Rural General Hospitals Research Articles

Factors to Effective Clinical Experience, Willingness to pursue Career in Rural Health Facilities among Nursing Students on Clinical Placement in Southeast Nigeria and Rural Development.

To describe the Factors to Effective Clinical Experience and Willingness to pursue Career in Rural Health Facilities among Nursing Students on Clinical Placement in southeast Nigeria. The study was conducted among 48 rural health centres and general hospitals with 528 respondents from different higher institutions of learning serving in these health facilities for their clinical experience. The study applied survey design and utilized questionnaire instrument for data collection. Majority of the students (60%) agreed that their school lacked functional practical demonstration laboratory for students' clinical practice, 66.7% agreed that their school lab lacked large space for all the students to observe what is being taught, 79.9% that their school lab lacked enough equipment that can enable many students to practice procedures; majority of the students (79.9%) answered that the hospitals where they are on clinical placement lacked enough equipment needed for the students on each shift of practice, 59.9% agreed that student/client ratio in each ward during clinical experience periods was not enough for students' practice under supervision, while 73.3% indicated that their school lacked library with current nursing texts for references. Personal, socioeconomic and institutional factors explain the 76% of the variance of effective clinical experience and the 52% of the variance of the willingness to work in rural health facilities in the future if offered employment. The factors surrounding effective clinical experience in rural healthcare facilities in southeastern Nigeria are unfavorable and could discourage future nurses from working there. It is necessary to implement strategies to improve the management of these centers in order to promote the perspective of improving sustainable rural health in this region.

지방 종합병원 밀레니얼 세대 간호사의 이직의도 영향요인

Purpose: This study aimed to assess the relationship between work-life balance, professionalism, the nursing work environment, job satisfaction, and turnover intention, and to identify the influencing factors on turnover intention among millennial nurses at rural general hospitals. Method: Participants were 154 nurses born after 1989, working in two general hospitals located in C city of G province. Data were collected from August 25 to September 6, 2023, using a self-report questionnaire. Descriptive statistics, independent t-tests, one-way ANOVA, Pearson correlation coefficients, and hierarchical regression analyses were conducted using SPSS version 25.0. Results: In the hierarchical regression analysis, the variables affecting turnover intention were years of total experience, with different impacts noted for those with less than 1 to 5 years (β=.34, p=.002) and more than 5 years (β=.38, p=.001) in Model 1. In Model 2, work-life balance (β=-.19, p=.019) and professionalism (β=-.26, p=.001) were significant variables affecting turnover intention. Model 3 showed that the nursing work environment was an additional significant variable affecting turnover intention (β=-.35, p<.001), but job satisfaction (β =-.06, p=.507) did not significantly affect turnover intention. The total explanatory power was 34.9% (F=9.73, p<.001, R²=.349). Conclusion: The results suggest that various nursing management strategies and career management programs that consider nurses’ clinical experience and the nursing work environment are needed to reduce nurses’ turnover intention.

Characteristics and clinical outcomes of patients with pre-delta, delta and omicron SARS-CoV-2 infection in Indonesia (2020–2023): a multicentre prospective cohort study

Limited data exist from southeast Asia on the impact of SARS-CoV-2 variants and inactivated vaccines on disease severity and death among patients hospitalised with COVID-19. A multicentre hospital-based prospective cohort was enrolled from September 2020 through January 2023, spanning pre-delta, delta, and omicron periods. The participant hospitals were conveniently sampled based on existing collaborations, site willingness and available study resources, and included six urban and two rural general hospitals from East Nusa Tenggara, Jakarta, and North Sumatra provinces. Factors associated with severe disease and day-28 mortality were examined using logistic and Cox regression. Among 822 participants, the age-adjusted percentage of severe disease was 26.8% (95% CI 22.7-30.9) for pre-delta, 50.1% (44.0-56.2) for delta, and 15.2% (9.7-20.7) for omicron. The odds of severe disease were 64% (18-84%) lower for omicron than delta (p<0.001). One or more vaccine doses reduced the odds of severe disease by 89% (65-97%) for delta and 98% (91-100%) for omicron. Age-adjusted mortality was 11.9% (8.8-15.0) for pre-delta, 24.4% (18.8-29.9) for delta and 9.6% (5.2-14.0) for omicron. The day-28 cumulative incidence of death was lower for omicron (9.2% [5.6-13.9%]) than delta (28.6% [22.0-35.5%]) (p<0.001). Severe disease on admission was the predominant prognostic factor for death (aHR34.0 [16.6-69.9] vs mild-or-moderate; p<0.001). After controlling for disease severity on admission as an intermediate, the risk of death was 48% (32-60%) lower for omicron than delta (p<0.001); and 51% (38-61%; p<0.001) lower for vaccinated participants than unvaccinated participants overall, and 56% (37-69%; p<0.001) for omicron, 46% (-5 to 73%; p=0.070) for pre-delta (not estimable for delta). Infections by omicron variant resulted in less severe and fatal outcomes than delta in hospitalised patients in Indonesia. However, older, and unvaccinated individuals remained at greater risk of adverse outcomes. University of Oxford and Wellcome Trust.

Pediatric Hospitalizations at Rural and Urban Teaching and Nonteaching Hospitals in the US, 2009-2019

National analyses suggest that approximately 1 in 5 US hospitals closed their pediatric units between 2008 and 2018. The extent to which pediatric hospitalizations at general hospitals in rural and urban communities decreased during this period is not well understood. To describe changes in the number and proportion of pediatric hospitalizations and costs at urban teaching, urban nonteaching, and rural hospitals vs freestanding children's hospitals from 2009 to 2019; to estimate the number and proportion of hospitals providing inpatient pediatric care; and to characterize changes in clinical complexity. This study is a retrospective cross-sectional analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative data set of US pediatric hospitalizations among children younger than 18 years. Data were analyzed from February to June 2023. Pediatric hospitalizations were grouped as birth or nonbirth hospitalizations. Hospitals were categorized as freestanding children's hospitals or as rural, urban nonteaching, or urban teaching general hospitals. The primary outcomes were annual number and proportion of birth and nonbirth hospitalizations and health care costs, changes in the proportion of hospitalizations with complex diagnoses, and estimated number and proportion of hospitals providing pediatric care and associated hospital volumes. Regression analyses were used to compare health care utilization in 2019 vs that in 2009. The data included 23.2 million (95% CI, 22.7-23.6 million) weighted hospitalizations. From 2009 to 2019, estimated national annual pediatric hospitalizations decreased from 6 425 858 to 5 297 882, as birth hospitalizations decreased by 10.6% (95% CI, 6.1%-15.1%) and nonbirth hospitalizations decreased by 28.9% (95% CI, 21.3%-36.5%). Concurrently, hospitalizations with complex chronic disease diagnoses increased by 45.5% (95% CI, 34.6%-56.4%), and hospitalizations with mental health diagnoses increased by 78.0% (95% CI, 61.6%-94.4%). During this period, the most substantial decreases were in nonbirth hospitalizations at rural hospitals (4-fold decrease from 229 263 to 62 729) and urban nonteaching hospitals (6-fold decrease from 581 320 to 92 118). In 2019, birth hospitalizations occurred at 2666 hospitals. Nonbirth pediatric hospitalizations occurred at 3507 hospitals, including 1256 rural hospitals and 843 urban nonteaching hospitals where the median nonbirth hospitalization volumes were fewer than 25 per year. Between 2009 and 2019, the largest decreases in pediatric hospitalizations occurred at rural and urban nonteaching hospitals. Clinical and policy initiatives to support hospitals with low pediatric volumes may be needed to maintain hospital access and pediatric readiness, particularly in rural communities.

Access To Oncology Services In Rural Areas: Influence Of The 340B Drug Pricing Program.

Rural-urban cancer disparities, including greater mortality rates, are partially attributable to the limited availability of oncology services in rural communities. Without these services, rural residents may experience delays in timely treatment and may be less likely to complete recommended care. The 340B Drug Pricing Program allows eligible not-for-profit and public hospitals to purchase covered outpatient drugs, including high-cost oncology drugs, at discounted prices. Using 2011-20 data, we evaluated the relationship between new enrollment in the 340B program and oncology services initiation in rural general acute care hospitals that lacked oncology services in 2011. Compared with hospitals that remained unenrolled in the 340B program through 2020, hospitals that enrolled during 2012-18 were 8.3percentage points more likely to have added oncology services as of 2020. The newly participating hospitals that added oncology services were disproportionately located in Medicaid expansion states and in counties with lower uninsurance rates. These findings suggest that the 340B program facilitates expanded access to oncology services in some rural communities, but opportunities remain to address disparities in the most disadvantaged service areas.

Preventive Measures against Ebola and COVID-19 and Their Impact on Human Dirty-Hand Disease Mitigation in Côte d’Ivoire

Hygiene is the most useful public health measure for preventing infections of important endemic and emerging diseases of global significance. This study aimed to assess the impact of these public health preventive measures on dirty hand diseases. A retrospective survey was conducted in the rural general hospitals of Taabo (south-central Côte d’Ivoire) and Marcory (urban Abidjan) to collect clinical data on dirty hand diseases in the patients’ records from 2013 to 2020. In addition, focus group discussions (N = 8) were conducted in the communities in both settings to identify the sociocultural and economic hindering or fostering factors that affected the adoption of and the compliance with handwashing and disinfection practices. A total of 3245 and 8154 patients’ records were examined in the general hospitals of Taabo and Marcory, respectively. Compared with women, men were more affected by typhoid fever (OR, 0.68 [95%CI, 0.53–0.88]) and influenza (OR, 0.87 [95%CI, 0.75–1]). Hygiene measures promoted during Ebola and COVID-19 outbreaks had no impact on the prevalence of typhoid fever in both settings; however, a positive impact was observed regarding influenza infections. Populations were aware of the importance of handwashing for public health but had difficulties adhering due to financial constraints, access to drinking water, and the absence or scarcity of handwashing facilities.

Remote and rural surgery training and recruitment: a national attitudinal survey of Scottish surgical trainees.

Scotland's healthcare system includes six rural general hospitals (RGHs) which provide a full surgical service to the most remote and rural populations. Constraints of geography and finance, and population need, mean that local delivery of surgical services will be required for the foreseeable future. These RGHs face difficulties in recruiting suitably trained general surgeons. This study aimed to describe Scottish surgical trainees' attitudes towards training and working in remote and rural surgery, perceived barriers to recruitment and potential solutions. A survey was distributed in paper and electronic forms to all Scottish trainees in core surgery (early-stage trainees) and general surgery (later-stage trainees). The survey collected data describing demographics, life and career experiences, and attitudes towards training in remote and rural environments. Univariate and multivariate analyses of influences on interest in rural training and recruitment were carried out, and thematic analysis of free-text responses. There were 152 respondents (response rate 59%). Most (81%) felt that surgical training should be offered in rural environments and 43% were personally interested in some rural training. On multivariate analysis, interest in rural training was associated with being a core trainee (odds ratio (OR) 7.54, 95% confidence interval (CI) 2.79-22.76), and rural work experience following graduation (OR 5.12, 95%CI 1.85-15.39). Respondents stating that they were likely to work in a rural environment (9.2%), were more likely on multivariate analysis to be core trainees (OR 5.70, 95%CI 1.37-28.99) and to have previously lived in a rural location (OR 5.49, 95%CI 1.33-25.93). When trainees were asked for their views on how RGH jobs could be made more attractive, themes identified were as follows: increasing and improving training opportunities in RGHs, increasing the breadth of surgical training, optimising links with referral centres, and improving pay and conditions. This is the first study in a UK setting to describe the views of surgical trainees towards training and working in rural environments. There is substantial support and interest for rural surgical training among Scottish surgical trainees. A minority are interested in a rural surgical career, with interest more likely in core trainees and in those who have lived rurally. Increasing surgical training opportunities in rural environments and maximising medical school intake from rural areas may be important in addressing recruitment concerns.

Time to revisit the skills and competencies required to work in rural general hospitals.

To determine the structure and demographic of medical teams working in Rural General Hospitals (RGHs) in Scotland, and to gain insight into their experiences and determine their opinions on a remote and rural medical training pathway. Structured face-to-face interviews. Interviews were partially anonymised, and underwent thematic analysis. Medical departments of the six RGHs in Scotland 2018-2019. 14 medical consultants and 23 junior doctors working in RGHs in Scotland. Inclusion criteria: Present at time of site visit, medical consultant in an RGH or junior doctor working in an RGH who provides care for medical patients. Exclusion criteria: Doctors on leave or off shift. Medical consultants with less than one month of experience in post. Non-medical specialty consultants e.g. surgical or anaesthetic consultants. Of 21 consultant posts in the RGHs, only eight are filled with resident consultants, the remainder rely on locums. Consultants found working as generalists rewarding and challenging, and juniors found it to be a good training experience. Consultants feel little professional isolation due to modern connectivity. The majority of consultants (12/14) and all junior doctors favour a remote and rural medicine training pathway encompassing a mandatory paediatrics component, and feel this would help with consultant recruitment and retention. RGHs medical departments are reliant on locum consultants. The development of a remote and rural training medical training pathway is endorsed by the current medical teams of RGHs and has the potential to improve medical consultant staffing in RGHs.

Pediatric Mental Health Boarding

The growing prevalence of pediatric mental and behavioral health disorders, coupled with scarce psychiatric resources, has resulted in a substantial increase in the number of youth waiting in emergency departments (EDs) and medical units for inpatient psychiatric care. To characterize the prevalence of pediatric mental health boarding and identify associated patient and hospital factors. Medline and PsycINFO. All studies describing frequencies, durations, processes, outcomes, and/or risk factors associated with pediatric mental health boarding in youth ≤21 years of age. Publications meeting inclusion criteria were charted by 2 authors and critically appraised for quality. Eleven studies met inclusion criteria; 10 were retrospective cohort studies and 9 were conducted at single centers. All of the single-center studies were conducted at children's hospitals or pediatric EDs in urban or suburban settings. Study sample sizes ranged from 27 to 44 328. Among youth requiring inpatient psychiatric care, 23% to 58% experienced boarding and 26% to 49% boarded on inpatient medical units. Average boarding durations ranged from 5 to 41 hours in EDs and 2 to 3 days in inpatient units. Risk factors included younger age, suicidal or homicidal ideation, and presentation to a hospital during nonsummer months. Care processes and outcomes were infrequently described. When reported, provision of psychosocial services varied widely. Boarding definitions were heterogeneous, study sample sizes were small, and rural regions and general hospitals were underrepresented. Pediatric mental health boarding is prevalent and understudied. Additional research representing diverse hospital types and geographic regions is needed to inform clinical interventions and health care policy.

The benefits of rural training: Producing the expert generalists of the future

Most doctors in the UK train in urban areas and tertiary centres are considered centres of excellence for training, with rural district general hospitals often seen as a training backwater. However, there are huge benefits to training in rural areas, particularly with an ageing population, increased medical complexity and a shift of care from hospitals to the community. This article examines the benefits of rural training and looks at its role in producing the 'expert generalists' of the future.

Beliefs and expectations of rural hospital practitioners towards a developing trauma system: A qualitative case study

BackgroundAn understanding of stakeholders’ views is key to the successful development and operation of a rural trauma system. Scotland, which has large remote and rural areas, is currently implementing a national trauma system. The aim of this study was to identify key barriers and enablers to the development of an effective trauma system from the perspective of rural healthcare professionals. MethodsThis is a qualitative study, which was conducted in rural general hospitals (RGH) in Scotland, from April to June 2017. We used an opportunistic sampling strategy to include hospital providers of rural trauma care across the region. Semi-structured interviews were conducted, recorded, and transcribed. Thematic analysis was used to identify and group participant perspectives on key barriers and enablers to the development of the new trauma system. ResultsWe conducted 15 interviews with 18 participants in six RGHs. Study participants described barriers and enablers across three themes: 1) quality of care, 2) interfaces within the system and 3) interfaces with the wider healthcare system. For quality of care, enablers included confidence in basic trauma management, whilst a perceived lack of change from current management was seen as a barrier. The theme of interfaces within the system identified good interaction with other services and a single point of contact for referral as enablers. Perceived barriers included challenges in referring to tertiary care. The final theme of interfaces with the wider healthcare system included an improved transport system, increased audit resource and coordinated clinical training as enablers. Perceived barriers included a rural staffing crisis and problematic patient transfer to further care. ConclusionsThis study provides insight into rural professionals’ perceptions regarding the implementation of a trauma system in rural Scotland. Barriers included practical issues, such as retrieval, transfer and referral processes. Importantly, there is a degree of uncertainty, discontent and disengagement towards trauma system development, and concerns regarding staffing levels and governance. These issues are unlikely to be unique to Scotland and warrant further study to inform service planning and the effective delivery of rural trauma systems.

Rural Rotations at Core: Rarefied Exposure or Real Experience?

Surgical rotations involving rural General Hospitals (rGH) are frequently associated with recruitment challenges, partly because of adverse perceptions regarding distances from social support networks and training opportunities. The aim of this study was to determine the outcomes of core surgical training rotations involving rGHs when compared with urban hospitals in a single UK Deanery. Online Intercollegiate Surgical Curriculum Programme portfolios from 163 core surgical trainees (CST) were examined related to postlocation, operative experience, workplace-based assessments, and academic achievement. Of the 163 CSTs, 27 had completed at least 50% of their 2-year training posts at rGHs and were compared with 136 control CSTs completing rotations in urban general and teaching hospitals (uGH). The primary outcome measures were MRCS pass rate and success at national ST3 selection. A core surgical training program serving a single UK Deanery. Consecutive 177 CSTs appointed to a single UK Deanery between 2010 and 2016. Success at MRCS and national ST3 selection were similar for CSTs from rGH vs uGH rotations-MRCS success: 70.4 vs 72.8% (p = 0.816), and ST3 success: 22.2% vs 27.0% (p = 0.811). Median rGH vs uGH curriculum-based outcomes were operative case load: 378 vs 422 (p = 0.300); workplace-based assessments completed: 79 vs 94 (p = 0.499); audits performed: 4 vs 4 (p = 0.966); learned society communications: 1 vs 2 (p = 0.020); and scientific publications: 0 vs 0 (p = 0.478). CST rotations including rGHs produced a different spectrum of training experience compared with uGH rotations but overall primary outcomes were similar.

Can telehealth help to deliver sustainable and equitable paediatric services in Northern Scotland?

Northern Scotland needs more equitable and sustainable paediatric unscheduled care. Rural hospital emergency departments are primarily staffed by GPs or junior doctors outside normal working hours. Achieving equitable access to paediatric specialist advice is challenging. The Paediatric Unscheduled Care (PuC) Pilot Service was driven primarily by the Scottish Centre for Telehealth and Telecare. The Centre for Rural Health undertook an evaluation of the activity during the first six months. We evaluated the experience of consultations, rates of patient transfers to specialist centres, consultant views, satisfaction with videoconferencing technology and quality of care. The PuC Telehealth Service pilot attempted to provide a single point of consultant led paediatric contact for Rural General or Community hospitals across northern Scotland, by providing non-specialist physicians and families with fast and appropriate access to specialist assessment and support via video conferencing. This pilot aimed to use telehealth as a contribution to integrated care and embed PuC into existing working practice within the rural hospitals. We assessed the progress of the pilot against its objectives, using mixed methods during the evaluation including both quantitative and qualitative data collection, an economic analysis and literature review. Although the PuC model was popular with families and junior physicians, it proved expensive and concerns emerged about where clinical responsibility lay. Recommendations for sustaining equitable paediatric unscheduled care will be made.This abstract was presented at the Innovative Solutions in Remote Healthcare - 'Rethinking Remote' conference, 23-24 May 2016, Inverness, Scotland.

A comparative assessment of the awareness of danger signs and practice of birth preparedness and complication readiness among pregnant women attending rural and urban general hospitals in Lagos State

Background: Nigeria still experiences a high burden of unsafe motherhood. The knowledge of obstetric danger signs and the effective application of the principles of birth preparedness and complication readiness (BPACR) have the potential to significantly reduce the high maternal and perinatal morbidity and mortality rates. However, rural-urban differences may exist in the knowledge and practice of BPACR among women, and these may limit its potential benefit. We set out to assess and compare the knowledge of obstetric danger signs and practice of BPACR among pregnant women attending Rural (Agbowa) and Urban (Gbagada) Hospitals in Lagos State. Materials and Methods: In this cross-sectional comparative study, pregnant women attending antenatal clinics in each health facility were recruited into the study using a systematic sampling method. A structured interviewer administered questionnaire adapted from the safe motherhood John Hopkins Program for International Education in Gynecology and Obstetrics prototype questionnaire was used for data collection. Data were analyzed using SPSS version 17.0. Results: Awareness of obstetric danger signs during pregnancy was good among rural and urban study participants accounting for 62.4% and 68.4%, respectively. The most commonly identified danger sign in pregnancy, labor, and after delivery was bleeding from the genital tract. The awareness of danger signs during labor and after delivery identified by the women was low in both settings, though relatively higher in the urban area. The level of BPACR was low in both groups of women but was higher among women attending the urban center (31.6%) compared with the rural center (13.2%) P-value < 0.001. Conclusion and Recommendations: Activities aimed at improving birth preparedness practices particularly among rural women should be considered.

Use of prothrombin complex concentrates: 4-year experience of a national aeromedical retrieval service servicing remote and rural areas

IntroductionProthrombin complex concentrates (PCCs) are recommended as first-line treatment for acquired or congenital factor II, VII, IX and X deficiencies in situations of major haemorrhage. The Emergency Medical Retrieval Service...

Locum tenens consultant doctors in a rural general hospital - an essential part of the medical workforce or an expensive stopgap?

Maintaining hospital consultant staffing levels often requires the employment of locum tenens to meet service needs. This is particularly so in hospitals where core clinical services are run by a small number of permanently appointed consultants. The problems associated with locum employment are underestimated and little attention has been directed towards addressing the issue in the rural general hospitals of Scotland. This study looked at the permanent and short- and long-term locum consultant usage over an 8 year period in one Scottish rural general hospital, the Western Isles Hospital in Stornoway. Data were extracted from the Human Resources Department of NHS Western Isles' list of locum consultants for most weeks from the beginning of January 2002 to the end of December 2009. The Western Isles Hospital in Stornoway has an establishment of 17 permanent consultants. During the 8 year study period 239 different consultants were employed, 20 held substantive permanent positions, 31 were long-term locums (employed >3 months) and 188 were short-term locums. The short-term locums worked for 535 different locum episodes. The pattern of usage varied according to service configuration. Study data revealed the alarming scope of the locum tenens issue, which will increase unless action is taken. For sustainable medical services to continue in the rural general hospitals of Scotland, staffing models must minimise the need to employ locum consultants.

Hospital efficiency with risk adjusted mortality as undesirable output: the Turkish case

We analyze the operational performance of 202 Turkish rural general hospitals. To help improve performance on both input and output space, we adopt a directional distance approach. We treat a mortality based measure as a “needs indicator”. We derive pure technical, scale and output congestion inefficiency measures and show how they vary across size classes. We show that “reducing mortality” involves sacrificing some good outputs. This is a trade off that holds at the potential output level. Second stage regressions of the inefficiency scores against hospital and rural district level variables, pinpoint critical areas for performance improvement. In particular we show the relative scarcity of nurses is linked to output congestion.

010 ‘Time well spent?’: a correlation between total time on-scene (TOST) and interventions delivered for an Aero medical retrieval service

IntroductionThe Emergency Medical Retrieval Service (EMRS) provides a retrieval service to remote and rural communities (>70% of EMRS referrals are from isolated general practices or GP led community hospitals). These...

Exploring pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland

The introduction of non-medical prescribing in the UK has provided opportunities and challenges for pharmacists to help ensure prudent use of antimicrobials. The objective of this research was to explore pharmacists' perceptions of the feasibility and value of pharmacist prescribing of antimicrobials in secondary care in Scotland. Pharmacists' perceptions were explored using focus groups in five Scottish regions representing (a) urban and rural areas and (b) district general hospitals and large teaching centres. Senior hospital pharmacists, both prescribers and non-prescribers, working in specialities where antimicrobials are crucial to patient management, were invited to participate. A topic guide was developed to lead the discussions, which were audio-recorded and transcribed. The framework approach to data analysis was used. Six focus groups took place and some emerging themes and issues are presented. Pharmacists believed that the feasibility of antimicrobial prescribing is dependent upon the patient's clinical condition and the area of clinical care. They identified potential roles and opportunities for pharmacist prescribing of antimicrobials. Perceived benefits included giving patients quicker access to medicines, reducing risk of resistance and better application of evidence-based medicine. Pharmacists feel they have a good knowledge base to prescribe and manage antimicrobial treatment, identifying possible opportunities for intervention. Roles within a multidisciplinary antimicrobial team need to be clearly defined.

Acute human self-poisoning with bispyribac-containing herbicide Nominee®: a prospective observational study

Introduction. Self-poisoning with herbicides is an important reason for hospital admission and death in Asia. Although some herbicides have a well-described toxicity profile in humans, many of the newer compounds rely on extrapolation from animal results as no published literature on clinical outcomes of human self-poisoning has been described. One example of these compounds is bispyribac, a selective herbicide used in rice and wheat cultivation that is marketed in two containers, one containing bispyribac 400 g/L with a solvent and the other the surfactant, polyethylene glycol. We present the first case series of acute human self-poisoning with an herbicide product containing bispyribac. Methods. Clinical data for all patients who presented with acute poisoning from a bispyribac-containing herbicide (Nominee®) to two general hospitals in Sri Lanka from June 2002 to January 2009 were collected prospectively. Admission and serial blood samples were collected from consenting patients to confirm exposure and to study the toxicokinetics of bispyribac, respectively. Results. One hundred ten patients with a history of bispyribac ingestion presented after a median time of 4 h post-ingestion. There were three deaths at 15, 6, and 5 h post-ingestion because of asystolic cardiac arrest. All three patients had reduced Glasgow Coma Score (GCS) (3, 12, and 13, respectively) of whom the former two had co-ingested ethanol and developed tonic-clonic seizures. Admission blood sample was obtained from the former two of these patients but bispyribac was detected in only one of these patients. The other patient presented 2.5 h post-ingestion with a GCS of 12 but bispyribac was not detected. Excluding the patient with undetectable bispyribac, a conservative estimate of the case fatality ratio at 1.81% (95% confidence interval 0.32–5.8) can be made. The majority of the remaining patients had self-limiting upper gastrointestinal symptoms and eight patients had an abnormal GCS on presentation to hospital. The overall median hospital stay was 3 days. Bispyribac was not detectable on admission in 21 patients; in the remaining patients, the median plasma concentration was 50.55 μg/mL (interquartile range 1.28–116.5; n = 32). The peak concentration was noted around 3 h post-ingestion and plasma bispyribac concentration did not predict the severity of poisoning. Conclusion. The majority of patients developed self-resolving symptoms and were successfully managed in rural general hospitals without transfer to larger tertiary hospitals. Patients who died developed significant poisoning within 6 h and plasma bispyribac concentrations did not appear to predict mortality. The lack of correlation between bispyribac outcomes and the available plasma concentrations may be because of exposure to nonbispyribac components or other undefined factors. Clinical outcomes from acute self-poisoning with bispyribac-containing herbicides appear to be relatively more favorable than other commonly used herbicides.