 82%of BHTs and good in only 2%. Around 67% of BHTs obtained good marks for the level of completeness of entries. Only 1% of BHTs had entries with a signature placed at the end. The date and time of the entry were recorded in 73.5% and 64.3% consecutively.Conclusion: Adherence to the MoH guidelines for clinical documentation practices was satisfactory at NHG, and regular audits and staff awareness and training are required to maintain the standards.

Assessment of the use of antibiotics based on the WHO access, watch, and reserve index in a multidisciplinary intensive care unit of a medical college in Eastern India

Background: Antibiotics are frequently prescribed to critically ill patients admitted to intensive care units (ICUs). About 30–60% of antibiotics prescribed in ICUs are unnecessary, inappropriate, or suboptimal and contribute substantially to the development of antimicrobial resistance. Aims and Objectives: The present study was undertaken to assess the use of antibiotics based on the World Health Organization (WHO) access, watch, and reserve (AWaRe) index in a multidisciplinary ICU of a medical college and hospital in Eastern India. Materials and Methods: The descriptive past record-based study was carried out among patients admitted in the multidisciplinary ICU of a medical college and hospital over 6 months. Information from the ICU bed head tickets (BHTs) was captured in a data record form and analyzed. Results: A total of 97 BHTs were reviewed, and 257 antibiotics were prescribed to 90 patients. The prevalence of antibiotic use was 92.78%. Average number of antibiotics per patient was 2.85. In most instances (88.89%, 80), either two (28.88%), three (27.77%), or even four (20%) antibiotics were used. Frequency of use of AWaRe antibiotics was 21.43% (51/238), 67.23% (160/238), and 11.34% (27/238), respectively. Meropenem (15.12%, 36), piperacillin-tazobactam (36, 15.12%), and ceftriaxone (35, 14.70%) were the three most frequently prescribed watch group antibiotics. Most antibiotics were used empirically (60%), and 40% (36/90) use was targeted. Conclusion: Empirical treatment with antibiotics is common in ICUs. The WHO AWaRe tool may check the injudicious and unnecessary use of antibiotics and thus promotes the rational use of antibiotics and prevent the development of antibiotic resistance in ICUs.

Implementing an Antibiotic Stewardship Program in National Cancer Institute, Sri Lanka

Abstract Bacterial infection is a dreaded complication in cancer patients worldwide. In low resource settings where supportive care facilities are less than ideal this takes on even more greater significance. In recent years, the emergence of antimicrobial resistance (AMR) has become a significant problem worldwide and cancer patients are those among most affected. Treatment of infections due to Multi Drug Resistant (MDR) bacteria represents a clinical challenge because therapeutic options are limited. Overuse and misuse of antimicrobials has been acknowledged as a main driver for resistance development and the need to optimize the use of antimicrobials has been stressed. National Cancer Institute is not an exception, children with cancer develop infections due to MDR bacteria when they are neutropenic and mortality and morbidity of those infections are very high. Therefore antibiotic stewardship program (AMSP) was implemented in the pediatric units to optimize clinical outcome while minimizing the unwanted effects, with the rational prescribing of antibiotics. Pediatric Oncology unit comprises of four wards with 150 beds and an intensive care unit with 8 beds. As a preliminary step meetings were conducted to outline a plan of action with the participation of relevant stake holders, microbiology team and pediatric Oncology team. Director of the hospital was also involved to the program. Workshops were conducted to educate and train health care workers and to create awareness on AMR. Antibiogram was established to see the antibiotic resistant patterns of bacterial isolates in the hospital. The audit on antibiotic use was conducted to see the use of antibiotics in the units. Also feedback of the audit was given to the clinicians, it showed deviations from standard practices in the use of antibiotics. It was noted that the antibiotic resistance rates in the unit was very high for both gram negative and gram positive isolates. Clinical practice guideline on fever and neutropenia was developed based on the sensitivity pattern of the antibiogram. The guideline comprised of introduction, basic investigations, antibiotic recommendations, follow-up assessments and antimicrobial dose and frequency. The clinical practice guideline was displayed as a poster in all units near the doctors table. Small booklet was also printed with pediatric dose, duration and route of commonly used antibiotics with their indications. A new drug chart was introduced to patients' bed head ticket with a separate section for antimicrobials including history of allergy, designation of the prescriber, reminder to collect cultures, dose, route, duration and periodic review. Fourteen antibiotics were included in the preauthorization list, which require approval prior to use. Antibiotic resistant rates in the unit was alarmingly high. Therefore, there should be a mechanism for continuous monitoring and auditing. Infection control practices need to be strengthen to prevent the spread of MDR organisms. Better coordination between clinical microbiologist and physicians is required on local resistant patterns of microorganisms. Periodic training of hospital staff should be carried out on AMSP, including adverse reactions, antibiotic resistance and optimal prescribing. Evaluation of AMSP and their perceive level of success needs to be performed periodically.

Incisional herniae following lower segment caesarean section: A 20-year chart review

Introduction: The rates of caesarean delivery is increasing worldwide as well as in Sri Lanka. Incisional hernia is a known complication of abdominal surgery. To our knowledge there has been no study to assess the incidence of incisional hernia following caesarean section in Sri Lanka. This study was to assess the incidence of incisional hernia requiring surgical repair after lower segment caesarean section (LSCS) in a cohort during a 20-year period.Methods: This was a chart review based on tertiary care private sector hospital in Sri Lanka. Hernia repairs performed during 2002 to 2022 were identified. The data was retrieved from computer based data base and previous bed head tickets. The main inclusion criterion was a caesarean delivery from the 01st of January 2002 to 31st of December 2022 in women with no history of previous abdominal surgery. The cohort was assessed from their first caesarean delivery until 20 years in the inclusion period for an event of hernia repair. The following exclusion criteria for the hernia repairs were used: Diastasis rectiwithout hernia, hernia not in the caesarean incision, and no hernia. The study was approved by the Research and Ethical Committee of Nawaloka Hospital Sri Lanka. The patient records and the data-set were anonymized before analysis. No conflict of interest.Results: There were 2675 records retrieved. The mean age of the patients was 28±7.5 years. There were 10/2675 (0.37%) patients were found to incisional herniae following LSCS. The majority (7/10) of patients with incisional hernia had lower midline incisions for their LSCS. The average time duration of the occurrence of incisional hernia following a single LSCS was 19.5±2.3 months and it was 14.3±1.6 and 12.3±1.5 months for following second and third LSCS respectively. Majority of the incisional herniae were done as routine cases. Following the incisional hernia repair one patient had a recurrence after year.Conclusion: The overall incidence of having an incisional hernia requiring repair of a caesarean delivery was 0.37%. Most herniae appeared within the first two years and associated with the lower midline incisions.

Predicting the efficacy of vaginal misoprostol in the management of early pregnancy failures: A signal center study

Introduction: Early pregnancy loss is a situation commonly experienced by pregnant women. Management includes expectant, medical and surgical evacuation. Medical management is effective and relatively safe option and involves use of vaginal misoprostol which was recently approved to use in Sri Lanka. Proper patient selection for the medical management will improve the success rate. Objectives: Aim is to develop a predictive model using different factors to determine the efficacy of vaginal misoprostol in medical management of early pregnancy losses. Method: This was a single center retrospective descriptive study and was carried out in Teaching Hospital, Mahamodara, Galle. Eligibility criteria was medically managed early pregnancies (<12 weeks of gestation) adherent to Health Ministry guidelines. Data was retrieved using bed head tickets and was entered to data retrieval sheet. Orange Statistics 3.26, a leading free and open-source software was used for the development, testing and validation of predictive model. One hundred thirty four cases, approximately 80% of total (5% precision level), were randomly selected using randomization to train, build, score and evaluate predictive models. The remaining 20% of the cases were used once to validate each model. Results: 167 women were recruited for the analysis. Overall success rate of vaginal misoprostol was 62.3%. Majority of women (76.6%) didn’t have significant adverse effects for misoprostol. Out of the twenty clinical and radiological parameters, only the presence of vaginal bleeding weakly associated with the success of medical management. Other factors were not statistically significant enough to develop a predictive model. Conclusion: Management of early pregnancy losses with misoprostol was relatively safe and successful in majority of patients. However, it was unable to develop a predictive model with selected factors in this study, except presence of per vaginal bleeding prior to treatment yield high info gain.

Medication Transcription Errors at a Tertiary Healthcare Facility in Uva Province, Sri Lanka: A Retrospective study.

Medication transcription is an error-prone process in healthcare settings with paper-based documentation. However, it is often preventable. In Sri Lanka, a uniform medication chart is not currently in use. To describe transcription errors with the aim of designing a standardized drug chart to minimize the transcription errors at a tertiary care facility in Uva province, Sri Lanka. This cross-sectional study was conducted in selected units at Provincial General Hospital, Badulla. All discharged patients after a minimum of 72 hours hospital stay were included. The drug charts of bedhead tickets were scrutinized for transcription errors. At the time of study, four types of charts were in use. In total 272 drug charts, the median number of drugs was 9 (Interquartile range - IQR 6-12). Median length of patient's stay was 4 days (IQR 3-6). We encountered at least one transcription error of medication details in 88.6% charts. Amongst, medication name transcription error was the most common (220, 80.9%) followed by route (114, 41.9%) and frequency errors (70, 25.7%). During transcribing drug names, majority of charts had spelling errors (203, 74.6%). Although there was a statistically significant association between number of prescribed drugs and presence of at least one medication transcription error (p<.001), there was no significant association to number of days of patient stay (p=.99). The selected center has a significantly high prevalence of medication transcription errors. Hence, introducing a uniform medication administration chart is encouraged to minimize the opportunities for adverse patient outcomes.

Knowledge and practice of prescription and administration of correct dose of paracetamol to children among a selected group of doctors and nurses

Introduction: In children, paracetamol is the most common agent involved in drug toxicity. Therefore, accurate prescription of paracetamol in healthcare facilities is important in paediatric patients. This study aimed to explore the knowledge and practice of doctors and nurses on administration of correct dose of paracetamol. Methods: A descriptive cross-sectional study was carried out recruiting doctors and nurses from paediatric units and Emergency Treatment Unit (ETU) at Teaching Hospital, Karapitiya, Galle. A self-administered pre-tested questionnaire and bed head tickets were used to collect data. Results: There were 100 participants in the study. Majority (98%) knew correct single therapeutic dose of paracetamol. Ninety three percent of them did not know the maximum daily dose of paracetamol for children. Statistically significant association was seen being a doctor (χ2 = 11.4, p = 0.004) and a doctor in ETU (χ2= 9.02, p = 0.009) on- the knowledge of maximum dose of paracetamol to a child/24 hours. Half of the participants (56%) knew the acute toxic single dose of paracetamol. There was a significant association between work experience in paediatric unit/ ETU with the knowledge of acute single toxic dose of paracetamol (χ2 = 14.8, p = 0.04). Almost all participants (99%) were aware that paracetamol dose calculation depends on the weight of the child. Eighty three percent of prescriptions for inward patients were prescribed with therapeutic doses. Conclusion: Even though paracetamol is a common drug there is a knowledge gap among nurses and doctors on prescription of paracetamol in the selected setting.

Nonobstetric lower genital tract injury patients of a tertiary care center in Eastern Uttar Pradesh, India: A cross-sectional study.

Injuries of lower genital tract are commonly seen in obstetrics patients during labor and delivery. Nonobstetric genital injuries are seen less commonly. Research on injuries to the lower genital tract from nonobstetric trauma is therefore scant. The purpose of this study was to document causes, treatment, and outcomes among patients of lower genital tract injuries visiting to B. R. D. Medical College and Nehru hospital, Gorakhpur, U.P. Admission and operation theater registers of the department of obstetrics and gynecology during 1 year were scrutinized for cases admitted with the diagnosis of genital trauma. Bed-head tickets of patients were scrutinized with the help of a data abstraction form, and information regarding age, cause of injury, site, size and pattern of injuries, treatment, and short-term outcome were recorded. Of a total of 43 cases of traumatic genital tract injuries, 39 women received treatment. Maximum cases were seen in girls aged 6-10 years. Three women were pregnant at the time of injury. Noncoital injuries predominated over coital injuries, i.e., 59% versus 38.4%. Among the noncoital injuries, fall was the most common cause accounting for 75% of the cases. Coital injuries following consensual sex occurred more commonly in women who were sexually active, lactating, or postmenopause. The chief presenting complaint was vaginal bleeding. Vaginal wall laceration/tear was the most common injury reported. Multiple injuries were seen in 40% (17/39) of the cases. Twenty-one cases of laceration/tear (53.8%) were repaired surgically of which seven required examination and repair under anesthesia. Vulvar hematomas were managed by incision and drainage. There was no major morbidity or mortality. The results of this study from eastern Uttar Pradesh, India, support those from other developing nations. Noncoital injuries were found to be the most predominant cause of non-obstetric genital trauma, though, contrary to others, children were seen to be at the greatest risk. It is important to teach children about playing safely and following safety measures while on the road. We must also make them aware so that they do not become victims of rape.

MATERNAL DEATH AND ITS CAUSES: A RETROSPECTIVE EVALUATION AT ASSAM MEDICAL COLLEGE AND HOSPITAL, DIBRUGARH, ASSAM: INDIA

Introduction: Reduction of maternal mortality ratio to achieve the target set for MMR for SDG is a global challenge. Maternal death has devastating impact on the newborn, family as well as in the society in long run. Most of the developing countries could not achieve the target MMR for MDG and are now far away from the target set for Sustainable Development Goal for maternal mortality ratio because of its gradual reduction. There are great differences in MMR in developed and developing countries as well as within the countries, states, districts depending upon the education ,socioeconomic status and provision of quality health care and its accessibility . This study was conducted to estimate the MMR , evaluate the causes of maternal deaths at Obstetrics and Gynaecology department of Assam Medical college and Hospital ,Dibrugarh Assam, India. Aim: To nd out the MMR and to evaluate the risk factors and causes of maternal deaths. Materials And Methods: A retrospective study of risk factors and causes of maternal deaths from 1st January 2019 to 31st December 2020 at Obstetrics and Gynaecology Department of Assam Medical College and Hospital Dibrugarh ,Assam ,India .The data were collected from Maternal Death Surveillance and Response Records ,Facility Based Maternal Death Review Form and Bed head tickets and analysis were made to nd out causes of death and MMR. MDSR meetings were conducted for all the maternal deaths at community , facility and CMO levels . The risk factors and causes responsible for maternal deaths were expressed in percentage Results: Results and Observations: There were 174 maternal deaths out of 22,209 live births resulting MMR of 783. Hypertensive disorders of pregnancy (37.93%) followed by Puerperal sepsis (12.64%) and Post partum haemorrhage (8.04%) were the leading direct causes and severe Anemia (10.92%) and Jaundice (5.17%) were the leading indirect causes of maternal death in our study. Conclusion:Reduction of maternal death is a global challenge to achieve the MMR target of SDG .Causes of maternal death are multifactorial .Though pregnancy and labour is a physiological condition, rapid deterioration occurs when complication arises. Targeted approach to the socioeconomically poorer section of the society is the need of the hour.

A Retrospective Study on Patients with ENT Injuries Following Road Traffic Accidents at a Tertiary Care Medical Institution in Sri Lanka

Road traffic accidents (RTAs) and ear, nose, and throat (ENT) injuries are common causative factors of morbidity and mortality among children and adult populations. In developing countries, RTAs are the leading cause of ENT injuries and have a profound impact on the health and well-being of individuals. In Sri Lanka, there is a dearth of published research specifically on ENT injuries due to RTAs. This study was conducted to identify ENT injuries due to RTAs, their prevalence according to age and gender, and the clinical presentation among the patients managed in the National Hospital Kandy (NHK), Sri Lanka. All individuals with ENT injuries following an RTA admitted to the ENT Unit of NHK from January 2016 to March 2019 were included in the study. Patient data were collected from the Bed-Head-Tickets (BHTs) and analyzed. Among the 62 patients studied, 49 were male, while 13 were female. The majority (58%) of patients were among the 21–40- year age group. The nose was observed as the most common localized injury site (58%), followed by the ear (6%), while none had injuries to the throat. Epistaxis was the most commonly observed clinical presentation (69%). The majority of admissions occurred during '18:00-24:00' hours. Nine individuals were under the influence of alcohol. In the future, prospective studies in this area would help further understand ENT injuries due to RTAs.

COVID-19 AMONG NEONATES: EXPERIENCE FROM AN SNCU OF A TERTIARY CARE HOSPITAL IN EASTERN INDIA

Background: Coronavirus disease 2019 (COVID-19) pandemic has spread to every corner of the globe with immense rapidity. The clinical presentation of neonates due to COVID19 is poorly understood. Aim and Objectives: The study assessed the clinical profile of neonates with COVID-19 from the Special Newborn Care Unit (SNCU) of a tertiary care hospital in eastern India. Materials and Methods: Data from the hospital record section was retrieved and bed head tickets (BHT) were collected. A thorough review of the BHTs was done. Retrieved data was presented in tabulated form and analyzed. Results: Out of the 285 neonates tested for COVID19 by reverse transcriptase-polymerase chain reaction (RT-PCR) from the nasopharyngeal swab, 23 tested positive. Fever was the most common presenting complaint in 9 cases (39.13%). Respiratory distress was the clinical presentation in 5 cases (21.73%), while 4 cases (17.39%) presented with diarrhea. The other symptoms included fever and cough with nasal congestion, found in 2 cases (8.69%). Mother being positive for COVID-19 was found to be a risk factor for COVID-19 in 3 (13.04%) cases. Conclusions: It is essential to screen neonates not only with the history of COVID-19 positive mothers but also other neonates presenting with symptoms suggestive of COVID-19.

Analysis of Different Factors Associated with Re-Laparotomy After Cesarean Section Deliveries at a Tertiary Care Hospital: A Retrospective Study

Aim: To evaluate factors that are associated with re-laparotomy after cesarean section. Study design: Retrospective study Place and Duration: This study was conducted at Sheikh Zaid Hospital Quetta, Bolan Medical Complex Hospital Quetta, Jinnah Medical and Dental College karachi, Sandeman Provincial Hospital Quetta, Mekran Medical College Teaching Hospital Turbat Kech, Pakistan from the year 2019 to 2021 Methodology: For this research interview sessions with patients were conducted. Clinical examinations were done and Bed Head ticket (BHT) was used for examining the medical history of patients. All the information related to age, parity, indications of caesarian section, and gestational age were observed including time interval of re-laparotomy from caesarian section. Furthermore, information related to clinical features of re-laparotomy, duration of re-laparotomy, and outcomes were also kept for statistical analysis. Results: Over two years, we observed 22192 cases of caesarian deliveries. Out of these 37 emergency caesarian required re-laparotomy procedure. We observed non-progress of labor as a major indication of LUCS in the primary caesarian section comprised of 21.62% of cases. Another dominion indication of the caesarian section was reported as CPD (5.40%), meconium stained liquor (MSL) with Bradycardia (10.81%), and PROM in 10.81% of cases. Rectus sheath hematoma was a major indication of re-laparotomy in 29.7% of cases while 27.02% of cases in our study reported peritoneal hemorrhage. Conclusion: Findings of our study revealed that unnecessary usage of caesarian surgery on patient leads to severe complications resulting in re-laparotomy. Factors like rectus sheath hematoma, Intra-peritoneal hemorrhage and abscess are the dominant reasons for re-laparotomy. Keywords: Caesarian section, Gynecology, Re-laparotomy

Availability legibility and adequacy of diagnosis as entered in bed head ticket in a base hospital Sri Lanka: a descriptive cross-sectional study

Introduction: Hospital information storage is done through an internationally accepted coding system. It is very important to have an accurate diagnosis for proper coding. Ministry of Health has issued a circular (No-01-05/99) for the documentation of Bed Head Ticket (BHT) including writing the correct diagnosis. Objective: To assess the availability, legibility, and adequacy of diagnosis as entered in the BHTs of selected wards in a base hospital in Sri Lanka. Methods: Descriptive cross-sectional study was conducted to assess availability, legibility, and adequacy of diagnosis as entered in 384 BHTs of selected wards in a Base Hospital in Sri Lanka. A data Extraction sheet (DES) was used as a study instrument. Results: Out of 384 BHTs diagnosis were not available in 12 (3.13%) BHTs and diagnosis were illegible in 36(6.99%) BHTs. In 244(67.59%) BHTs diagnosis were written as abbreviations. Only in136(37.46%) BHTs, diagnosis were written in block capital letters. Conclusion and recommendation: Documentation diagnosis in the BHTs is not according to the standards. Therefore, medical administrators, policymakers, and clinicians should take urgent actions to improve documentation diagnosis in BHTs.

Cross sectional analysis of factors associated with leptospirosis cases treated at district general hospital, Matara, Sri Lanka during 2015-2018

Background: Leptospirosis is a zoonotic illness with a global disease burden impacting both developed and developing nations and is caused by pathogenic spirochetes of the genus Leptospira. In this study, selected characteristics of confirmed leptospirosis cases were studied; hence modifiable risk factors were elucidated. This information would be useful to prevent further transmission of leptospirosis by public health care workers in Sri Lanka and take appropriate administrative decisions regarding leptospirosis control in the community. Methods: This was a descriptive cross sectional survey of Bed Head Tickets (BHTs), Case Surveillance Forms of confirmed leptospirosis cases treated at district general hospital, Matara during 2015-2018. The study was conducted from 21.02.2019 to 01.03.2019.Results: Age &gt;35 years (OR 3.92:, 95% CI:2.72-5.65), male sex (OR:2.30, 95% CI:1.61-3.29), paddy field as source of infection (OR:2.45, 95% CI:1.69-3.54), positive history of recent skin lesions/injury (OR:2.29, 95% CI:1.58-3.34), (OR:3.14, 95% CI:1.62-6.06), (OR:2.88, 95% CI:1.31-6.36), (OR:2.13, 95% CI:1.27-3.58) were risk factors for leptospirosis. Positive history of chemo prophylactic treatment (doxycycline administration) and its duration were not associated with leptospirosisConclusions: Age &gt;35 years (OR 3.92:, 95% CI:2.72-5.65), male sex (OR:2.30, 95% CI:1.61-3.29), paddy field as source of infection (OR:2.45, 95% CI:1.69-3.54), positive history of recent skin lesions/injury (OR:2.29, 95% CI:1.58-3.34) were risk factors for leptospirosis.

Estimation of Time Since Death from Rigor Mortis - An Autopsy Study in Tertiary Care Hospital of Malwa Region of Punjab state of India

Background: Postmortem interval estimation is an important tool in forensic medicine. Estimating time since death is extremely important in cases where there is doubt about the period of death. After death, many changes occur in a regular sequence and can be used to arrive at an approximate time since death. When a post-mortem is conducted, doctor conducting the post-mortem examination has to give his opinion about post-mortem interval i.e. the probable time that elapsed between death and post-mortem examination even in cases of decomposed dead bodies. While giving this opinion, we always think we should have some other dependable methods to be more accurate in answering this question. Algor mortis, Rigor mortis, and Livor mortis have been the basis for ascertaining the post-mortem interval collectively. Among them, Rigor Mortis is an important indicator of post-mortem interval. Although it is a dependable tool for estimating post-mortem interval, it is influenced by many endogenous and exogenous factors like nature of death, nature of the body, temperature, humidity etc. Time of death is almost always asked by investigating authorities to connect the crime with criminals. Determining the death time has always been a topic of keen interest amongst forensic pathologists from its inception to date. Many workers in forensic medicine have tried to investigate to determine the time of death based on post mortem findings. To date, it is still an important and fascinating criterion to ascertain the time since death. With this study, we aimed to demonstrate the intricacies of Rigor Mortis with fluctuating temperature and humidity of the local region. We planned to estimate and compare the post-mortem interval based on Rigor Mortis in different body muscles. Materials and Methods: This study was conducted in the Department of Forensic Medicine and Toxicology at G.G.S. Medical College, Faridkot after taking clearance from the institutional ethics committee. Thirty medico-legal autopsy cases were included in the study where the exact time of death was known and included only hospital deaths. The relatives of the deceased were explained the purpose and nature of the study and provided with the patient information sheet and informed consent was taken. The details of the cases were noted from the hospital bed head ticket, relative interview and the police inquest papers. The exact temperature and humidity were noted at the start of autopsy using a digital hygrometer. Results: A total of 30 cases were observed out of which males outnumbered the females by approximately 3:1. Maximum cases consisted of Roadside Accidents (43.3%) followed by poisoning, assault and hanging, in that order. The average temperatures during the study months varied from a maximum of 41.3°C (June) to a minimum of 33.7°C (July). The average humidity varied from a maximum of 62.6% (July) to a minimum of 29.3% (May). The average temperatures during the study months varied from a maximum of 41.3°C (June) and a minimum of 33.7°C (July). The average humidity during the study months varied from a maximum of 62.6 % (July) and a minimum of 29.3% (May). Fully established Rigor Mortis was observed at a minimum of 10 hours and a maximum of 29 hours in May and June.

Adherence to National Antimicrobial Guidelines in Hospitalized Geriatric Patients with Community-Acquired Pneumonia: A Prospective Observational study in a Malaysian Hospital

The evaluation of disease progression and onsite therapeutic care choices for community-acquired pneumonia (CAP) patients is vital for their well-being and the optimum utilization of healthcare resources. The current study was conducted to assess physicians’ adherence to clinical practice standards and antibiotic prescribing behavior for the treatment of CAP in older people. A prospective study that included 121 consecutive patients admitted for CAP was conducted at Kulim Hospital, Kedah, from March 2020 to August 2020. Medical records including demographic data, comorbidity, physical examination, laboratory or radiologic findings, and drugs used for the treatment of CAP were accessed from bed head tickets (BHT). The mean age for patients was 73.5 ± 6.2 years, 73 (60.3%) and 48 (39.6%) were males and females, respectively. Amoxicillin/clavulanate (19.8%) was the most prescribed antibiotic for non-severe pneumonia followed by ampicillin sodium/sulbactam sodium (6.6%), while in patients with severe CAP beta-lactam + beta lactamase inhibitors (BLIs) with a combination of macrolide were the most common antibiotics prescribed either in patients with (21.4%) or without co-morbidities (8.2%). The average length of stay in the hospital with severe pneumonia was 6–7 days for 23.9% of patients and < 5 days for 21.4% of patients. The duration of intravenous antibiotics in patients with severe pneumonia was 6–7 days for 32.2% of patients. The present findings revealed the adherence of antibiotic prescribing practices to the Malaysian National Antimicrobial Guideline 2019 for CAP therapy among geriatric patients and adherence to the CAP criteria for hospital admissions.

Flexible Fibreoptic Bronchoscopy Performed Through a Laryngeal Mask Airway (FFB-LMA) in a Paediatric Population: Experience of a Tertiary Care Children's Hospital in Sri Lanka

Studies suggest that flexible fibreoptic bronchoscopy, when performed through a laryngeal mask airway (FFB-LMA), have fewer rates of complications and better efficacy. In comparison to rigid bronchoscopy, FFB is safer for the operator, as it prevents direct exposure to respiratory tract infections such as Covid-19. Airway maintenance with LMA is uncommon when performing FFB in Sri Lanka. This study aimed to report the efficacy and peri-procedural complications of FFB performed through LMA at a tertiary care children's hospital in Sri Lanka. Data were retrieved retrospectively from anaesthetic charts and bed head tickets of all the patients who underwent FFBs performed through LMA at the Sirimavo Bandaranayake Specialized Children's Hospital, Peradeniya. Collected data included age, gender, indication, duration of the procedure, bronchoscopy findings, and complications, if any. Of the total of 176 patients, the majority were infants and between 1-5 years (33.52% each). The most common indication was recurrent/persistent respiratory tract infections (57.9%) followed by foreign body aspirations (21.6%). Clinically significant abnormalities were detected in 87% of the cases. The success rate of extraction of positively identified foreign bodies was 100%. Perioperative complications were observed in 4.5% of the patients. Risk factor analysis, based on multivariate logistic regression, identified the duration of the procedure as a risk factor for complications (OR= 15.57, p = 0.0011). FFB performed through LMA has good efficacy and low complication profile in the studied patient sample.

Effect of Prior Symptomatic Dengue Infection on Dengue Haemorrhagic Fever (DHF) in Children.

Pathogenesis of dengue haemorrhagic fever is not fully understood, but it is thought that there is antibody enhancement during the secondary infection, which causes severe dengue haemorrhagic fever (DHF). Therefore, patients who have DHF should have a documented history of symptomatic dengue infection in the past. A retrospective descriptive-analytical study was conducted at the University Paediatric Unit at Lady Ridgeway Hospital for Children, Colombo, Sri Lanka. All children who had fulfilled the criteria for DHF admitted to the unit from April 2018 to September 2018 were recruited into the study. Relevant data were collected from bed head tickets. One hundred and eighty-four children were included in the final analysis. Thirty-three (17.9%) had a past history of documented symptomatic dengue infection, while 82.1% did not have a documented dengue infection. Twelve patients had dengue shock syndrome, and none of them had previously documented symptomatic dengue fever. Dextran was used in 96 patients in the critical phase. Twelve (42%) patients with past documented symptomatic dengue fever needed dextran while 84 (54.9%) patients without a documented past history of dengue fever needed dextran. In our clinical observation, we noticed that children with DHF mostly did not have a documented symptomatic prior dengue infection, while those with a documented symptomatic prior infection had a milder subsequent illness. In fact, the majority (82.1%) of patients with DHF did not have documented previous symptomatic dengue infection. It was also observed that the clinical course of subsequent dengue infection was less severe in patients with previously documented symptomatic dengue fever. This finding should be further evaluated in a larger scale study minimizing the all-confounding factors. This fact is more important in selecting recipients for vaccines against the dengue virus, which are supposed to produce immunity against the virus without causing the severe disease.

A Systematic Assessment of Service Delivery in Preliminary Care Unit at a State Hospital in Sri Lanka

Preliminary Care Unit is the Sri Lankan model of the emergency department in the state health facilities above the level of Base Hospitals in the country. Provision of prompt, quality, and comprehensive patient care without any unnecessary delay, minimizing unnecessary admissions to wards, and reducing the cost of patient management were the objectives of establishing such units. The current study aimed to systematically assess the process of service delivery in the Preliminary Care Unit of District General Hospital, Gampaha. The study was descriptive with both cross-sectional and retrospective components and was conducted in 2019. Study instruments and techniques included are key informant interviews, focus group discussions, the desk review of secondary data, and direct observation. Key informant interviews with the medical officer-in-charge and nursing sister in charge of the unit were conducted by the principal investigator. Two focus group discussions were conducted, with ten randomly selected medical officers and 8 nursing officers with a minimum one-year of work experience at the Preliminary Care Unit. Data gathered from the desk review of the secondary data from the admission book, Bed Head Tickets, and record of monthly statistics of the preliminary care unit using a checklist to ascertain the total number of admissions and their outcome in 2018. All admissions of a randomly selected week of 2018 were studied to assess the age and gender distribution and they were classified into two categories as medical and surgical, according to the admitting doctor’s notes. Direct observation was used to triangulate the data. The major deficiencies of the process of service delivery in the Preliminary Care Unit elicited at the key informant interviews and focus group discussions were overcrowding and excess waiting which were multifactorial in causation. Less organized process flow and inadequate resource availability led to overcrowding and excess waiting.

Clinical Documentation Practice: A Study of Doctors’ Medical Documentary Compliance in Government Hospitals in Gampaha District, Sri Lanka

Doctors play a key role in health information system through clinical documentation. The study aimed to assess doctors’ compliance with national medical documentation standards. The study was carried out in government hospitals having in-ward patient care facilities in Gampaha district, Sri Lanka. The doctors’ knowledge and practices were assessed using a questionnaire. 500 Bed Head Tickets (BHTs) which are the medical records of inward patients, were audited in selected government hospitals in the same district using a check list to ascertain the doctors' compliance with standards in practice. Only 29.46% doctors were aware of the government circular on standards of medical record. Although 82.84%, 66.37% and 76.3% doctors knew that final diagnosis should be written according to International Classification of Diseases (ICD) 10, in block capitals and without any abbreviations, respectively. Only 7.61% BHTs were found to have fulfilled all standards. There were gaps in the knowledge of doctors regarding standards in clinical documentation practice. The awareness of and reference to published guidelines were not satisfactory. Poor transfer of knowledge into practice was evident by the results of BHT survey. As publishing guidelines or teaching alone may not improve the compliance of doctors with the standards in clinical documentation practice, more innovative strategies should be sought for.