Level Public Hospital Research Articles

Long-term outcomes of hepatic resection for colorectal liver metastases at a New Zealand tertiary level public hospital.

Colorectal cancer is common with half of all patients developing metastases to the liver. The aim of this study was to document the survival for patients undergoing liver resection for colorectal cancer metastases. A review of all patients undergoing hepatic resection for colorectal liver metastases at a New Zealand tertiary level public hospital over a 9-year period was performed. Primary survival outcomes assessed were overall survival (OS) and disease-free survival (DFS). Of the 116 patients followed-up with a median (range) of 53 (10-116) months, the OS at 5 years was 53%. Median survival was 6.5 years. At end of follow-up, 57% of patients were alive and 49% were alive without recurrence. The overall rate of recurrence was 39%. This study confirms that excellent long term survival can be achieved with hepatic resection for colorectal liver metastases.

Pattern of episiotomy use & its immediate complications among vaginal deliveries in 18 tertiary care hospitals in India.

Background & objectives:In developed countries, efforts have been made to restrict episiotomy practice. However, in developing countries the episiotomy rates continue to be high. This study was conducted to evaluate the pattern of episiotomy use and its immediate complications among women delivering at tertiary level public hospitals in India.Methods:Prospective data of all women undergoing vaginal delivery including instrumental delivery were collected daily from the labour room registers of the 18 tertiary care hospitals on a structured proforma. Weekly data from all sites were sent to a central unit for compilation and analysis. Odds ratio was used to compare the proportion of genital trauma among women with and without episiotomy both in nulliparous and multiparous women.Results:Among 1,20,243 vaginal deliveries, episiotomy was performed in 63.4 per cent (n=76,305) cases. Nulliparaous women were 8.8 times more likely to undergo episiotomy than multiparous women. The various genital tract injuries reported were first degree perineal tear (n=4805, 3.9%), second degree perineal tear (n=1082, 0.9%), third and fourth degree perineal tear (n=186, 0.2%), anterior vaginal trauma requiring suturing (n=490, 0.4%), extension of episiotomy/vaginal laceration/excessive bleeding from episiotomy or tear (n=177, 0.15%), vulval/vaginal haematoma (n=70, 0.06%) and cervical tear (n=108, 0.08%). The combined rate of third and fourth degree perineal tears was observed to be significantly lower (P<0.001) among nullipara who received episiotomy (0.13%) compared to those who delivered without episiotomy (0.62%).Interpretations & conclusions:Significantly lower rates of third or fourth degree perineal tear were seen among nulliparous women undergoing episiotomy. The risk and benefit of episiotomy and its complications need to be evaluated through randomized clinical trials in the Indian context.

Emergency Department Care Survey

Through its Healthcare Transformation Program, Turkey has successfully introduced health system changes to provide its citizens with the right to health. One of the most important changes that was brought about by the Program was the rearrangement of the organizational structure of the Ministry of Health. Within this framework, The Turkish Public Hospitals Union was founded and commissioned to carry out the operations of secondary and tertiary level healthcare facilities. The establishment of the Union has aimed to provide savings, increase productivity, distributes human resources equally and provide cooperation between partners to carry out equal, high quality and efficient care delivery. As a result, 89 hospital unions were launched countrywide. Secondary and tertiary level public healthcare facilities within the same province have been unified under the management of a Public Hospitals Union. More than one Union has been established in the same province if the size of the service provided was appropriate. There are 6 such Unions serving in the city of Istanbul and Beyoglu Public Hospitals Union (BKHB) is one of them. It was established in November 2012 and encompasses 11 hospitals. The union mainly serves a population of 2.3 Million in the Beyoglu, Sisli, Besiktas and Sariyer local municipalities; although patients from other districts are free to apply. 63% of the people residing in this region have at least once visited our hospitals. Approximately 25% of patients come from other districts. There are 5 Teaching Hospitals (TH), 5 secondary level Public Hospitals (PH) and 1 Oral and Dental Health Hospital within our union and the union is responsible for providing health services to the citizens efficiently. Our union is also positioned as the Coordinating Union for Istanbul and manages Human Resource and Medical Services planning for the whole city.

Access to and quality use of non-communicable diseases medicines in Nepal.

Noncommunicable diseases are a major healthcare problem in Nepal and their burden is increasingevery year. Noncommunicable diseases (NCDs) bring additional challenges to the Nepalese healthcaresystem which is already experiencing infrastructure shortages, poor service delivery, inadequate essential medicines coverage and shortages of healthcare workers. The Nepal government provides a limited number of free essential medicines through the free essential healthcare services program. This consists of a basic healthcare package provided through primary healthcare (PHC) facilities and district hospitals. Though around 40 essential medicines are provided without charge, studies have reported problems with access especially in all rural areas. There is a need to improve access to, coverage and quality use of medicines. The government has decided to provide some free medicines for NCDs alongside free essential medicines to be distributed via current healthcare structures. Though well intended, this decision will put extra strain on the essential medicines program. It should be supplemented by a comprehensive NCDs policy that takes account of the issues of sustainability and quality use of medicines. Complex cases of NCDs will be managed by tertiary hospitals but most of the cases of NCDs especially for rural people and the poor will end up in secondary level public hospitals (district and zonal hospitals). Therefore, the government needs to strengthen these public hospitals. Meanwhile, given the severity of the NCDs problem in Nepal, the Ministry of Health and Population (MoHP) should liaise with nongovernmental and missionary hospitals especially in rural areas to run NCDs management services. The Ministry should encourage these hospitals to run hospital pharmacies to improve people’s access to and quality use of NCDs medicines. At the primary healthcare level, the Ministry could run NCDs prevention and control programs but existing PHC workers need training to perform proper dispensing of NCDs medicines. PHC facilities need a medical record system so that they can address the needs of NCDs patients requiring long term medication supply via a proximate PHC facility.

Care for both mother and child immediately after childbirth: a descriptive study

Aim: To understand the perceptions of users about the care provided to them and their newborns immediately after childbirth. Method: This is a descriptive study in which a qualitative approach was used, involving 20 postpartum women admitted to a secondary level Public Hospital of Fortaleza. Semi-structured interviews were carried out and were analyzed by means of Bardin’s content analysis technique. Results: Three categories were highlighted: Care provided to newborns; care (or lack of care) provided to postpartum women; and structural failures of the maternity hospital. Discussion: Postpartum care was primarily focused on guidance on breastfeeding, without considering other demands of women, such as: the need for greater attention by the health team; more humane behavior of some health professionals; and guidance on self-care. Conclusion: Postpartum care is still limited and it requires greater attention and commitment from health professionals, as well as adjustments in the structural and organizational conditions of the maternity hospital so that it may provide decent and humane care.

Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels

BackgroundThe importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts...

Cost of neonatal intensive care delivered through district level public hospitals in India

To assess the unit cost of level II neonatal intensive care treatment delivered through public hospitals and its fiscal implications in India. Cost analysis study. Four Special Care Newborn Units (SCNUs) in public sector district hospitals in three Indian states, i.e. Bihar, Madhya Pradesh and Orissa, for the period 2010. Bottom-up economic costing methodology was adopted. Health system resources, i.e. capital, equipment, drugs and consumables, non-consumables, referral and overheads, utilized to treat all neonates during 2010 were elicited. Additionally, 360 randomly selected treatment files of neonates were screened to estimate direct out-of-pocket (OOP) expenditure borne by the patients. In order to account for variability in prices and other parameters, we undertook a univariate sensitivity analysis. Unit cost was computed as INR (Indian national rupees) per neonate treated and INR per bed-day treatment in SCNU. Standardized costs per neonate treatment and per bed day were estimated to incorporate the variation in bed occupancy rates across the sites. Overall, SCNU neonatal treatment costs the Government INR 4581 (USD 101.8) and INR 818 (USD 18.2) per neonate treatment and per bed-day treatment, respectively. Standardized treatment costs were estimated to be INR 5090 (USD 113.1) per neonate and INR 909 (USD 20.2) per bed-day treatment. In the event of entire direct medical expenditure being borne by the health system, we found cost of SCNU treatment as INR 4976 (USD 110.6) per neonate and INR 889 (USD 19.8) per bed-day. Level II neonatal intensive care at SCNUs is cost intensive. Rational use of SCNU services by targeting its utilization for the very low birth weight neonates and maintenance of community based home-based newborn care is required. Further research is required on cost-effectiveness of level II neonatal intensive care against routine pediatric ward care.

Delírium en pacientes mayores de 60 años en un hospital público de tercer nivel en la ciudad de Pereira (Colombia): subdiagnóstico y subregistro

IntroductionDelirium is a common disorder in the hospitalized geriatric population and it has a great importance on the clinical outcome of inpatients; however, delirium is not diagnosed properly. ObjectiveTo clarify the state of delirium diagnosis and records in a tertiary level public hospital in the city of Pereira. MethodsA cross-sectional descriptive study was performed by searching the clinical records of hospitalized patients older than 60 years 2010 and 2011, using the ICD-10 classification as a filter, and verifying the diagnostic criteria of DSM-IV in the clinical records. ResultsIn the years 2010 and 2011, 5325 patients older than 60 years were hospitalized (19.3%). According to the official statistical records; 0.08% of them were reported with an unspecified diagnosis of delirium (F059). In the clinical records search 455 additional delirium patients were found using the same criteria (40.2%), of which 90.1% had delirium, and only 29.5% were classified with the code F059. ConclusionsThe diagnoses and recording of delirium patients over 60 years old patients are underestimated, which is demonstrated by the incongruence of the data obtained from the official records and those obtained from the clinical records. This fact increases the risk and vulnerability of patients with undetected delirium or diagnosed but not reported delirium in hospital statistical sources. Liaison psychiatry is a necessity in third level health institutions, as well as a program of continued education for the health staff about prevention, diagnosis criteria and treatment of delirium.

Results of medium-term survival in patients undergoing cardiac transplantation: institutional experience

Introduction The heart transplant became a consecrated therapy for patients with terminal heart failure, increasingly improving the survival. Objective To identify the medium-term results in patients undergoing cardiac transplantation. Methods This is a descriptive, documentary and retrospective study, using a quantitative approach, developed in a Unit of Transplant and Heart Failure, of a tertiary level public hospital, located in Fortaleza, CE, Brazil. The data were obtained from a sample of 188 patients (154 men and 34 women), submitted to the heart transplant, in the period from October 1997 to March 2011. There were calculated survival rates based on Kaplan-Meier methods. Results There were identified information about the patient's gender (male 81.91%), medical diagnosis which determined the heart transplantation (idiopathic cardiomyopathies 23.98%, ischemic 23.4% and Chagasic 17.02%). The median age of patients was 48 years old (interquartile range = 17.25 years) and the median observation period was 877 days. During this period, 78 patients died, resulting in survival ratios of 72%, 59% and 47% after 1, 5 and 9 years of cardiac transplantation, respectively. Younger patients had longer survival (P=0.0418). Conclusion The medium-term survival of patients undergoing cardiac transplantation is significant, especially for younger patients.

Variabilidad en el porcentaje de cesáreas y en los motivos para realizarlas en los hospitales españoles

ObjectiveTo describe variability in the cesarean ratio and indications for this procedure in women with and without a previous cesarean section. MethodsWe conducted a cross-sectional study of 111 hospitals (year 2010) categorized in six levels. Ten groups of indications for cesarean section were developed. Measures of central tendency and diversity were used to determine variability and the Kruskal-Wallis test was used for comparisons among hospital levels. ResultsThe percentage of cesarean sections was 25.4%. In women without a previous cesarean section, the percentage was higher in private and public hospitals with a lower technological level (34.7% and 30.4% in private and 22.4% in lower level public hospitals). Among public hospital levels, no differences in the percentage of cesarean sections indicated were observed. ConclusionsResearch on non-clinical factors could clarify the differences in the ratio of cesarean sections in private hospitals compared with public hospitals and among distinct levels of public hospitals.

The role and functions of Clinical Nurse Consultants, an Australian advanced practice role: A descriptive exploratory cohort study

BackgroundThe NSW Health Policy Directive (NSW Department of Health, 2000) lists clinical service and consultancy; clinical leadership; research; education; clinical services planning and management as the five domains of practice for nurses appointed as Clinical Nurse Consultants (CNCs), an Australian advanced practice nurse (APN) role. However, there is no clear definition of what is meant by advanced practice in the Australian nursing context. Nowhere is this more evident than in differentiating between the roles of Clinical Nurse Consultants (CNCs) and Nurse Practitioners (NP) in NSW. To date, limited empirical research has been done to characterise or delineate CNC role activity and responsibility. ObjectivesTo investigate (i) the nature of CNC roles, activities and responsibilities, (ii) differentiate between CNCs by their work patterns and activities, and (iii) empirically conceptualise and differentiate ways CNCs practice in terms of an APN typology. ParticipantsThe study sample was 56 CNCs at one tertiary level public hospital in Australia. MethodsA descriptive exploratory cohort study was conducted to explore CNC role characteristics and patterns of activity. Data were triangulated using an online survey, a follow-up survey, and semi-structured interviews. The data were analysed using descriptive statistics to examine differences between CNC work patterns and role activities. The survey data and the individual reports were thematically analysed to investigate for difference across the population of CNCs. ResultsInterpretation of survey and interview data led to an analyst-developed CNC typology of four CNC categories based on the work patterns and activities of Sole Practitioner, Clinic Coordinator, Clinical Team Coordinator and Clinical Leader. The typology was based on the themes interprofessional, role focus, clinical focus and setting as these themes distinguished and differentiated CNC roles. ConclusionsThe study provides evidence of great diversity and prioritisation within CNC roles. The CNC typology identified in this study is similar to the categorisation of the roles of APNs reported by other researchers. With further testing, the CNC typology could be useful to service managers and policy makers in making decision on the category of CNC required for a position and may also be able to be applied to other APN roles.

Sigma Level Performance of the Innovated Process in the Imaging Department at a Mexican Health Institute

The National Institute of Respiratory Diseases is a third level public hospital in Mexico City, which in 2007 acquired an RIS-PACS to be implemented at its Imaging Department (ID), with the objective to enhance its service. This department attends an average of 3,500 patients per month developing different image modalities. The objective of this work was to determine the overall sigma level performance of four processes of the ID: reception, X-ray, computed tomography, and radiologist diagnosis, considering process analysis and innovation through Six Sigma methodology, measuring the innovation effectiveness by means of indicators and learning curves. Initially, a first measurement (M 1) of the original processes was determined; once 13 innovations were implemented in a pilot program, two more measurements were done, 15 days after (M 2) and 30 days after (M 3), in order to know the impact of the innovations in the ID processes. The initial sigma level of the ID before innovations was σ 1 = 2.0, which means that there were 36 patients per day with a process defect during their stay at the ID. In the two following measurements, σ 2 = 2.2 which means that there were 28 patients per day with a process defect, and σ 3 = 2.3 with 24 patients per day with a process defect. These results demonstrate that the percentage of performance enhancement between the original process and 15 days later was 23 % and 30 days later an enhancement of 15 %. In total, an overall enhancement of 38 % was obtained at the ID of the institute.

Tackling perinatal loss, a participatory action research approach: research protocol

The aim of this study was to promote changes to improve the care provided to parents who have experienced a perinatal loss through participatory action research. The birth of a child is a joyful event for most families, however, unfortunately some pregnancies end in loss. Perinatal loss creates a heavy emotional impact not only on parents but also on health professionals, where in most cases there is an evident lack of skills, strategies and resources to cope with these kinds of situations. Participatory action research is the methodology proposed to achieve the purpose of this study. Participatory action research consists of five stages: outreach and awareness, induction, interaction, implementation and systematization. The working group will include professionals from the Mother and Child Unit for patients at a tertiary level public hospital in Spain. The duration of the study will be 3 years since the approval of the protocol in January 2011. The qualitative techniques used will include group dynamics such as the SWOT analysis the nominal group technique, focus groups and brainstorming, among others that will be recorded and transcribed, generating reports throughout the evolution of the group sessions and about the consensus reached. Content analysis will be conducted on the field diaries kept by the participants and researchers. This project has been funded by the Andalusian Regional Ministry of Health. Participatory action research is a methodological strategy that allows changes in clinical practice to conduct a comprehensive transformative action in the care process for perinatal loss.

Influenza vaccination uptake amongst pregnant women and maternal care providers is suboptimal

ObjectiveTo assess the uptake of influenza vaccination by pregnant women and maternity care providers and explore their attitudes towards influenza vaccination. Design, setting and participantsCross-sectional survey administered in a Victorian tertiary level public hospital to 337 pregnant women and 96 maternity care providers. Results31.3% of patients planned to or had received influenza vaccination this year, but only a quarter had received education about influenza. Women were more likely to receive influenza vaccination if they had been vaccinated in the last two years (RR 4.5, 95% CI: 3.1–6.4, p<0.001), received education about influenza (RR 2.3, 95% CI: 1.6–3.2, p<0.001) or believed that they were at high risk of influenza-related complications while pregnant (RR 2.0, 95% CI: 1.4–2.7, p<0.001). While only 56.8% of maternity care providers believed pregnant women were at high risk of influenza-related complications, 72.9% would recommend influenza vaccination to all pregnant women. Of the maternity care providers studied, 69% planned to or had been vaccinated in 2011, with this group more likely to recommend vaccination to their patients (RR 2.0, 95% CI: 1.3–3.0, p<0.001). Significantly more maternity care providers indicated that they would routinely recommend influenza vaccination than the proportion of patients who reported receiving education. ConclusionsInfluenza vaccination rates in pregnant women are low, reflecting inadequate patient education despite most maternity care providers indicating that they would routinely recommend influenza vaccination. Increasing influenza vaccination uptake by women in pregnancy will require better education of both women and maternity care providers.

The influences of patient's satisfaction with medical service delivery, assessment of medical service, and trust in health delivery system on patient's life satisfaction in China.

BackgroundPatient’s satisfaction with medical service delivery/assessment of medical service/trust in health delivery system may have significant influence on patient’s life satisfaction in China’s health delivery system/in various kinds of hospitals.The aim of this study was to test whether and to what extent patient’s satisfaction with medical service delivery/patient’s assessments of various major aspects of medical service/various major aspects of patient’s trust in health delivery system influenced patient’s life satisfaction in China’s health delivery system/in various kinds of hospitals.MethodsThis study collaborated with National Bureau of Statistics of China to carry out a 2008 national urban resident household survey in 17 provinces, autonomous regions, and municipalities directly under the central government (N = 3,386), and specified ordered probit models were established to analyze dataset from this household survey.ResultsThe key considerations in generating patient’s life satisfaction involved patient’s overall satisfaction with medical service delivery, assessment of doctor-patient communication, assessment of medical cost, assessment of medical treatment process, assessment of medical facility and hospital environment, assessment of waiting time for medical service, trust in prescription, trust in doctor, and trust in recommended medical examination. But the major considerations in generating patient’s life satisfaction were different among low level public hospital, high level public hospital, and private hospital.ConclusionThe promotion of patient’s overall satisfaction with medical service delivery, the improvement of doctor-patient communication, the reduction of medical cost, the improvement of medical treatment process, the promotion of medical facility and hospital environment, the reduction of waiting time for medical service, the promotion of patient’s trust in prescription, the promotion of patient’s trust in doctor, and the promotion of patient’s trust in recommended medical examination could all help promote patient’s life satisfaction. But their promotion effects were different among low level public hospital, high level public hospital, and private hospital.

Should baseline PSA testing be performed in men aged 40 to detect those aged 50 or less who are at risk of aggressive prostate cancer?

We aimed to evaluate the presenting features and treatment outcome of prostate cancer in men aged <50 years, in a region where prostate specific antigen (PSA) screening is not readily available and most men present with symptoms. We analysed the data of 1 571 men with prostatic adenocarcinoma treated between January 1997 and December 2008 at out institution, a tertiary level public secotr hospital serving a largely indigent population. Statistical analysis was performed using Student's, the Mann-Whitney and Fisher's exact tests where appropriate (p<0.05 accepted as statistically significant). Of 1 571 men, 47 (3%) were aged < 50 years. The group aged <50 years compared with that aged >50 years, had a siginificantly greater proportion with poorly differentiated adenocarcinoma (53%), locally advanced (stage T3-4) tumours (56%), haematogenous metastases (75%), significantly higher serum PSA at diagnosis (mean 621, median 74 ng/ml) and shorter survival. Men aged <50 years presenting with symptoms owing to prostate cancer had significantly higher risk disease, higher mean PSA, and poorer prognosis than men aged >50 years. To diagnose prostate cancer at a potentially curable stage in men aged <50 years, it is necessary to initiate asleine PSA testing at age 40 and 45 years, and to select high-risk men for PSA surveillance in order to diagnose potentially curable cancer in those with a life expectancy >20-25 years.

Gestión de la calidad de atención en laboratorios clínicos de hospitales públicos en Maracaibo, Venezuela

Evaluating how clinical laboratories' quality was being managed according to the view of external users, thereby determining the dimensions of quality related to their satisfaction and sociodemographic characteristics. The study was descriptive; the sample consisted of 1,875 outpatients attending the laboratories of type 3 and 4 care level public hospitals located in the metropolitan area of Zulia State in Venezuela between October and December 2008. A previously validated survey was applied. Frequency allocation, multivariate analysis and variance analysis were used for analysing data. The results showed that the most users were female (72.7 %), of local origin (87.9 %), aged between 15 and 45 (65.7 %) and had received primary and secondary education (70.5 %). Multivariate analysis showed that quality management could be evaluated in terms of accessibility, tangible elements, response ability, safety and professional competence. There were highly significant differences (p<0.001) between educational level and age when evaluating management quality. Weaknesses were revealed concerning time spent waiting in reception, waiting room comfort and safety measures used by technical staff. The results should lead to establishing action aimed at evaluating the degree of improvement in service and proposed targets for improving the quality of attention; such measures will form part of a quality assurance programme in accordance with international standards.

Costs of vaginal delivery and Caesarean section at a tertiary level public hospital in Islamabad, Pakistan

BackgroundPublic hospitals in developing countries, rather than the preventive and primary healthcare sectors, are the major consumers of healthcare resources. Imbalances in rational, equitable and efficient allocation of scarce resources lie in the scarcity of research & information on economic aspects of health care. The objective of this study was to determine the average cost of a spontaneous vaginal delivery and Caesarean section in a tertiary level government hospital in Islamabad, Pakistan and to estimate the out of pocket expenditures to households using these services.MethodsThis hospital based cost accounting cross sectional study determines the average cost of vaginal delivery and Caesarean section from two perspectives, the patient's and the hospital. From the patient's perspective direct and indirect expenditures of 133 post-partum mothers (65 delivered by Caesarean section & 68 by spontaneous vaginal delivery) admitted in the maternity general ward were determined. From the hospital perspective the step down methodology was adopted, capital and recurrent costs were determined from inputs and cost centers.ResultsThe average cost for a spontaneous vaginal delivery from the hospital's side was 40 US$ (2688 rupees) and from the patient's perspective was 79 US$ (5278 rupees). The average cost for a Caesarean section from the hospital side was 162 US$ (10868 rupees) and 204 US$ (13678 rupees) from the patient's side. Average monthly household income was 141 ± 87 US$ for spontaneous vaginal delivery and 168 ± 97 US$ for Caesarean section. Three fourth (74%) of households had a monthly income of less than 149 US$ (10000 rupees).ConclusionThe apparently "free" maternity care at government hospitals involves substantial hidden and unpredicted costs. The anticipated fear of these unpredicted costs may be major factor for many poor households to seek cheaper alternate maternity healthcare.

Assessment of Cognitive and Motor Development in 150 Children with Refractory Epilepsy

Objective Neuropsychological impairment is an important co-morbidity of chronic epilepsy. The aim of this study was to determine the state of the cognitive and motor development of patients with refractory epilepsy. Materials & Methods We studied 150 consecutive children with epilepsy who were referred to Mofid Children Hospital, a third level public referral University Hospital in Tehran, Iran, from October 2007 to October 2008. Refractory epilepsy was defined as therapeutic failure of three antiepileptic drugs which were used appropriately. Data regarding sex, age, age at which the first seizure occurred, microcphaly, muscle tonicity, EEG findings, kind of treatment for controlling seizures and cognitive and motor development delay were collected from medical records. Development delay was defined as delay in acquiring cognitive ability and motor skills for age according to the Denver Scale II. Results Of 150 patients 72% were younger than 2 years old and 56.7% were male. About 35.3% were microcephalic while 76% had normal muscular tonicity.Only 2.7% had normal EEGs. About 37.3% showed a good response to anticonvulsive drugs and became seizure free, 13.3% showed a relative response to anticonvulsants but 49.3% did not respond. In the present study, 68% had cognitive developmental delay and 60.7% suffering motor delay. There was a significant difference in response to treatment between patients with cognitive and motor development delay. Conclusion Cognitive developmental delay was more frequent in patients with refractory epilepsy, suggesting that early cognitive screening and introduvtion of rehabilitation programs are necessary for patients with refractory epilepsy .

Clinical skills required of ophthalmic nurse practitioners in tertiary level public hospitals in the Western Cape Province

South Africa has a 32-year history of training ophthalmic nurse practitioners (ONPs). The role and required skills and competencies of ONPs are not well documented in the international literature and are also absent from South African publications, including South African Nursing Council publications. This study aims to inform curriculum development and human resource planning by reporting on the clinical skills expected of ONPs by members of multidisciplinary ophthalmology teams. A limited survey was undertaken in the ophthalmology wards and outpatient departments of three tertiary level hospitals in the Western Cape Province. A researcher-designed structured self-completion questionnaire was distributed to 30 ophthalmology practitioners: doctors, nurses and technicians. Respondents were asked to indicate the expected clinical skills of ONPs. All questionnaires were completed. All respondents favoured ONPs taking histories and performing emergency eye irrigations. There was less support for more complex procedures, such as B-scans. One-third of respondents did not expect ONPs to have skills in eight key areas, including examination of the anterior chamber angle for glaucoma. No statistically significant differences were found between responses of doctors and nurses, with one exception: more nurses (15/18) than doctors (4/10) had confidence in the ONP undertaking basic eye examinations for ocular motility (Fisher's exact test, P = 0.035). In the study settings, ONPs are not using their specialist skills to the full. Not all practitioners were receptive to ONPs using the skills that they had acquired during their postgraduate diploma, threatening the educational effectiveness of this initiative.