Rural Ugandan Hospital Research Articles

A Novel CPAP Device With an Integrated Oxygen Concentrator for Low Resource Countries: In Vitro Validation and Usability Test in Field.

Goal: To develop and validatea novel neonatal non-invasive respiratory support device prototype designed to operate in low-resource settings. Methods: The device integrates a blower-based ventilator and a portable oxygen concentrator. A novel control algorithm was designed to achieve the desired fraction of inspired oxygen (FiO2) while minimizing power consumption. The accuracy of the delivered FiO2 and the device power consumption were evaluated in vitro, and a formative usability test was conducted in a rural hospital in Uganda. Results: The agreement between the set and delivered FiO2 was high (limit of agreement:-5.6 ÷ 3.8%). For FiO2 below 60%, the control algorithm reduced the power drain by 50%. The device was also appreciated by intended users. Conclusion: The prototype proved effective in delivering oxygen-enriched continuous positive airway pressure in the absence of compressed air and oxygen, holding promise for a sustainable and effective implementation of neonatal respiratory support in low-resource settings.

Differences in Virulence Factors and Antimicrobial Susceptibility of Uropathogenic Enterococcus spp. Strains in a Rural Area of Uganda and a Spanish Secondary Hospital.

Enterococcus faecalis and Enterococcus faecium have become two of the most important agents of nosocomial diseases due to their constantly growing resistance. Enterococcal infections are associated with biofilms, which are intrinsically sensitive to antimicrobials. The main goal of this study was to compare and relate their capacity to form biofilm and their antimicrobial sensitivity, as well as their virulence factors and their implicated genes, of strains isolated from patients with urinary tract infection (UTI) in a rural hospital in Uganda and a secondary hospital in Spain. A prospective study was conducted with 104 strains of E. faecalis and E. faecium isolated from patients with suspected UTI and who presented leukocyturia at the Saint Joseph Kitgum hospital (Uganda) and at the Hospital Universitario Principe de Asturias (Spain). All microorganisms were identified in Spain by MALDI-TOF mass spectrometry. Antimicrobial susceptibility studies were carried out using the Vitek® 2 system (Biomériux, France). The biofilm formation capacity was studied by photospectrometry. Phenotypic and genotypic virulence factors were studied in all cases by PCR or expression techniques. In Uganda, we found a higher incidence of E. faecium (65.3%, n = 32), contrary to the situation found in Spain where most of the bacteria found belonged to E. faecalis (92.7%, n = 51). All E. faecalis strains were found to have very low levels of resistance to ampicillin, imipenem, and nitrofurantoin. However, E. faecium exhibited more than 25% resistance to these antibiotics. Although the esp gene has been shown in the results obtained to be an important initial agent in biofilm formation, we have also demonstrated in this study the intervention of other genes when esp is not present, such as the ace1 gene. No statistically significant relationships were found between the presence of agg and gelE genes and increased biofilm formation. The significant difference between the incidence of E. faecalis and E. faecium and biofilm formation, between samples from Spain and Uganda, shows us very different profiles between countries.

Oral Morphine versus Rectal Ketamine in Pain Management during Burn Wound Dressing: An Open Label Randomized Clinical Trial

Background: Oral morphine has been widely used to manage children’s pain during burn wound dressing. Rectal ketamine may also be safely administered to children.
 Objective: To evaluate and compare the efficacy of oral morphine vs. rectal racemic ketamine in management of pain during burn wound dressing in a pediatric population in a rural study population.
 Methods: This was a randomized open-label clinical trial done in a rural hospital in Uganda. Study participants were randomly assigned to one of the treatment groups, either oral morphine or rectal ketamine, with a ratio of 1:1. Overall, we enrolled 44 participants, with 22 in each treatment arm.
 Assessment of baseline vital signs, including pulse rate, blood pressure, respiratory rate, temperature, oxygen saturation (SPO2), pain assessment (using Face Legs Activity Cry Consolability [FLACC]), and sedation scores (using Richmond’s agitation and sedation scale [RASS]) among others was done. Study participants were followed up hourly for 8 hours for outcomes of interest: adequate pain management/adverse events.
 Results: The mean age of the study participants was 2.56 (±1.59) years. The overall mean intra-procedural pain difference score for children who received oral morphine was 2.7 (SD±2.2) compared to 0 (SD±0) among those who received rectal ketamine, and the mean difference of 2.7 was statistically significant (p < 0.0001). Sialorrhea (hyper-salivation) was the only significant adverse event, with more occurrence in the rectal Ketamine treatment arm (n= 8, 36.3%) compared to 1 (5%) in the oral Morphine treatment arm, p = 0.009. There were no significant adverse effects noted in either treatment arm.
 Conclusion: The study showed the non-inferiority of rectal ketamine over oral morphine and concluded that administration of rectal ketamine was better at pain management and safety compared to oral morphine. Rectal ketamine is associated with an increased incidence of sialorrhea compared to oral morphine.

Ailing neurosurgical services in rural Africa

Ailing neurosurgical services in rural Africa

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial.

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda. Randomized clinical trial. Regional referral hospital in Uganda. Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019. Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24). The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications. Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection. In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Norepinephrine may improve survival of septic shock patients in a low-resource setting: a proof-of-concept study on feasibility and efficacy outside the Intensive Care Unit

ABSTRACT Septic shock treatment in sub-Saharan African hospitals is challenging due to limited availability of ICUs, central venous catheters, vasopressors, and trained staff. We designed this proof-of-concept study to determine efficacy, safety, and feasibility of norepinephrine (NE) use in a non-intensive setting in a low-resource country, consisting in a peripheral infusion via a mechanical drop counter. Septic shock patients accessing a rural hospital in Uganda were included: the 2020 group (N = 12) was prospectively enrolled (Jan–Mar 2020) when NE was available; the 2019 group (N = 11) was retrospectively enrolled (Oct–Dec 2019). Enrollment was continuous to reduce selection bias. Basic clinical endpoints (noninvasive blood pressure, tissue perfusion, diuresis) defined shock control and the prognostic endpoint was survival at hospital discharge. Shock control at 6 and 12 hours was higher in the 2020 group (p = 0.012 for both). Survival at hospital discharge was 75% and 27.3%, respectively (p = 0.039). NE infusion was associated with a Hazard Ratio of 0.23 (p = 0.041) in a multivariate Cox model. No NE-induced adverse effects were detected. These preliminary results suggest that implementing NE infusion in a low-resource setting without ICU could be a safe and effective strategy in managing septic shock and that this approach could lead to a lower mortality rate.

Solitary Juvenile Polyp at a Rural Ugandan Hospital Presenting with Recurrent Rectal Bleeding

Juvenile polyps (JP) are rare but important causes of acute gastrointestinal symptoms in children. They are a recognized cause of painless rectal bleeding in preschool age children and also the most common intraluminal disorder of the colon in children They are often solitary, pedunculated and small in size but may occasionally grow to large sizes or occur in great numbers, as in juvenile polyposis syndrome. Histologically juvenile polyps are similar to inflammatory polyps with irregular dilated glands, lamina propria expansion and granulation tissue expansion. Sporadic juvenile polyps of the colon occur in up to 2 percent of children under the age of 10 years, are usually solitary, and are not associated with an increased cancer risk. The etiology, diagnosis, clinical presentation, and management of these intestinal polyps depend on the type of polyp or polyposis syndrome. A change in bowel habits, abdominal pain, rectal bleeding, rectal prolapse, and even intussusception may be the initial presentation in children. In addition to a careful history, including a detailed family history, a physical examination, contrast studies, and endoscopic examination are vital diagnostic tools. Juvenile polyps may also present with prolapse of the polyp from the anus, abdominal pain due to intussusception or may even be asymptomatic. All such polyps should be removed by colonoscopy or transanal resection

One dollar incentive improves tuberculosis treatment outcomes in programmatic settings in rural Uganda

The study aim was to determine the association of a one United States dollar (USD) dollar incentive and tuberculosis (TB) treatment outcomes among people with TB receiving treatment at a rural hospital in Uganda under programmatic settings. We conducted a quasi-experiment in which people with TB were randomised (1:1 ratio) to receive either a one USD incentive at months 0, 2, 5 and 6 (Dollar arm) or routine care (Routine arm). A second control group (Retrospective controls) consisted of participants who had a treatment outcome in the preceding 6 months. Treatment outcomes were compared between the intervention and control groups using Pearson’s chi-square and Fisher’s exact tests. The association between the incentive and treatment outcomes was determined using Poisson regression analysis with robust variances. Between November 2018 and October 2019, we enrolled 180 participants (60 in the Dollar arm and 120 in the Control group). TB cure (33.3% vs. 20.8%, p = 0.068) and treatment success (70.0% vs. 59.2% p = 0.156) were higher in the Dollar arm than the Control group, while loss-to-follow-up was lower in the Dollar arm (10.0% vs. 20.8% p = 0.070). Participants in the Dollar arm were more likely to be cured (adjusted incidence rate ratio (aIRR): 1.59, 95% CI 1.04–2.44, p = 0.032) and less likely to be lost to follow-up (aIRR: 0.44, 95% CI 0.20–0.96, p = 0.040). A one-dollar incentive was associated with higher TB cure and lower loss-to-follow-up among people with TB in rural Uganda.

45 Educational Outcomes of Nursing-Focused Triage and Shock Management Course in Rural Ugandan Hospital

Emergency conditions constitute a large proportion of the global burden of disease and have higher morbidity and mortality in low- and middle-income countries. With education of health care providers in triage and basic emergency care for the critically ill, a large proportion of death and disability can be prevented. In this study we explore the pedagogic design of an educational curriculum to train nurses in rural Uganda in the triage and management of shock and evaluate its effectiveness using pre- and post-training assessments. Investigators, including a physician with extensive experience working at the Masindi Kitara Medical Center (MKMC) in Uganda, created an educational curriculum by adapting elements from the World Health Organization Basic Emergency Care course, the South African Triage System and curricula from the AFEM. A 4-day training was given to 60 health care personnel from local private and public hospitals at MKMC in January 2020. Training included didactic, small-group and simulation-based education. Participants completed anonymous pre- and post-training surveys and pre- and post-knowledge-based-tests. A comparison of pre- and post-knowledge-based-test scores was performed using chi-squared tests. Qualitative analysis of survey results was performed by two independent investigators to ensure agreement and nominal pre- and post-survey responses were compared using chi-squared tests. Forty-seven health care providers completed the pre-assessment and 48 completed post-assessments. The percent of providers who felt very confident with triage strategies and shock increased significantly following training as shown in table 1. On the knowledge-based post-test there was a 10.1% increase in correct responses after completion of the course (p<0.0001). Learners identified discussion-based, small-group learning and hands-on activities as the most effective teaching strategies in this setting, despite an acknowledgement that their previous formal education involved more traditional didactic modalities. Areas for improvement identified included providing more printed handouts, shorter presentation times with more group activities and providing additional and more frequent trainings. In this analysis of the effectiveness of a curriculum for teaching nursing-focused basics of triage and shock management, the course delivered statistically significant improvements in both education and comfort levels based on a pre- and post-analysis. Limitations included the anonymity of the assessments which prevented pre- and post-assessment analysis at the individual level. The insights gained into successful teaching modalities and potential improvements can serve to benefit the development of future educational programs in similar settings.

Nurse Managers’ Perspectives on Care Quality and Safety in Rural Hospitals in Uganda

Rural hospitals in sub-Saharan African countries play a key role in dealing with a high level of disease burden, but are usually poorly equipped with resources. Ward nurse managers in rural hospitals are in an ideal position to negotiate resources and bridge gaps in quality improvements. The aim of this study was to explore nurse managers’ perspectives on quality and safe care in rural hospitals in Uganda. This was a qualitative interpretive study in which 11 ward nurse managers with at least two years’ experience in the role were purposively selected to participate in the study. In-depth interviews using a semi-structured interview guide were applied for data collection. Thematic analysis was applied to analyse the data. Four themes were identified from the interviews. These themes explained how nurse managers engaged stakeholders in quality and safe care for patients; supported staff through supervision; improvised practices to cope with resource and equipment constraints; and being constrained by poor working conditions. Nurse managers in rural hospitals in sub-Saharan Africa face unique challenges in ensuring quality and safe care for patients due to a lack of basic human and material resources. The strategies they apply in quality improvements have implications for policy and resource development.

Delayed initiation of enteral feeds is associated with postnatal growth failure among preterm infants managed at a rural hospital in Uganda

BackgroundPrematurity is the leading cause of mortality in children under 5 years of age globally and is also frequently associated with postnatal growth failure (PGF). Although most preterm births occur in low resource settings, little is known about their postnatal growth outcomes especially in rural areas. We evaluated the incidence and factors associated with PGF among preterm infants managed at a rural hospital in Uganda.MethodsRetrospective cohort study of preterm infants discharged from Kiwoko Hospital neonatal intensive care unit (NICU) from July 2017 to June 2018. Inclusion criteria included gestational age 26 up to but not including 37 weeks, admission within 24 h of birth and at least 7 days hospital stay. Exclusion criteria included major congenital anomalies and missing gestational age or birth weight. Birth and discharge weights from clinical notes were plotted on Fenton 2013 growth charts. Gestation age was determined by last normal menstruation period (LNMP), extracted from the mother’s antenatal card or early obstetric ultrasound scan reports. Postnatal growth failure was diagnosed if discharge weight was less than the 10th percentile for estimated gestational age. Other data from the clinical notes included demographic characteristics, neonatal morbidities as assigned by the attending physician and infant feeding practices. Multivariable logistic regression was used to explore factors associated with PGF.ResultsA total of 349 preterm infants with a mean gestational age of 31 (range 26 to 36) weeks were included. The incidence proportion of PGF was 254/349 (73%). Factors significantly associated with postnatal growth failure included: delayed initiation of enteral feeds [AOR = 3.70, 95% (CI 1.64 to 8.33)], sepsis [AOR = 6.76, 95% (CI 2.15 to 21.2)], multiple gestation [AOR = 1.81, 95% (CI 1.01 to 3.24)] and male gender [AOR = 1.71 95% (CI 1.01 to 2.91)].ConclusionNearly three quarters of preterm infants managed at a rural hospital in Uganda had postnatal growth failure. Delayed initiation of enteral feeds and sepsis were highly associated with postnatal growth failure. Enteral feeds should be initiated as soon as possible in these infants to reduce early protein deficits and hence postnatal growth failure.

Primary HIV prevention in pregnant and lactating Ugandan women: A randomized trial.

BackgroundThe ‘Primary HIV Prevention among Pregnant and Lactating Ugandan Women’ (PRIMAL) study aimed to assess the effectiveness of an enhanced HIV counseling intervention for preventing HIV acquisition among HIV-uninfected mothers during pregnancy and throughout the breastfeeding period.MethodsWe conducted an unblinded randomized control trial between 22 February 2013 and 22 April 2016 to assess the effectiveness of an extended repeat HIV testing and enhanced counseling (ERHTEC) intervention aimed at preventing primary HIV infection among HIV-uninfected pregnant and lactating women in Uganda. HIV-uninfected pregnant women aged 15–49 were enrolled 1:1 individually or in couples together with their partner. Enrolled women and couples were randomized 1:1 to an intervention (ERHTEC) or control (extended repeat HIV testing and standard counseling) group and followed up to 24 months postpartum or six weeks past complete cessation of breastfeeding, whichever came first. Both groups were tested for sexually transmitted infections (STIs) and HIV at enrollment, delivery, 3 and 6 months postpartum and every 6 months thereafter until the end of follow-up. The intervention group received enhanced HIV prevention counseling every 3 months throughout follow-up. The control group received standard counseling at the time of HIV retesting. Both intervention and control couples were offered couple HIV testing and counseling at all study visits.Main outcome measuresFrequency of condom use and incidence of HIV, syphilis, gonorrhea, chlamydia and trichomoniasis over follow-up.ResultsBetween February 2013 and April 2014, we enrolled 820 HIV-uninfected pregnant women presenting for antenatal care individually (n = 410) or in couples (n = 410 women and 410 partners) in one urban and one rural public Ugandan hospital. Women’s median age was 24 years (IQR 20–28 years). At baseline, participants did not differ in any socio-demographic, reproductive health, HIV testing history, sexual behavior, medical history or STI status characteristics; 96% (386/402) of couples were tested and counseled for HIV together with their partners at enrolment, 2.1% (7/329) of whom were found to be HIV-infected. Six hundred twenty-five (76%) women completed follow-up as per protocol (S1 Protocol). Women were followed for an average of 1.76 years and cumulated 1,439 women-years of follow-up or 81% of the maximum 1,779 women-years of follow-up assuming no dropouts. Men were followed for an average of 1.72 years.The frequency of consistent condom use and the proportion of women who used condoms over the last 3 months or at last vaginal sex increased substantially over follow-up in both arms, but there were no statistically significant differences in increases between the intervention and control arms.During follow-up, on average 42% (range 36%-46%) of couple partners were counseled together. Between 3.8% and 7.6% of women tested positive at any follow-up visit for any STI including syphilis, gonorrhea, C. trachomatis or T. vaginalis. Four women (two in each arm) and no enrolled men became infected with HIV, representing an overall HIV incidence rate of 0.186 per 100 person-years. Three of the women seroconverters had enrolled individually, one as a couple. At or before seroconversion, all four women reported their partners had extramarital relationships and/or had not disclosed their suspected HIV-infected status. There were no statistically significant differences between study arms for STI or HIV incidences.ConclusionsA sustained enhanced HIV prevention counseling intervention for up to 2 years postpartum among pregnant and breastfeeding women did not have a statistically significant effect on condom use or HIV incidence among these women. However, in both study arms, condom use increased over follow-up while STI and HIV incidence remained very low when compared to similar cohorts in and outside Uganda, suggesting that repeat HIV testing during breastfeeding, whether with enhanced or standard counseling, may have had an unintended HIV preventive effect among pregnant and lactating women in this setting. Further research is needed to verify this hypothesis.Trial registrationClinicalTrials.gov NCT01882998

Socio-Demographic and Maternal Determinants of Birth Preparedness among Pregnant Women Seeking Skilled Birth Services at a Rural General Hospital, Mid Western Uganda

Background: Although the practice of preparing for childbirth among pregnant women is associated with 24.0% and 53.0% reduction in neonatal and maternal mortality respectively in low income countries, it remains inadequately practiced in Uganda. This study sought to assess socio-demographic and maternal determinants of birth preparedness among pregnant women at one of the rural hospitals in Uganda. Methods: This was a descriptive cross sectional study conducted among 332 pregnant women in first stage of normal labour between April and May 2017 at Kagadi hospital, mid western Uganda. In order to understand socio-demographic and maternal determinants of birth preparedness, we considered overall level of birth preparedness as our dependent variable and determined it using five elements. Data were collected using a researcher administered questionnaire. We used descriptive statistics to understand characteristics of respondents and multivariable logistic regression model to determine factors associated with birth preparedness. Results: Only 94 (28.3%) of the 332 pregnant women who were included in the study were prepared for childbirth. We found that male partners having secondary level of education (aOR 1.86, CI 1.107 - 3.243, p 0.02), discussing birth plan with spouse (aOR 1.97, CI 1.06 - 3.490, p 0.03), monthly income of at least eighty three dollars (aOR 2.98, CI 1.847 - 5.981, p 0.002), being escorted by the spouse during ANC visit (aOR 1.73, CI 1.010 - 2.964, p 0.04), intention to conceive (aOR 1.99, CI 1.087 - 3.65, p 0.026) and being health educated about birth preparedness during antenatal visit (aOR 1.90, CI 1.006 - 3.59, p 0.048) were associated with birth preparedness. Conclusion and Recommendations: We observed that the level of birth preparedness among respondents was associated with many socio-demographic and maternal factors. To scale up birth preparedness in rural settings, we recommend improving household financial income, reducing contraceptive unmet needs, male involvement and health education services to couples during antenatal visits.

Infection control and treatment guidelines and neonatal mortality in a rural hospital in Uganda

ABSTRACTBackground: The neonatal mortality rate in Uganda has been 24–27/1000 live births for the last 14 years.Aim: To determine the impact on neonatal mortality of the introduction of infection prevention and treatment guidelines in a resource-poor setting.Methods: A prospective study was undertaken in Kagando Hospital, a rural hospital in Western Uganda of infants live-born in hospital and those admitted from the community or other hospitals between 2013 and 2017. Guidelines were developed from a literature review and informed by local doctors and nurses and a visiting paediatrician. The guidelines highlighted that unwell infants should be admitted to the neonatal unit which was a section of the paediatric ward, emphasised hand hygiene, the separation of infants with and without sepsis and that unwell infants should be treated with evidence-based antibiotic regimens and enteral feeds withheld from unwell infants. Mortality within 28 days of birth was audited for 3 months before and after the intervention; the audit was repeated 3 and 5 years later.Results: Pre-intervention, there were 137 neonatal admissions and 79 neonatal deaths in 3 months (0.58 deaths per admission). Post-intervention there were 187 admissions and the death rate was lower (0.26 deaths per admission, p < 0.001). Three years after the intervention, there were 60 deaths among 233 admissions (0.26 deaths per admission, p < 0.001) and, at 5 years, 53 deaths among 315 admissions (0.17 deaths per admission, p < 0.001).Conclusion: These data suggest that the introduction of infection, prevention and treatment guidelines can reduce neonatal mortality in a resource-poor setting.

POST CESEREAN WOUND SEPSIS: Recognizable Risks and Causes at a Rural Ugandan Hospital

Post cesarean wound sepsis refers to a superficial surgical site infection that occurs within 30 days of the operative procedure and involves only the skin or subcutaneous tissue of the incision, and at least a purulent drainage from the incision or isolation of Organisms on culture or one of the cardinal signs of inflammation. Wound sepsis increases morbidity, mortality and length of hospital stay (Oliver, et al). In Uganda, rates of severe wound infection are as high as 25% [1]. Caesarean section rates at the Bwindi community Hospital are 30% of the total deliveries. Purpose: To determine the factors associated with post cesarean wound sepsis among mothers at Bwindi Community Hospital. Methods: This was a retrospective cross sectional study. Consecutive sampling was used to obtain 50 files of mothers who got post cesarean wound sepsis and a matching equal sample of controls at Bwindi Community Hospital from July 2015 to June 2017. Results: The rate of post caesarean sepsis was 3.5%.Multiple factors were associated with postoperative wound sepsis; Age between 26-30 years(OR 3.46, p0.008), Parity of greater than 5(OR 3.14, p0.010), Duration of labor of 5 -8hrs or greater (OR 10.67, p0.013), delayed time of ambulation greater than 24-72hrs (OR 0.14, p&lt;0.001), intra operative blood loss of 500- 1000mls or greater(OR 8.00, p0.023) and Post-operative administration of ampicillin and metronidazole (OR40.00,p&lt;0.001). Conclusion: Post-operative wound sepsis in caesarean section is a relatively common occurrence in low-resource settings and mitigation of the multiple identified modifiable associated factors will greatly reduce patient morbidity and improve their outcomes.

POST CESEREAN WOUND SEPSIS: Recognizable Risks and Causes at a Rural Ugandan Hospital

Post cesarean wound sepsis refers to a superficial surgical site infection that occurs within 30 days of the operative procedure and involves only the skin or subcutaneous tissue of the incision, and at least a purulent drainage from the incision or isolation of Organisms on culture or one of the cardinal signs of inflammation. Wound sepsis increases morbidity, mortality and length of hospital stay (Oliver, et al). In Uganda, rates of severe wound infection are as high as 25% [1]. Caesarean section rates at the Bwindi community Hospital are 30% of the total deliveries. Purpose: To determine the factors associated with post cesarean wound sepsis among mothers at Bwindi Community Hospital. Methods: This was a retrospective cross sectional study. Consecutive sampling was used to obtain 50 files of mothers who got post cesarean wound sepsis and a matching equal sample of controls at Bwindi Community Hospital from July 2015 to June 2017. Results: The rate of post caesarean sepsis was 3.5%.Multiple factors were associated with postoperative wound sepsis; Age between 26-30 years(OR 3.46, p0.008), Parity of greater than 5(OR 3.14, p0.010), Duration of labor of 5 -8hrs or greater (OR 10.67, p0.013), delayed time of ambulation greater than 24-72hrs (OR 0.14, p&lt;0.001), intra operative blood loss of 500- 1000mls or greater(OR 8.00, p0.023) and Post-operative administration of ampicillin and metronidazole (OR40.00,p&lt;0.001). Conclusion: Post-operative wound sepsis in caesarean section is a relatively common occurrence in low-resource settings and mitigation of the multiple identified modifiable associated factors will greatly reduce patient morbidity and improve their outcomes.

A Comparative Analysis of the Costs and Benefits of Outsourcing Vs. Insourcing Cleaning Services in a Rural Hospital in Uganda

Background:This study estimates the net cost benefit of outsourcing cleaning services in a hospital in Uganda. The aim is to demonstrate an approach that can be applied by hospital managers using readily available data to conduct a cost benefit analysis as part of pre-sourcing evaluation.Methods:A before and after design was used to analyze, from the hospital manager’s perspective, the impact of outsourcing cleaning services on the hospital’s costs. Cost and service quality data was collected for the pre- and post- outsourcing period. Net costs of outsourcing were determined using a total cost pre- and post-out-sourcing approach. Benefits were monetized by comparing the costs of outsourcing with the theoretical in-sourcing costs that would be required to achieve the same quality as outsourced cleaning services. The theoretical in-sourcing costs were estimated by weighting the actual insourcing costs by a quality factor based on the hospital manager’s rating of service quality pre- and post-outsourcing. The outcome measures were the net total cost and cost per square meter cleaned for a one-year period.Results:Before adjusting for quality, outsourcing cleaning services were more costly than insourcing, with an annual cost of UGX 644.35 ($ 0.25) and UGX 568.07 ($ 0.22) per square meter cleaned, respectively. After adjusting for quality, outsourcing is cost-beneficial, providing a cost saving of UGX 372.20 ($ 0.14) per square meter cleaned. Sensitivity analysis indicates that cost of the outsourcing contract and manager’s quality rating of outsourced services have the greatest impact on value for money from outsourcing. An annual contract cost above UGX 1000 ($ 0.38) per square meter cleaned makes outsourcing less beneficial, keeping all other factors constant. An average quality rating below 5 for the outsourced service makes outsourcing less beneficial cost wise.Conclusion:Outsourcing resulted in additional hospital expenditure compared to in-sourcing, but also resulted in better quality service. Adjusting for quality makes outsourcing more cost beneficial. The magnitude of the cost benefit is sensitive to the contract value and the managers’ quality rating of the outsourced services.

933: Comparing potential risk factors for perinatal death in singleton and twin pregnancies at a rural hospital in Uganda

Perinatal deaths, defined as stillbirths (fetal deaths before delivery, at or after 22 weeks gestation) and neonatal deaths within 7 days of birth, occur more frequently in twin gestations than singleton gestations. Given the limited data on this phenomenon in low resource areas, our study aims to compare risk factors associated with perinatal death in singleton and twin pregnancies in rural Uganda. We conducted a retrospective case-control study using data from birth registers at Tororo District Hospital, a regional hospital in rural Uganda. All cases of perinatal deaths from January to December 2014 were collected. Controls were derived from the labor admissions immediately preceding and following the cases of perinatal death. Each pregnancy was the unit of analysis. Statistical comparisons were performed using Fisher’s exact test, chi-square and t-test. During the study period, there were 185 cases of perinatal death, including 19 twin pregnancies. There were 354 control pregnancies, including 5 twin pregnancies. Twin gestation was associated with an odds ratio (OR) of 8.0 for perinatal death compared to singleton gestation (95% confidence interval (CI) 2.8 - 27.7, p = 0.0000). Perinatal deaths among twins were more likely to be fresh stillbirths (e.g. without findings suggestive of death prior to labor) (68.4% vs 35.8%, OR 3.9, CI 1.28 - 13.1, p = 0.0057) and more likely to be affected by low birth weight than singleton gestations (93.3% vs 33.1%, OR 28.3, CI 4.0 - 1209.6, p = 0.0000). There were no statistically significant associations between twin gestation and maternal age or gravidity, premature delivery, or mode of delivery. Our results confirm a higher frequency of perinatal deaths in twin gestations compared to singleton gestations in Tororo and identity an association with low birth weight. The greater proportion of fresh stillbirths among twins compared to singletons implies more deaths shortly before delivery for the former. Prenatal identification of twin pregnancies may reduce the perinatal loss rate in similar settings.

Alcohol-based hand rub and incidence of healthcare associated infections in a rural regional referral and teaching hospital in Uganda (\u2018WardGel\u2019 study)

BackgroundGood hand hygiene (HH) practice is crucial to reducing healthcare associated infections (HAIs). Use of alcohol-based hand rub (ABHR) at health facilities is strongly recommended but it is limited in Uganda. Data on the practice of HH and the incidence of HAIs is sparse in resource-limited settings. We conducted a quasi-experimental study to evaluate HH practices of health care providers (HCPs) utilizing locally made ABHR and the incidence of HAIs.MethodsHH compliance among HCPs and the incidence of HAIs were assessed at Mbale Regional Referral Hospital, a teaching hospital in rural Uganda. Inpatients from the obstetrics/gynecology (OBGYN), pediatric and surgical departments were enrolled on their day of admission and followed up during their hospital stay. The baseline (pre-intervention) phase of 12-weeks was followed by a 12-week intervention phase where training for HH practice was provided to all HCPs present on the target wards and ABHR was supplied on the wards. Incidence of HAIs and or Systemic Inflammatory Response Syndrome (SIRS) was measured and compared between the baseline and intervention phases. Multivariate survival analysis was performed to identify associated variables with HAIs/SIRS.ResultsA total of 3335 patients (26.3%) were enrolled into the study from a total of 12,665 admissions on the study wards over a 24-week period. HH compliance rate significantly improved from 9.2% at baseline to 56.4% during the intervention phase (p < 0.001). The incidence of HAIs/SIRS was not significantly changed between the baseline and intervention phases (incidence rate ratio (IRR) 1.07, 95% CI: 0.79 – 1.44). However, subgroup analyses showed significant reduction in HAIs/SIRS on the pediatric and surgical departments (IRR 0.21 (95% CI: 0.10 – 0.47) and IRR 0.39 (95% CI: 0.16 – 0.92), respectively) while a significant increase in HAIs/SIRS was found on the OBGYN department (IRR 2.99 (95% CI: 1.92 – 4.66)). Multivariate survival analysis showed a significant reduction in HAIs/SIRS with ABHR use on pediatric and surgical departments (adjusted hazard ratio 0.26 (95% CI: 0.15 – 0.45)).ConclusionsTo our knowledge, this study is one of the largest studies that address HAIs in Africa. During the 24-week study period, significant improvement in HH compliance was observed by providing training and ABHR. The intervention was associated with a significant reduction in HAIs/SIRS on the pediatric and surgical departments. Further research is warranted to integrate HAIs surveillance into routine practice and to identify measures to further prevent HAIs in resource limited settings.Trial registrationClinicalTrials.gov NCT02435719, registered on 20 April, 2015 (retrospectively registered).

Pediatric Poisonings in a Rural Ugandan Emergency Department.

This study aims to describe pediatric poisonings presenting to a rural Ugandan emergency department (ED), identifying demographic factors and causative agents. This retrospective study was conducted in the ED of a rural hospital in the Rukungiri District of Uganda. A prospectively collected quality assurance database of ED visits was queried for poisonings in patients under the age of 5 who were admitted to the hospital. Cases were included if the chief complaint or final diagnosis included anything referable to poisoning, ingestion, or intoxication, or if a toxicologic antidote was administered. The database was coded by a blinded investigator, and descriptive statistics were performed. From November 9, 2009, to July 11, 2014, 3428 patients under the age of 5 were admitted to the hospital. A total of 123 cases (3.6%) met the inclusion criteria. Seventy-two patients were male (58.5%). The average age was 2.3 (SD, 0.97) years with 45 children (36.6%) under the age of 2 years. There were 19 cases (15.4%) lost to 3-day follow-up. The top 3 documented exposures responsible for pediatric poisonings were cow tick or organophosphates (36 cases, 29.2%), general poison or drug overdose (26 cases, 21.1%), and paraffin or hydrocarbon (24 cases, 19.5%).Of the admitted patients, 1 died in the ED and 2 died at 72-hour follow-up, for an overall 72-hour mortality of 2.4%. Patients who died were exposed to iron, cow tick, and rat poison. Pediatric poisoning affects patients in rural sub-Saharan Africa. The mortality rate at one rural Ugandan hospital was greater than 2%.