South African Public Hospitals Research Articles

The effectiveness of a performance management system at a South African public hospital in Cape Town

Background: In 1994, South Africa instituted the Public Service Act of 1994 which is presumably applicable and must be adhered to by all public institutions. Because of the adoption of the Public Service Law, all employees employed in the Western Cape Government (WCG) are obligated to participate in the Performance Management System (PMS). Consequently, the authors were interested to know how the PMS performs and how employees respond to this system at a public hospital.Aim: The purpose of this study was to examine the processes of PMS to identify its effectiveness. Of uttermost significance, through the findings of the study, was to make recommendations that contribute to improving the implementation of PMS.Setting: The study is based at a public hospital to examine the effectiveness of a PMS at a South African public hospital. The hospital is situated in Cape Town, South Africa.Methods: In pursuing the study, the authors employed an exploratory research design. Consequently, a qualitative research method was applied.Results: The study discovered that the PMS at the hospital is ineffective to enhance the performance of the employees and achieve organisational goals.Conclusion: The system appears to be a great tool designed to measure the employees’ effectiveness. However, its implementation seems to suggest a need for a thorough investigation of its efficiency.

Barriers of Intraprenurship Practice at South African Public Hospitals: Perspectives of Unit Nurse Managers

The paper highlights the barriers of intrapreneurship practice experienced by unit nurse managers working within the embattled public hospitals. The qualitative study was, descriptive, explorative and contextual in nature. The focus groups’discussions shed light on the plight of front runners constantly experiencing numerous intrapreneurial barriers frustrating ideation into implementable transformative programs. The barriers identified in this study include; lack of resources, security issues affecting freedom of staff and patients, poor staff ratios impacting on the rights of staff and patients, poor communication and unfair incentivised performance management system. The minimal conceptualization of intrapreneurship being quite foreign to nursing revealed in the findings is a wakeup call for senior teams pressured to improve performance. A number of public hospitals reforms consider the salient contribution of human capital in health care being key in driving quality improvement initiatives. Capacity development measures in education and clinical practice is a sensible recommendation through empowering nurses on business inclined management strategies like intrapreneurship practice improving the health care outcomes.

An audit of unnecessary preoperative urea and electrolyte panel tests in patients undergoing major orthopaedic surgery at a quaternary South African hospital

Background: Preoperative urea and electrolyte (U&E) panels are frequently requested for major surgery patients at risk for postoperative acute kidney injury (AKI). There is only one published study that has audited unnecessary preoperative U&E test panel utilisation in major surgery patients at a South African (SA) public sector hospital. This has significant implications for laboratory workloads, healthcare expenditure, and patient-friendly practice in the resource-limited SA public healthcare sector. Objective: To audit preoperative U&E panel requests in a sample of SA patients undergoing major orthopaedic surgery. Methods: We conducted a retrospective audit of adult primary hip arthroplasty patients who attended a quaternary SA hospital. Data on demographics, medical history, preoperative anaesthetic evaluations, operation details, and U&E panel requests were collected from each patient’s medical chart. The National Institute for Health and Care Excellence (NICE) guidelines, based on American Society of Anesthesiologists (ASA) grading and the presence of AKI risk factors, was used to distinguish between necessary and unnecessary preoperative U&E requests. We used descriptive statistics to analyse our study data. Results: Of the 175 patients comprising our study sample, 23 (13.1%) had preoperative U&E panels requested unnecessarily. All 23 patients were otherwise healthy and did not have any AKI risk factors. Conclusion: A small proportion of preoperative U&E test panels in our study sample of major orthopaedic surgery patients were deemed unnecessary. With that being said, there is still room for improvement in practices around preoperative U&E panel requests, which could be achieved through educational, computerised, and audit feedback interventions.

Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study

BackgroundEncouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice.MethodsFrom May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice.ResultsTwenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%).ConclusionQuality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative.Trial registrationThe study was registered with ClinicalTrials.gov (NCT03540667).

Determining the Need for After-Hours Diagnostic Radiological Reporting in Emergency Departments at Public Hospitals in South Africa: Perceptions of Emergency Physicians in KwaZulu-Natal

BackgroundEmergency departments in South African public hospitals have a high patient load after hours, with inadequate numbers of health care professionals available to satisfy patient influx. In addition, there is often no provision of after-hours diagnostic reporting services in public hospitals, to an extent that the emergency physician is responsible for interpreting all radiographic images requested themseves.Emergency physicians, in this study, can be described as any medical doctor registered with the Health Professions Council of South Africa and working in the emergency department as a registrar or consultant physician because there were no physicians specialized in emergency medicine working at the hospitals selected for this study. AimThe aim of this study was to determine the views of emergency physicians on whether there is a need for an after-hours diagnostic radiological reporting service in selected public hospitals in KwaZulu-Natal Province, South Africa. MethodsA descriptive cross-sectional quantitative research design was utilized, through means of a survey, to assess the emergency physicians’ perceptions regarding the need for after-hours diagnostic radiological reporting. In addition, the study used a descriptive quantitative research design to record the number of conventional diagnostic radiographic examinations performed at the selected hospitals, after hours, and the proportional number of these radiographic examinations that were reported on by radiologists during office hours, the following day. The distribution of questionnaires and data collection, with regard to the number of examinations reported on, and those not reported on, were carried out simultaneously during the execution of this study. The study was conducted over a three-month period in 2017, at four public hospitals in KwaZulu-Natal—one of the nine provinces of South Africa. ResultsThis study found that, during the study period, between 0.1% and 0.6% of the conventional diagnostic radiographic examinations performed, after hours, were reported on by radiologists during office hours, the following day. The surveyed emergency physicians felt that the interpretation of diagnostic images took up valuable time that could be spent on patient management, and there was near-total agreement, whereby 92% (n = 36) of the physicians would have preferred after-hours reporting to be performed by a radiologist. Physicians agreed that having a radiologist or reporting radiographer to provide radiological reports would allow for more effective and efficient patient management. ConclusionThe results of this study indicated that there is a need for after-hours radiographic reporting at the selected public hospitals and for the further training of emergency physicians in radiographic image interpretation. Based on the findings of this study, it is recommended that after-hours radiological reporting services be considered for public hospitals and that courses be offered to emergency physicians on the interpretation of diagnostic radiographic images. A hospital policy review may therefore be needed to adjust the focus of hospitals toward reducing the workload of emergency physicians, wherever possible, such as by incorporating support services like radiographic reporting and by providing further training on the interpretation of diagnostic radiographic images, which will both act to reduce the potential risk of misdiagnosis.

Organizational structures and early mobilization practices in South African public sector intensive care units-A cross-sectional study.

Understanding current early mobilization practice of patients in intensive care unit (ICU) is critical to the design and implementation of strategies to facilitate its application in a diverse population of critically ill patients encountered in public sector hospitals. To evaluate the organizational structures of South African public sector hospital ICUs and to describe early mobilization practices in these units. A cross-sectional survey was done in participating public hospitals from eight provinces in South Africa. Convenience sampling was done. Data collected included hospital and ICU structure, adult patient demographic and clinical data, and mobilization activities done in ICU over the previous 24 hours prior to the day of the survey. A total of 29 ICUs from 13 participating hospitals were surveyed resulting in 205 patient records. Majority of the surveyed ICUs were "open" type (n = 16; 55.2%). A standardized sedation scoring system was used in 18 units (62.1%) and only two units (6.9%) had an early mobilization protocol in place. Mean age of the patients surveyed was 43.5 (±17.7) years and 148 (72.2%) patients were on mechanical ventilation. Primary reasons for admission to ICU included traumatic injury (n = 86; 42%) and postoperative care (n = 33; 16.1%). Mobilization activities performed in the previous 24 hours included turning the patient in bed (n = 88; 42.9%), marching on the spot (n = 9; 4.4%) and walking (n = 10; 4.9%). Out-of-bed mobilization was done in only 40 (19.5%) patients. The most common barriers to early mobilization included patient unresponsiveness (n = 50; 24.4%) and hemodynamic instability (n = 42; 20.5%). The type of ventilation was found to have a significant positive relationship with out-of-bed patient mobilization (P = .000). A small proportion of patients attained their highest level of mobilization in ICU. The type of ventilation influenced early mobilization practices in public sector ICUs in South Africa.

A 10-year analysis of organ donor referrals to a South African tertiary public sector hospital.

South Africa (SA) has one of the lowest deceased organ donor rates in the world (1.4 donors per million population), with thousands of patients awaiting solid-organ transplantation. In order to improve access to transplantation we have to clearly define the reasons for the low deceased donation rate, specific to the population we serve. Review of actual donor statistics highlights our successes, yet is not able to contextualise the factors responsible for the unsuccessful conversion of referred organ donors to actual organ donors. In an attempt to identify key factors preventing referred donors from becoming actual donors, we analysed the donor referral patterns at our institution over a 10-year period. This was a retrospective descriptive study of consecutive deceased donor referrals at Groote Schuur Hospital, Cape Town, SA (from January 2007 to December 2016), utilising a regional donor referral registry. Qualitative and quantitative data were collected and presented as descriptive statistics and temporal trends. Over the 10-year study period, 861 possible organ donors were referred, with a steady increase in the number of referrals over time. Of the referrals, 514 (59.7%) were eligible for donation of at least one solid organ. Of the 508 families that were approached for consent to donation, 342 declined consent for a variety of reasons, resulting in a consent rate of 32.7%. Ultimately, at least one solid organ was obtained from 159 of the 166 consented donors. Despite the increasing number of possible and eligible donors, a statistically significant decline in consent rate was observed over time (ptrend=0.023). Furthermore, increasing trends in medical (as opposed to trauma) (ptrend<0.001) and extended criteria (as opposed to standard criteria) donor referrals (ptrend<0.001) were observed over the 10-year study period. Donor referral patterns have changed over time, with a notable increase in medical and extended criteria donors. Despite the increase in possible and eligible donors, the consent rate has declined. Further qualitative and quantitative research studies are required to understand and address this trend.

Availability and Use of Therapeutic Interchange Policies in Managing Antimicrobial Shortages among South African Public Sector Hospitals; Findings and Implications.

Background: Therapeutic interchange policies in hospitals are useful in dealing with antimicrobial shortages and minimising resistance rates. The extent of antimicrobial shortages and availability of therapeutic interchange policies is unknown among public sector hospitals in South Africa. This study aimed to ascertain the extent of and rationale for dealing with antimicrobial shortages, describe policies or guidelines available, and the role of pharmacists in the process. Methods: A quantitative and descriptive study was conducted with a target population of 403 public sector hospitals. Data were collected from hospital pharmacists using an electronic questionnaire via SurveyMonkeyTM. Results: The response rate was 33.5% and most (83.3%) hospitals had experienced shortages in the previous six months. Antimicrobials commonly reported as out of stock included cloxacillin (54.3%), benzathine benzylpenicillin (54.2%), and erythromycin (39.6%). Reasons for shortages included pharmaceutical companies with supply constraints (85.3%) and an inefficient supply system. Only 42.4% had therapeutic interchange policies, and 88.9% contacted the prescriber, when present, for substitution. Conclusions: Antimicrobial shortages are prevalent in South African public sector hospitals with the most affected being penicillins and cephalosporins. Therapeutic interchange policies are not available at most hospitals. Effective strategies are required to improve communication between pharmacists and prescribers to ensure that safe, appropriate, and therapeutically equivalent alternatives are available.

Breast Cancer Care Quality in South Africa's Public Health System: An Evaluation Using American Society of Clinical Oncology/National Quality Forum Measures.

PURPOSEThe quality of breast cancer care in sub-Saharan Africa contributes to the region’s dismal breast cancer mortality. ASCO has issued quality measures focusing on delivery of adjuvant chemotherapy, radiotherapy, and endocrine therapy. We applied these measures in five South African public hospitals and analyzed factors associated with care concordance.MATERIALS AND METHODSAmong 1,736 women with breast cancer who were enrolled in the South African Breast Cancer and HIV Outcomes study over 24 months, we evaluated care using ASCO’s three measures. We also evaluated adjuvant chemotherapy receipt in 957 women with an indication. We used logistic regression to estimate associations between measure-concordant care and patient factors.RESULTSOf 235 women with hormone receptor–negative cancer, 173 (74%) began adjuvant chemotherapy within 120 days from diagnosis. Of 194 patients who received breast-conserving surgery, 73 (37%) began radiotherapy within 365 days from diagnosis. Of 999 women with hormone receptor–positive cancer, 719 (72%) initiated endocrine therapy within 365 days from diagnosis. Chemotherapy and radiotherapy measure-concordant care were more common among women residing < 20 km from the hospital (odds ratio [OR], 1.79; 95% CI, 1.32 to 2.44 and OR, 3.17; 95% CI, 1.57 to 6.42). Endocrine therapy measure-concordant care was more common among English-speaking women (OR, 2.12; 95% CI, 1.12 to 4.02). Participating hospitals varied in care concordance. HIV infection did not affect care quality.CONCLUSIONMore timely delivery of chemotherapy, radiotherapy, and endocrine therapy is needed in South Africa, particularly for women living > 20 km from the hospital or not speaking English. Focused quality improvement efforts could support that goal.

Best Practice Guideline for Patient-Centred Care in South African Public Hospitals

Delivery of quality healthcare in South African is framed by the Batho Pele (“People First”) principles and the National Patients’ Rights Charter, both of which emphasise patient-centred care. However, underfunding, mismanagement, and neglect of the South African public infrastructure result in the implementation of these policy documents often not being evident in practice. The challenges of rendering patient-centred care under such circumstances spurred the development of an evidence-based best practice guideline to assist professional nurses in public hospitals. This article outlines the development of a best practice guideline for patient-centred care in public hospitals. An adapted version of the approach recommended by the Clinical Guidelines Advisory Committee of the National Institute for Health and Clinical Excellence was applied to develop the guideline. The draft guideline was submitted to experts for review. Thereafter it was modified and finalised. Nine sets of recommendations related to practice, education, organisation and policy were developed as part of the guideline. These involve (1) embracing values and beliefs foundational to patient-centred care; (2) optimal communication in all facets of care; (3) rendering of basic nursing care practices; (4) family involvement; (5) awareness of the importance of culture in patient-centred care; (6) organisational and managerial support; (7) organisational champions; (8) positive work environment; and (9) organisational structure that promotes interprofessional collaborative practice. It is anticipated that the guideline can be implemented after pilot testing and can be used by professional nurses rendering care to patients in public hospitals in South Africa.

BMI-based figure rating scale (FRS) as an adjunctive aid in nutritional screening and assessment in a resource-limited setting

Objectives: Many existing malnutrition screening and diagnostic tools require body mass index (BMI) and quantification of weight change to detect malnutrition or risk thereof. This is often a challenge in South African public hospitals due to missing data, including patient records. This study investigated the extent to which hospitalised patients can gauge their current and usual body size from a validated BMI-based figure rating scale (FRS). It also ascertained whether a relationship exists between a change in clothing size and a change in perceived BMI, derived from the FRS. Methods: A total of 196 adult patients participated in a cross-sectional study, in three Eastern Cape public hospitals. Data were collected by consulting medical files, patients and taking anthropometric measurements. Validated FRSs were used to determine patients’ accuracy of actual and usual BMI. Data were analysed with Statistica® and Microsoft Excel 2016. Results: Some 66% (n = 131) of participants were accurate in selecting an image representative of their BMI, which was statistically significant (r 2 = 0.80; p < 0.001). Female participants were more likely to select the correct corresponding BMI image (p < 0.05; r 2 = 0.77 for males; r 2 = 0.82 for females). Altogether, 61% (n = 79) of participants with a known previous weight were accurate in selecting an accurate image representative of their usual BMI, also statistically significantly (r 2 = 0.71; p < 0.001). Conclusion: An existing FRS may be a useful adjunctive aid in clinical practice to estimate certain anthropometric indices when not otherwise available. This may be especially relevant to nutritional screening practices conducted by frontline healthcare professionals, e.g. nurses and doctors not specifically trained in anthropometry. This in turn may improve malnutrition detection rates and facilitation of appropriate nutrition care pathways.

Transforming South African Public Hospitals Through Intrapreneurship Practice: Views of Unit Nurse Managers Regarding Their Potential Contribution

The insurmountable challenges confronting public hospitals globally jeopardize envisaged quality. South Africa health care system faces a number of challenges calling for strategic business approaches embodied through intrapreneurship practice. As a foreign concept in nursing, intrapreneurship is least understood. Views of unit nurse managers concerning their potential contribution towards improving services at public hospitals are least understood. A qualitative, descriptive and explorative study done through focus groups shed light. Data analysed through Tesch approach culminated in rich verbatim. The participants&amp;rsquo; shared the following views concerning their intrapreneurial contribution; ability to take&amp;ndash;risk in bureaucratic public hospitals; they associate the initiative with creativity and novelty through leading transformative projects in teams, the business leaders are knowledgeable, and share ideas internally or outside. The remarkable paradigm shift in nursing adopting business strategies has a significant impact on outcome of nursing care. The proposed recommendations adding significant value, transform health care policy, practice, education. On-going capacity development for the nurses in clinical practice is a necessary quality improvement initiative.

Venous thromboembolism risk and prophylaxis prescription in surgical patients at a tertiary hospital in Eastern Cape Province, South Africa.

Venous thromboembolism (VTE) is a common complication during and after hospitalisation, and is regarded as the most common cause of preventable death in hospitalised patients worldwide. Despite its importance, there are few data on VTE risk and adherence to prophylaxis prescription guidelines in surgical patients from the South African (SA) public sector, especially from low-resource environments such as Eastern Cape Province. To evaluate the risk and prescription of VTE prophylaxis to surgical patients at a tertiary government hospital in the Eastern Cape. A cross-sectional clinical audit of general surgical inpatients was performed on two dates during July and August 2017. Patients' VTE risk was calculated by using the Caprini risk assessment model (RAM) and thromboprophylaxis prescription evaluated accordingly. A total of 179 patients were included in the study, of whom 56% were male and 44% female. The average age was 45 (range 18 - 83) years. Of the total number of participants, 33% were elective cases and 67% were emergency admissions. With application of RAM, 77% of patients were at risk of VTE (Caprini score ≥2), with 81% of elective and 74% of emergency patients being at risk. The most prevalent risk factors for VTE were major surgery (34%), age 41 - 60 years (30%), age 61 - 74 years (20%) and sepsis during the previous month (27%). A contraindication to chemoprophylaxis was recorded in 30% of patients, with the most prevalent being renal dysfunction (40%), peptic ulcer disease (34%), active bleeding (17%), liver dysfunction (17%), coagulopathy (6%) and recent cerebral haemorrhage (6%). With regard to VTE risk profile and contraindications to chemoprophylaxis, the correct thromboprophylactic treatment was prescribed to 26% of at-risk patients, with 21% of elective and 27% of emergency admission patients receiving the correct therapy. Despite a high proportion of patients being at risk of VTE, the rate of adequate thromboprophylaxis prescription for surgical inpatients at Frere Hospital, East London, SA is very low. Increased availability of mechanical prophylaxis, as well as interventions to improve the rate of adequate prophylaxis prescription, needs to be evaluated for feasibility and effect in this hospital and other SA public hospitals.

Admissions for post-discharge surgical site infection at a quaternary South African public sector hospital

Reports of post-discharge admissions for surgical site infection (SSI) in African settings are lacking. This information could assist with allocating resources within hospitals, as well as developing targeted interventions aimed at reducing post-discharge SSI. The primary objective of this study was to determine trends in admissions for post-discharge SSI at a South African quaternary/teaching hospital. The secondary objective was to determine trends in mortality rates for these admissions. This was a retrospective review of adult admissions for post-discharge SSI at a quaternary/teaching South African hospital between 2006 and 2015. Admissions for post-discharge SSI were identified using the hospital administrative database and appropriate International Classification of Disease, 10th Revision codes. Mortality was determined from the discharge disposition for each admission. Data were analysed with simple regression and trend line statistics. The geospatial distribution of post-discharge SSI, based on the residential postal codes recorded on the hospital administrative database for each admission, was determined using the Power Map® software program. There was no change in admissions for post-discharge SSI over the study period (p = 0.17). Mortality in elderly admissions declined during the study period (p = 0.03). Most admissions for post-discharge SSIs originated from urban areas. Despite the implementation of universal SSI prevention methods, admissions for post-discharge SSI remained consistent during the study period. Urban areas appeared to be more.

Implementation and monitoring of decisions by pharmacy and therapeutics committees in South African public sector hospitals

ABSTRACTIntroduction: The National Drug Policy in South Africa has achieved its objective in establishing and strengthening Pharmacy and Therapeutics Committees (PTCs) in public sector hospitals. However, little is known about the implementation of decisions by PTCs and the monitoring thereof. Consequently, there is a need to investigate this.Areas covered: We sought to address this via an online survey distributed to pharmacists working in public sector hospitals across South Africa with perceived functioning PTCs, with a 32.3% response rate to the survey.Expert commentary: Membership of all PTCs included a pharmacist, who in most cases (51.2%) held the secretariat position. Principal PTC activities were encouraging rational medicine use (RMU) (86.0%), pharmacovigilance (82.6%) and implementing standard treatment guidelines (STGs) (77.9%). Only a third (37.5%) stated that they were using indicators to monitor PTC performance. Where collected, indicator data were mostly used for providing feedback to PTCs (83.3%). Most hospitals (95.1%) implemented PTC decisions; however, 62.0% mentioned guidelines on implementing PTC decisions did not exist in their hospital. The majority of respondents (65.4% and 83.8%, respectively) indicated PTC decisions were evaluated and reviewed in their hospitals. Overall, a high percentage of respondents stated the main activities of PTCs were to enhance RMU as well as implement STGs. However, guidelines on implementation of decisions by PTCs are currently lacking and most PTCs were not monitoring their performance. This needs to be addressed.

Mid-upper arm circumference (MUAC) as a feasible tool in detecting adult malnutrition

Objectives: This study aimed to expand on the limited South African malnutrition prevalence data and investigate the feasibility of mid-upper-arm circumference (MUAC) as a malnutrition screening tool.Design: A cross-sectional, multi-centre, descriptive design was adopted.Setting: The study was undertaken in three tertiary public hospitals in the same urban area within the Eastern Cape of South Africa.Subjects: Adult hospitalised patients volunteered to participate (n = 266).Methods: Data were collected using interviewer-administered questionnaires; obtaining anthropometric measurements; and consulting medical files. For maximum accuracy of various MUAC cut-off points, receiver operating characteristic curves were generated and area under the curve determined.Results: Both body mass index (BMI) and MUAC identified 21% of participants as underweight or malnourished, and 39% as overweight or obese. The Malnutrition Universal Screening Tool (MUST) found 23% at increased malnutrition risk. Nurses or doctors detected and referred only 19% of underweight patients (BMI < 18.5 kg/m2), to dietetics services. Direct measurements of BMI and MUST were unobtainable in 38% and 43% of patients respectively, whilst MUAC was obtainable in 100%.A statistically significant relationship (p < 0.001) exists between MUAC, BMI and MUST to detect malnutrition or malnutrition risk. MUAC cut-offs for undernutrition were determined at < 23 cm (BMI < 16 kg/m2) and < 24 cm (BMI < 18.5 kg/m2), respectively, for the study’s population groups.Conclusion: Malnutrition prevalence was high in this study, but often unidentified, with only a fifth referred to dietetic services. MUAC is a feasible method to identify adult malnutrition and should be considered as a malnutrition screening tool and key nutritional status indicator in South African public hospitals.

Adult malnutrition: prevalence and use of nutrition-related quality indicators in South African public-sector hospitals

Objectives: The aim of this study was to describe the prevalence of malnutrition among adult hospitalised patients in three South African public hospitals and to determine the availability of nutrition-related quality indicators at ward and institutional level.Method: A descriptive, cross-sectional, multi-centre study was used to determine the prevalence of malnutrition, whilst a descriptive exploratory design was used to determine the use of nutrition-related quality indicators for the identification and treatment of malnutrition. A total of 141 adult hospitalised patients in three public hospitals in an urban setting participated. Mid-upper arm circumference (MUAC), body mass index (BMI), and malnutrition universal screening tool (MUST) were used to determine the prevalence of malnutrition or malnutrition risk. A Hospital Nutrition Review Tool (HNRT) determined the use of nutrition-related quality indicators.Results: The overall malnutrition risk according to MUST was 72.3% (48.2% high risk and 24.1% medium risk), whilst 45.4% were malnourished based on MUAC. No routine nutritional screening was conducted in any of the wards to identify patients at nutritional risk. The majority of nurses reported inadequate training or knowledge to calculate patients’ BMI or percentage weight loss, or to perform nutritional screening.Conclusion: Both malnutrition prevalence and malnutrition risk among adult hospitalised patients are high in the public sector. Inadequate resources may lead to delays in malnutrition identification and appropriate nutritional intervention, which may adversely affect both the patient and the institution. This study contributes to baseline data on adult malnutrition in the South African public hospital setting.

The impact of uterine artery embolisation on fibroid volume at 43.6 months in women with symptomatic fibroids at a tertiary-level hospital

Background. Symptomatic uterine fibroids have a significant impact on women’s health. Surgical intervention (myomectomy and hysterectomy) has been the mainstay of treatment. Women living with symptomatic uterine fibroids contribute significantly to a growing waiting list for surgery in South African public hospitals. Uterine artery embolisation (UAE) is a newer treatment option and has shown to be a minimally invasive, safe and effective alternative to surgery for such women. Objective. To evaluate the efficacy of UAE in women with symptomatic fibroid uterus. Methods. A prospective, observational, single-centre study of 51 women with symptomatic fibroid uterus who underwent UAE at Steve Biko Academic Hospital from February 2007 to November 2012. Results. A total of 51 women underwent UAE, 3 of whom were lost to follow-up. The remaining 48 women were followed for a mean duration of 43.6 months. There was a statistically significant reduction in the mean uterine and dominant myoma volumes, as well as improvement in the haemoglobin levels ( p =0.001). The mean uterine and dominant fibroid volume reductions were 38% and 58%, respectively. Minor complications were reported in 19% of the women (fever, post-embolisation syndrome and vaginal fibroid passage were frequently reported complications). Reintervention (hysterectomy and gonadotropin-releasing hormone analogue use) was required in 35% of women. Conclusion. UAE has a good clinical effect on fibroid volume reduction. It is a treatment option that can be considered prior to major surgery in a select group of women with symptomatic fibroid uterus.

Hospital-associated methicillin-resistant Staphylococcus aureus: A cross-sectional analysis of risk factors in South African tertiary public hospitals.

IntroductionHospital-associated methicillin-resistant S. aureus (HA-MRSA) remains a significant cause of morbidity and mortality worldwide. We conducted a study to determine risk factors for HA-MRSA in order to inform control strategies in South Africa.MethodsWe used surveillance data collected from five tertiary hospitals in Gauteng and Western Cape provinces during 2014 for analysis. A case of HA-MRSA was defined as isolation of MRSA from a blood culture 48 hours after admission and/or if the patient was hospitalised in the six months prior to the current culture. Multivariable logistic regression modelling was used to determine risk factors for HA-MRSA.ResultsOf the 9971 patients with positive blood cultures, 7.7% (772) had S. aureus bacteraemia (SAB). The overall prevalence of MRSA among those with SAB was 30.9% (231/747; 95% confidence interval [CI] 27.6%– 34.3%). HA-MRSA infections accounted for 28.3% of patients with SAB (207/731; 95% CI 25.1%– 31.7%). Burns (adjusted odds ratio [aOR] 12.7; 95% CI 4.7–34.4), age ≤1 month (aOR 8.7; 95% CI 3.0–24.6), residency at a long-term care facility (aOR 5.2; 95% CI, 1.5–17.4), antibiotic use within two months of the current SAB episode (aOR 5.1; 95% CI 2.8–9.1), hospital stay of 13 days or more (aOR 2.8; 95% CI 1.3–5.6) and mechanical ventilation (aOR 2.2; 95% CI 1.07–4.6), were independent risk factors for HA-MRSA infection.ConclusionThe prevalence of MRSA remains high in South African tertiary public hospitals. Several identified risk factors of HA-MRSA infections should be considered when instituting infection and prevention strategies in public-sector hospitals, including intensifying the implementation of antimicrobial stewardship programmes. There is an urgent need to strengthen infection prevention and control in burn wards, neonatal wards, and intensive care units which house mechanically ventilated patients.

Risks associated with suspected dysphagia in infants admitted to a neonatal intensive care unit in a South African public hospital

Background . The prevalence of neonatal dysphagia is increasing, as medical advances contribute to the survival of critically ill and preterm infants. Additional factors such as low birth weight (LBW), gastro-oesoephageal reflux disorder, failure-to-thrive (FTT), and HIV may increase the complexity of dysphagia symptoms. Knowledge of context-specific risk factors for dysphagia may lead to an effective pathway of diagnosis and management in vulnerable neonates. Objective . To describe the feeding characteristics and categories of underlying medical conditions in infants of gestational age 24 - 42 weeks. Methods . The study was a retrospective review of 231 purposively selected medical and speech-language therapy records. Participants had a mean stay of 28.5 days in a neonatal intensive care unit in a peri-urban public hospital and were referred for a swallowing and feeding assessment. An existing seven-category framework for the classification of suspected dysphagia was used. Results . Most participants (90.0%) presented with multiple medical conditions. Underlying neurological conditions (48.5%) and feeding difficulties secondary to systemic illness (65.8%) contributed mostly to suspected dysphagia in the sample. It was found that 71.0% of infants presented with feeding difficulties secondary to other conditions such as LBW and prematurity, highlighting the need for an expanded dysphagia classification framework. Conclusion. The results concur with the outcomes of previous studies and confirm the need for a unique classification framework in South Africa. Dysphagia is a complex condition and frequently cannot be attributed to a single risk factor.