Tertiary Level Public Hospital Research Articles

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

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

Primary health centres: preferred option for birthing care in tamilnadu, India, from users' perspectives.

Tamilnadu state of India witnessed an increasing trend of institutional deliveries since the beginning of 1990s, with decline of domiciliary deliveries to nearly zero now. Among the institutional deliveries, a shift has been observed since 2006 wherein primary health centres (PHC) have shown a four-fold increase in the number of deliveries while other public and private health facilities showed a decline, despite equal access by people to all categories of health facilities. A qualitative study was designed to explore the determinants that led to increased preference of PHCs for birthing care. In-depth interviews and FGDs were conducted with recently-delivering women and their spouses. User-friendly ambience, courteous attitude and behaviour of staff, good infrastructure, availability of qualified staff, and relative absence of informal payments have contributed to increased preference for birthing care in PHCs. Barriers to seeking care from secondary and tertiary-level public hospitals and private hospitals have also made women prefer PHCs.

Pattern, clinical features and response to corticoids of glomerular diseases in a Brazilian population. An analytical cross-sectional study.

Glomerular disease registries are increasing all around the world. The aim of this study was to evaluate the clinical characteristics and treatment response among patients with glomerular diseases followed up in a tertiary hospital in Brazil. Analytical cross-sectional study; tertiary-level public hospital. This study included patients with glomerular diseases followed up at a tertiary hospital in Fortaleza, northeastern Brazil. Clinical and laboratory data on each patient were registered. The response to specific treatment was evaluated after 3, 6 and 12 months. The study included 168 patients of mean age 37 ± 14 years. The most prevalent glomerular diseases were focal segmental glomerulosclerosis FSGS] (19.6%), minimal change disease MCD] (17.9%), membranous nephropathy MN] (16.7%) and lupus nephritis LN] (11.9%). The main clinical presentations were nephrotic proteinuria (67.3%) and renal insufficiency (17.9%). The mean proteinuria value decreased after the treatment began. Regarding 24-hour proteinuria on admission, there was no significant difference between patients with a good response and those with no response (7,448 ± 5,056 versus 6,448 ± 4,251 mg/24 h, P = 0.29). The glomerular disease with the highest remission rate was MCD (92%). Absence of interstitial fibrosis presented a strong correlation with remission (remission in patients without fibrosis = 83.4% versus 16.3% in those with fibrosis, P = 0.001). The present study found that the most frequent glomerular disease was FSGS, followed by MCD, MN and LN. The presence of interstitial fibrosis was a predictor of poor therapeutic response.

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

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

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

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

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

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

Evaluation of the effectiveness of hospital discharge planning and follow‐up in the primary care of patients with chronic obstructive pulmonary disease

To evaluate the effectiveness of protocolised intervention for hospital discharge and follow-up in the primary care of patients with chronic obstructive pulmonary disease (COPD). Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. A quasi-experimental design was adopted, with a control group and it was pseudorandomised by services. Patients with COPD admitted to two tertiary-level public hospitals in Spain were recruited (2007-2008). The outcome variables included: readmission rate, patient satisfaction (LOPSS12), quality of life (St. George's Respiratory Questionnaire) and level of knowledge about COPD. 48 hours after admission, both groups were evaluated by specialist coordinating nurses. At the hospital, a coordinating nurse visited each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, explain treatment, identify care problems and needs and facilitate communication between professionals. 24 hours after discharge, the coordinating nurses informed the primary care nurses about patient discharge. The two nurses made the first home visit together. There were follow-up phone calls at 2, 6, 12 and 24 weeks after discharge. A total of 143 patients were recruited (Intervention group=56; Control group=87). The results showed a significant improvement in the evolution of quality of life, at 12 and 24 weeks after discharge; the level of knowledge about COPD revealed significant differences between the groups. There were no differences according to satisfaction or readmission rate. Multivariate analysis (non-conditional logistic regression) showed the intervention to be ineffective in reducing the readmission rate. The planning of discharge for patients with COPD is effective in terms of improving the patients' quality of life and level of knowledge about the disease. The characteristics of patients with COPD make it necessary to include them in hospital discharge planning programmes.

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

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

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

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

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

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

Effectiveness of planning hospital discharge and follow‐up in primary care for patients with chronic obstructive pulmonary disease: research protocol

To evaluate the effectiveness of a protocolized intervention for hospital discharge and follow-up planning for primary care patients with chronic obstructive pulmonary disease. Chronic obstructive pulmonary disease is one of the main causes of morbidity and mortality internationally. These patients suffer from high rates of exacerbation and hospital readmission due to active problems at the time of hospital discharge. A quasi-experimental design will be adopted, with a control group and pseudo-randomized by services (protocol approved in 2006). Patients with pulmonary disease admitted to two tertiary-level public hospitals in Spain and their local healthcare centres will be recruited. The outcome variables will be readmission rate and patient satisfaction with nursing care provided. 48 hours after admission, both groups will be evaluated by specialist coordinating nurses, using validated scales. At the hospital, a coordinating nurse will visit each patient in the experimental group every 24 hours to identify the main caregiver, provide information about the disease, and explain treatment. In addition, the visits will be used to identify care problems and needs, and to facilitate communication between professionals. 24 hours after discharge, the coordinating nurses will inform the primary care nurses about patient discharge and nursing care planning. The two nurses will make the first home visit together. There will be follow-up phone calls at 2, 6, 12 and 24 weeks after discharge. The characteristics of patients with this pulmonary disease make it necessary to include them in hospital discharge planning programmes using coordinating nurses.

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

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

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

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

Quality of Chlorine-Based Antiseptics and Disinfectants Circulating in Dar es Salaam, Tanzania

Background: Chlorine-based antiseptics and disinfectants have a stability problem especially when formulated as aqueous solutions. They tend to decompose slowly liberating chlorine on storage. Despite this instability, these products are commonly manufactured and labeled with a long shelf-life. Thus the labeled content of available chlorine is doubtful and this could pose a danger to public health by not providing adequate disinfection. Broad Objective: This study aimed at assessing the quality of chlorine-based antiseptics and disinfectants circulating in Dar es Salaam, Tanzania. Study setting: The study was carried out in the city of Dar es Salaam Methods and materials: Nineteen (19) samples representing various product batches circulating in Dar es Salaam were collected randomly from pharmacies, shops and from a tertiary-level public hospital. Analysis of the samples was immediately done in which the content of available chlorine was determined using a titrimetric method (Iodometric titration) according to the British Pharmacopoea (BP) specifications. Measures of outcome: Results for contents of available chlorine was compared to the limits of assay specified in the BP and thus the percent compliance was calculated. Samples with contents below that specified in the BP were deemed to have failed the quality tests. For those products for which no official specifications are available (eg. Waterguard®), the BP limits for assay (± 10% of label claim) was applied to assess compliance. Results: Out of the 19 sample batches analyzed 12 (63%) did not comply with the specifications for available chlorine (BP Limits of Assay or within 90-110% manufacturer's label claim). This was especially serious with preparations containing calcium hypochlorite with boric acid (Eusol) which had a mean content of only 12% of the recommended strength. Conclusion and recommendations: The results from this study have shown clearly that chlorine-based antiseptics/disinfectant products should not be manufactured on a large scale by pre-dilution. Rather, they should be supplied as concentrates or powders for reconstitution at the time of use to ensure quality, efficacy and safety to public health. Tanzania Medical Journal Vol. 22 (1) 2007: pp. 17-19

Community-associated Methicillin-resistantStaphylococcus aureus, Singapore

Community-associated Methicillin-resistant<i>Staphylococcus aureus</i>, Singapore

The limited clinical usefulness of taking a history in the evaluation of women with tubal factor infertility

Objective To evaluate whether patient histories of gynecological infections predict tubal pathology seen at laparoscopic exam in infertile women. Design Cross-sectional analysis from a subset of case-control subjects. Setting Tertiary-level public hospitals with infertility clinics, Mexico City. Patient(s) Three hundred twenty-one nulligravid infertile women seeking diagnostic workup. Intervention(s) Interviews conducted before evaluation by laparoscopy. Main outcome measure(s) Sensitivity, specificity, and predictive values for correlating previous pelvic inflammatory disease symptoms, vaginal discharge, genital tract infections, and antibodies to Chlamydia trachomatis to confirmed diagnoses of tubal pathology and to severe tubal pathology. Result(s) Tubal pathology was found in 58% of participants (n = 185), and severe pathology was found in 29% (n = 92). None of the historical infection-related factors alone was a good overall predictor of tubal pathology; high sensitivity values (up to 73%) were offset by low specificity (down to 30%) and vice versa, for each factor. When considered simultaneously, the factors improved the overall predictive ability just slightly (84% sensitivity and 29% specificity) over the individual factors. The validity measures did not improve when examining severe tubal pathology alone. Conclusion(s) History taking related to past genital tract infections appears to be of little use in the evaluation of infertile women.

Identificación de lesiones mamarias malignas en México

To evaluate the modes of detection of breast malignancies in Mexico City and to estimate the number of patients diagnosed in advanced stages. This cross-sectional study was conducted between 1994 and 1996, among 256 women with a histological diagnosis of breast cancer, at three tertiary level public hospitals in Mexico City. Personal interviews were conducted to collect data on reproductive characteristics, clinical history, and breast cancer modes of detection. Data analysis consisted of percentages, odds ratios, and 95% confidence intervals. Ninety percent of women sought medical care after identifying a breast lump by themselves. Only 10% of patients had a stage-I tumor; all 27 cases first identified by a physician were in stage II-B and higher. An increasing trend of breast cancer mortality in Mexico City will persist, unless a greater proportion of tumors in situ is detected; this would require enhancing breast cancer screening programs and conducting an intense educational intervention among women at risk.