Secondary Level Hospital Research Articles

Documentation of spinal anaesthesia technique and block level at caesarean section at a secondary-level obstetrics hospital in South Africa

Documentation of spinal anaesthesia technique and block level at caesarean section at a secondary-level obstetrics hospital in South Africa

Patient-Controlled Sedation in Port Implantation (PACSPI 1) - A feasibility trial.

Central venous access is essential for the administration of chemotherapy and frequent blood sampling in patients with cancer. The subcutaneous venous port is commonly used for this purpose. Subcutaneous venous port implantation is a minor surgical procedure; however, it can provoke pain and anxiety in these vulnerable patients. The aim of this study was, before a full-scale RCT, to determine the feasibility of patient-controlled sedation with propofol and alfentanil as an adjunct to local anaesthesia during SVP implantation. We prospectively studied 40 patients scheduled for SVP implantation between 14 April 2021 and 15 October 2021 at a 500-bed secondary level hospital in Sweden. Anaesthesiologists performed subcutaneous venous port implantation with patient-controlled sedation using propofol and alfentanil. We determined pain perception (primary outcome), patient satisfaction, sedation score, and key safety measures. Of the 40 patients with cancer, 80% reported a pain score ≤3 on an 11-point numeric rating scale during subcutaneous venous port implantation. Overall satisfaction with pain management and operating conditions was graded as 10 of 10 on the numeric rating scale. Four patients (10%) had bradypnoea (<8 bpm) without oxygen desaturation to ≤90%. Rescue sedation was administered to one patient (2.5%). Patient-controlled sedation with propofol and alfentanil during subcutaneous venous port implantation is feasible and well accepted. Ultimately the efficacy of patient-controlled sedation with propofol and alfentanil needs to be evaluated in an RCT to provide clinicians with evidence-based guidance for choosing the optimal perioperative strategy for subcutaneous venous port implantation. NCT04631393.

Standard operating procedure for prevention and initial management of COVID-19 in pregnancy at a secondary level hospital in rural South India: a quality improvement project

Background: During the COVID-19 pandemic there was an influx of antenatal patients presenting with symptoms while still requiring essential obstetric care. We needed to follow a standard operating procedure (SOP) at this rural maternity hospital for the prevention and initial management of COVID-19 in pregnancy.Methods: An SOP was formulated using national and international guidelines that were tailored to a resource-constrained setting. Healthcare workers were trained to implement the SOP. Sequential Plan-Do-Study-Act (PDSA) cycles enabled fine contouring of the prevention and initial management steps. Data was collected using an observational checklist at the end of each PDSA cycle and compared statistically to the baseline assessments using chi-square test.Results: Patients wearing face mask appropriately increased from 60% to 82.4% (P=0.0007). Patients using hand sanitizer provided at the hospital improved from 50% to 84.8% (P=0.0004). Proportion of patients screened for covid-19 symptoms rose from 74% to 94.4% (P=0.0002). Patients counselled for COVID-19 vaccination increased from 42% to 87.2% (P&lt;0.0001). Proportion of patients triaged at the OPD using the SOP improved from 66.6% to 87.2% (P=0.004). All improvements were statistically significant.Conclusions: The SOP for prevention and the initial management of COVID-19 symptoms in pregnancy was successfully implemented followed by PDSA cycles and can be used in similar health-care settings.

Maternal &amp; Fetal Outcome of Preterm Premature Rupture of the Membranes in Secondary Level Hospital in Bangladesh

Background: Premature rupture of membrane (PROM) is linked to significant fetal and maternal morbidity and mortalities. The maternal and fetal outcomes in PROM are very important to decrease maternal and child mortality and for better management and prevention of complications. Objective: To find out maternal &amp; fetal outcomes of preterm premature rupture of the membranes. Methods and Material: This is a cross-sectional observational study carried out in the Department of Obstetrics &amp; Gynaecology, 250 Beded District Hospital, Chapainawabganj, Rajshahi, Bangladesh from January 2016 to July 2016. 50 pregnant women with preterm premature rupture of the membranes. Result: The majority of patients with preterm PROM (30%) belong to the age group 31-35 years. The mean age of the patients and SD were 26.4±6.58. 60% of respondents were multipara and 40% primipara. Most of the patients had irregular antenatal checkups (56%), 24% had regular antenatal checkups, and 20% had no antenatal checkups. Twenty percent of patients developed labor pain within 15 hours of rupture of membrane, 24% within 16-30 hours, 56% within 31-45 hours, 10% within 46-60 hours, and 12% without the onset of labour pain. 37 (74%) patients with preterm PROM had a normal vaginal delivery, and 13(26%) delivered by caesarian Section. Forty-three percent of patients delivered within 24 hours of the ruptured membrane, followed by 24% of patients within 24-48 hours, and 28% of patients within more than 48 hours. Among 50 patients, 12 (24.0%) had a previous history of abortion, 24 (48%) had H/O preterm delivery due to PROM, 2 (4.0%) had H/O MR, and 6 (12.0%) had H/O D &amp; C. Among 50 respondents with PPORM 4 (8.0%) had diabetes mellitus, (12.0%) had HTN, 15 (2.0%) had urinary tract infection and 10 (20.0%) had lower genital tract infection. In this study, the total number of the alive baby was 42, and the stillborn baby was 2. Out of 42 alive babies, 18(42.86%) were affected by the consequence of preterm PROM and the birth process. Among 48 alive babies, 6(12.50%) developed birth asphyxia, 5(10.42%) developed jaundice, 3(6.25%) developed neonatal sepsis, and 4 (8.33%) developed respiratory distress syndrome. Maternal morbidity were chorioamnionitis 4(8%) puerperal sepsis 5(10%), postpartum endometritis 2(4%), abruptio placenta 1(2%) and wound infection 2(4%). Conclusion: The incidence of preterm PROM was more in multipara. The majority of the patients were from lower- and middle-class families. This study found some factors, e.g., Coitus, the recent history of abortion, M.R., D &amp; C, and previous history of PROM. The study was done with a small population, but it introduces us to certain risk factors that can be prevented. Proper health education, patient motivation, improved health hygiene, and adequate maternity and childcare services are needed to reduce morbidity and mortality.

Cost-effectiveness and sustainability of improved hospital oxygen systems in Nigeria

IntroductionImproving hospital oxygen systems can improve quality of care and reduce mortality for children, but we lack data on cost-effectiveness or sustainability. This study evaluated medium-term sustainability and cost-effectiveness of...

Outcome of Spontaneous Vaginal Delivery and Elective Induction of Labour in Postdated Pregnancy

Background: Postdated pregnancies are associated with increased perinatal morbidity and mortality. The risk increases when pregnancy continues beyond 41 wks. So, the Induction of labor conducted at or beyond 41 wks could help prevent these complications. But there are certain risks associated with Induction of labor. Again, Induction success varies widely and depends on some modifiable and nonmodifiable factors. Objective: To assess the feto-maternal outcome and analyze the factors affecting the outcome of electively induced labour in postdated pregnancy with a low bishop score compared to spontaneous onset labour in a secondary level hospital. Materials and methods: Prospective analytical study involving 220 participants divided into induction (study) and spontaneous labour (control) groups. Data collected on socio-demographic data, characteristics of the study population, causes of failed Induction, maternal complications and neonatal outcomes. Results: Among electively induced postdated pregnancy (study group) vaginal delivery was 45.45% with caesarean section 54.54% compared to 80% and 20% respectively in the spontaneous labour (control group). Cervical dystocia was the commonest indication for caesarean section (P=0.001). Among maternal complications control group had significant perineal lacerations (P=0.016) and study group had a longer duration of hospital stay (P&lt;0.001). The neonatal outcome didn’t show significant difference. Conclusion: The present study showed routine Induction of labor in prolonged pregnancy may encourage higher caesarean section rate with prolonged hospital stay but judicious Induction even in poor bishop score is not associated with any major feto-maternal complication. Further multicentric study with a larger sample size is recommended. J Bangladesh Coll Phys Surg 2022; 40: 175-182

An Architectural Study on Spatial Configuration of Emergency, Out Patient Department (OPD) and Isolation w.r.t. Infectious Diseases-Focused on Secondary Level Hospitals of Khyber Pukhtunkhwa Province

An Architectural Study on Spatial Configuration of Emergency, Out Patient Department (OPD) and Isolation w.r.t. Infectious Diseases-Focused on Secondary Level Hospitals of Khyber Pukhtunkhwa Province

Challenges and recommendations to improve implementation of phototherapy among neonates in Malawian hospitals

BackgroundSevere neonatal jaundice can result in long term morbidities and mortality when left untreated. Phototherapy is the main-stay intervention for treating moderate jaundice and for prevention of the development of severe jaundice. However, in resource-limited health care settings, phototherapy has been inconsistently used. The objective of this study is to evaluate barriers and facilitators for phototherapy to treat neonatal jaundice at Malawian hospitals.MethodsWe conducted a convergent mixed-method study comprised of a facility assessment and qualitative interviews with healthcare workers and caregivers in southern Malawi. The facility assessment was conducted at three secondary-level hospitals in rural districts. In-depth interviews following a semi-structured topic guide were conducted at a district hospital and a tertiary-level hospital. Interviews were thematically analysed in NVivo 12 software (QSR International, Melbourne, Australia).ResultsThe facility assessment found critical gaps in initiating and monitoring phototherapy in all facilities. Based on a total of 31 interviews, participants identified key challenges in diagnosing neonatal jaundice, counselling caregivers, and availability of infrastructure. Participants emphasized the need for transcutaneous bilirubinometers to guide treatment decisions. Caregivers were sometimes fearful of potential harmful effects of phototherapy, which required adequate explanation to mothers and family members in non-medical language. Task shifting and engaging peer support for caregivers with concerns about phototherapy was recommended.ConclusionImplementation of a therapeutic intervention is limited if accurate diagnostic tests are unavailable. The scale up of therapeutic interventions, such as phototherapy for neonatal jaundice, requires careful holistic attention to infrastructural needs, supportive services such as laboratory integration as well as trained human resources.

Pattern of Antibiotic Use among Hospitalized Patients according to WHO Access, Watch, Reserve (AWaRe) Classification: Findings from a Point Prevalence Survey in Bangladesh.

For supporting antibiotic stewardship interventions, the World Health Organization (WHO) classified antibiotics through the AWaRe (Access, Watch, and Reserve) classification. Inappropriate use of antimicrobials among hospital-admitted patients exposes them to the vulnerability of developing resistant organisms which are difficult to treat. We aimed to describe the proportion of antibiotic use based on the WHO AWaRe classification in tertiary and secondary level hospitals in Bangladesh. A point prevalence survey (PPS) was conducted adapting the WHO PPS design in inpatients departments in 2021. Among the 1417 enrolled patients, 52% were female and 63% were from the 15–64 years age group. Nearly 78% of patients received at least one antibiotic during the survey period. Third-generation cephalosporins (44.6%), penicillins (12.3%), imidazoles (11.8%), aminoglycosides (7.2%), and macrolides (5.8%) were documented as highly used antibiotics. Overall, 64.0% of Watch, 35.6% of Access, and 0.1% of Reserve group antibiotics were used for treatment. The use of Watch group antibiotics was high in medicine wards (78.7%) and overall high use of Watch antibiotics was observed at secondary hospitals (71.5%) compared to tertiary hospitals (60.2%) (p-value of 0.000). Our PPS findings underscore the need for an urgent nationwide antibiotic stewardship program for physicians including the development and implementation of local guidelines and in-service training on antibiotic use.

Effect of a perinatal care quality improvement package on patient satisfaction: a secondary outcome analysis of a cluster-randomised controlled trial

ObjectiveTo investigate the effect of a quality improvement (QI) package on patient satisfaction of perinatal care.DesignSecondary analysis of a stepped-wedge cluster-randomised controlled trial. Participating hospitals were randomised by size into...

Pranlukast treatment and the use of respiratory support in infants with respiratory syncytial virus infection.

In infants, respiratory syncytial virus (RSV) infection occasionally causes severe symptoms requiring respiratory support; however, supportive care is the primary treatment. This study compared the use of respiratory support among infants with RSV infection treated with or without pranlukast. This retrospective cohort study included infants aged <10 months with RSV infection who were admitted to three secondary level hospitals in Japan between 2012 and 2019. The infants were divided into two groups depending on whether they were treated with pranlukast. The primary outcome was the receiving respiratory support (high-flow nasal cannula, nasal continuous positive airway pressure, or ventilator). The secondary outcomes were the length of hospital stay, and the Global Respiratory Severity Score (GRSS) on starting respiratory support or at the time of the worst signs during hospitalization. We performed a propensity score-matched analysis. A total of 492 infants, including 147 propensity score-matched pairs, were included in the analysis. The use of respiratory support was significantly lower in infants treated with pranlukast (3.4% [5/147]) than those treated without pranlukast (11.6% [17/147]; P = 0.01). In the propensity score-matched analysis, pranlukast use was associated with a significantly lower chance of needing respiratory support (odds ratio: 0.27, 95% confidence interval: 0.08-0.79; P = 0.01); however, the length of hospital stay (median: 4 days) and the GRSS (median: 2.804 and 2.869 for infants treated with and without pranlukast, respectively) did not differ significantly between propensity score-matched pairs. Pranlukast use was associated with a reduced likelihood of requiring respiratory support in infants aged <10 months with RSV infection.

Valor predictivo de las alteraciones electrocardiográficas en la ocurrencia de complicaciones cardiovasculares en el síndrome coronario agudo sin elevación del segmento ST

IntroductionCardiovascular diseases cause approximately 18 million deaths annually, especially in developed or developing countries where life expectancy is usually higher. Material and methodProspective analytical cohort study in 598 patients diagnosed with non-ST segment elevation acute coronary syndrome who were admitted to a secondary level hospital between 2016 and 2020. ResultsST segment alteration was identified as a variable independent predictor of non-fatal cardiovascular complications with RR: 2.59 (95% CI: 1.64-4.10; p<.001) as well as haemodynamic complications, RR: 3.48 (95% CI: 2, 04-5.94, p<.001). In the particular case of patients with electrocardiographic abnormalities and cardiovascular complications, survival was significantly lower, HR: 3.01 (95% CI: 1.84-4.95; p<.001). ConclusionsAntecedent ST segment abnormalities were independent predictors of cardiovascular complications.

Myeloproliferative neoplasms – a global view

Myeloproliferative neoplasms – a global view

Starting of a new pediatric palliative care program in a general hospital: characteristics of the population and use of resources

This article sets out to describe the characteristics of patients at a second-level hospital who are likely to receive pedi-atric palliative care (PPC), the frequency of visits to the emergency room, admissions and technological devices used. A retrospective study was carried out of the patients who received care from the start of the PPC program (January 2017 to January 2020) at a secondary-level hospital. Twenty-nine patients were included, 58.6% male with mean age at entry into the study of 2.3 years (SD: 2.4); 44.8% of them were from rural areas. The prevalence of multimorbidity was 41%, with a higher frequency of neurological patholo-gy. Respiratory infection was the most frequent cause of emergency care (n = 360) and hospitalization (n=145). Half of patients (51.7%) depended on medical devices. Better knowledge of the resources used by this population can lead to more effective distribution/management that in turn can enable PPC to be offered regardless of the place of residence.

Outreach screening to address demographic and economic barriers to diabetic retinopathy care in rural China.

Poor access to existing care for diabetic retinopathy (DR) limits effectiveness of proven treatments. We examined whether outreach screening in rural China improves equity of access. We compared prevalence of female sex, age > = 65 years, primary education or below, and requiring referral care for DR between three cohorts with diabetes examined for DR in neighboring areas of Guangdong, China: passive case detection at secondary-level hospitals (n = 193); persons screened during primary-level DR outreach (n = 182); and individuals with newly- or previously-diagnosed diabetes in a population survey (n = 579). The latter reflected the "ideal" reach of a screening program. Compared to the population cohort, passive case detection reached fewer women (50·8% vs. 62·3%, p = 0·006), older adults (37·8% vs. 51·3%, p < 0·001), and less-educated persons (39·9% vs. 89·6%, p < 0·001). Outreach screening, compared to passive case detection, improved representation of the elderly (49·5% vs. 37·8%, p = 0·03) and less-educated (70·3% vs. 39·9%, p<0·001). The proportion of women (59.8% vs 62.3%, P>0.300) and persons aged > = 65 years (49.5% vs 51.3%, p = 0.723) in the outreach screening and population cohorts did not differ significantly. Prevalence of requiring referral care for DR was significantly higher in the outreach screening cohort (28·0%) than the population (14·0%) and passive case detection cohorts (7·3%, p<0·001 for both). Primary-level outreach screening improves access for the poorly-educated and elderly, and removes gender inequity in access to DR care in this setting, while also identifying more severely-affected patients than case finding in hospital.

Perceptions of the Doctor-Patient Relationship Among Patients in a Private, Secondary-Level Hospital in Southern India.

IntroductionAn epidemic of non-communicable diseases (NCDs) in India is fueling a growing demand for primary care and hospitalization services. Difficulties in coordinating inpatient and outpatient care create significant barriers to providing high-quality medical care. In this paper, we describe patient experiences, perceptions, and expectations of doctor-patient relationships in a secondary-level private hospital in Karnataka, India.MethodsWe conducted a cross-sectional, mixed-method needs assessment with surveys and in-depth interviews at Dr. TMA Pai Hospital (TMAPH), a secondary-level, private sector hospital in Karnataka, India. Inclusion criteria included all adults over 18 years old hospitalized at TMAPH in the past year. Patients were consecutively recruited from August 2019-October 2019 and asked to rate aspects of their relationship with their primary care provider (PCP). Descriptive statistics and multivariable logistic regression were used to analyze predictors of the doctor-patient relationship. Patients were interviewed regarding their perceptions of care coordination and doctor-patient relationships. General Thematic Analysis was utilized to analyze qualitative data and develop themes. Quantitative and qualitative findings were then merged to interpret the various dimensions of doctor-patient relationships.ResultsA total of 150 patients (47.3% male) enrolled. Ten patients underwent qualitative interviews. The median patient age was 67 years (IQR 56–76). 112 (74.7%) of patients identified a PCP either at or outside of TMAPH. 89% had diabetes and/or hypertension. Compared to patients without a PCP, having a PCP led to a significantly higher adjusted odds of always spending optimal time with their doctors (aOR 2.7, 95% CI 1.1–6.8, p = 0.04), and always receiving clear instructions on managing their medical conditions (aOR 2.5, 95% CI 1.0–6.1, p = 0.04). The following themes were developed from patient interviews: (1) patients trusted and respected their PCP believing they were receiving high quality care; and (2) despite perceived fragmentation in care, patients spoke favorably of their relationships with their doctors.ConclusionsAmong a sample of recently hospitalized patients, those with a PCP reported more positive doctor-patient relationships, though rates of dissatisfaction with doctors were still high. Further research and strategies are required to optimize continuity of care and doctor-patient relationships across the entire continuum of outpatient and inpatient care.

Epidemiological characteristics of Yersinia enterocolitica in patients with diarrhea from 2013 to 2019 in Pudong New Area, Shanghai

Objective: To investigate the epidemiological characteristics of Yersinia enterocolitica in patients with diarrhea in Pudong New Area, Shanghai. Methods: Active surveillance of diarrhea was conducted in 14 sentinel hospitals (three tertiary-level hospitals, nine secondary-level hospitals, and two primary-level hospitals) from January 2013 to December 2019 in Pudong New Area of Shanghai, China base on their location, catchment area, and patient volume. Cold enrichment method was used to isolate Y. enterocolitica and further detection of bioserotype, virulence genes and antimicrobial susceptibility of the isolates were conducted. The difference of rates was determined using chi-square test or Fisher's exact test. Results: A total of 12 941 diarrhea cases were included, and 0.7% (88/12 941) cases were confirmed with Yersinia enterocolitica infection. 67.0% (59/88) cases were single infection, 33.0% (29/88) cases were mixed infections. Detection rates of Y. enterocolitica increased annually (0.3%-1.2%) and were highest in children<5 years of age (1.1%, 37/3 218) and in spring (1.1%, 32/2 998) (χ2 were 18.64 and 9.76, respectively, P<0.05). 58.0% (51/88) cases had watery diarrhea, 15.9% (14/88) had fever and 14.8% (13/88) had vomiting. The predominant bioserotypes were 3/O:3 (53.4%, 47/88), followed by 1A/O:8 (15.9%, 14/88) and 1A/O:5(6.8%, 6/88), respectively. Bioserotype 3/O:3 counted for the highest proportions (89.2%, 33/37) in children <5 years of age. All the strains of bioserotype 3/O:3 harbored ail, ystA, yadA and virF genes, which encoded pathogenic Y. enterocolitica. 11/14 strain of 1A/O:8 and 4/6 strains of 1A/O:5 harbored ystB gene. Most strains were resistant to ampicillin (80.7%,71/88) and amoxicillin/clavulanic acid (71.6%,63/88), and 63.8% (56/88) strains were multidrug resistance (MDR). The difference of antimicrobial resistance rates between 3/O:3 and non 3/O:3 was statistically significant in ampicillin, cefoxitin, nalidixic acid, tetracycline and ampicillin/sulbactam (χ2 was 14.68, 43.80, 41.86, 30.54 and 5.07, respectively, P<0.05). Conclusion: The detection rate of Yersinia enterocolitica was higher in children than in adults in Pudong New Area, Shanghai. The predominant bioserotype was pathogenic 3/O:3 with multidrug resistance.

Esophageal cutaneous fistula, complication from penetrating neck trauma caused by air shotgun in pediatric patient

Penetrating neck trauma are uncommon in the pediatric population, but they constitute a significant management challenge. An air shotgun remains a significant source of injury to children. It causes severe damage and can involve the brain, eyes, heart, abdomen, and other body parts. Penetrating neck wounds account for almost 20% of firearm-related injuries in children and adolescents. Esophagus injury happened 9.6% of children with non-intracranial firearm injury. A 3 -years-old boy referred from secondary level hospital by dr. Soetomo General Hospital with a history of accidently shot by an air shotgun at the neck area. Patient underwent two surgeries in a second level hospital. First surgery was removing the bullet. The second surgery was indicated due to complications of subcutis emphysema. Because the drain production was milk, the patient was referred to our hospital. We suspected there were a esophageal cutaneous fistula. Patient was admitted and managed conservatively with IV fluids, IV antibiotics, adequate wound care, and surgical nutritional care by gastrostomy feeding. After one week, the patient was discharged from hospital. Patient is having a diet from gastrostomy feeding and is scheduled to take esophagogram evaluation. Esophagus injury in penetrating neck trauma by air shotgun in pediatric is a rare case, the esophageal cutaneous fistula as complications is even rarer. We conclude that they can be successfully managed by an active nonoperative approach. A good antibiotic coverage, nutritional support, adequate wound care, limited surgical interventions like gastrostomy are vital and may be induced secondary healing to close the fistula.

Direct patient costs of maternal care and birth-related complications at faith-based hospitals in Madagascar: a secondary analysis of programme data using patient invoices

ObjectivesWe aimed to determine the rate of catastrophic health expenditure incurred by women using maternal healthcare services at faith-based hospitals in Madagascar.DesignThis was a secondary analysis of programmatic data obtained...

TO PROGNOSTICATE THE OUTCOME IN PATIENT WITH PERFORATION PERITONITIS BY EVALUATING MANNHEIM PERITONITIS INDEX &amp; APACHE-II SCORING SYSTEM

Introduction: Peritonitis presents most commonly due to the localized or generalized infection. Studies have reported APACHE II to be a better system for prognostication of the outcome of patients with peritonitis, while others concluded that MPI provides a more reliable means of risk evaluation. The present study is conducted with the objective to nd out efcacy of MPI in comparison to APACHE II to prognosticate the outcome in patients with perforation peritonitis. Material and methods: This was a prospective hospital based analytical study conducted in department of surgery at Dr. BRAM Hospital, Raipur of Pt. JNMCH Raipur. Total 100 patients with peritonitis fullls the inclusion criteria was included in the study. Both scoring system is applied for the individual patient at admission or within 24 hours. Data was analysed using SPSS version 20.0. Descriptive statistics; frequency, percentage statistical signicance and p value were calculated. Results: The mean age of study subjects was 43.89±15.75 years. Of that (84%) were males. The chief complaint was abdominal pain and not passing atus. The primary outcome shows that one third was died during treatment and rests were discharged. The mean APACHE-II and MPI score among death cases was 14.7 and 25.2. APACHE-II score has sensitivity of 83% and specicity of 94% whereas MPI score has sensitivity of 51% and specicity of 77%. Conclusion: Though MPI did not prove to be as good as APACHE II in this study, there is denitely benet in using the MPI scores in primary and secondary level hospitals where facilities are less and investigations such as blood gas may not be available. They can be used to ascertain a certain extent of the patient's present condition and the prognosis