Tertiary Referral Hospital In Tanzania Research Articles

Virulence genes and plasmid replicon profiles of selected β-lactamase-producing Acinetobacter baumannii from orthopaedic patients and the environment in a tertiary referral hospital in Tanzania, East Africa

Acinetobacter baumannii has emerged as an important nosocomial pathogen due to its high resistance to multi-drugs and disinfectants plus its ability to survive in hospital environments. Rectal swabs were collected for screening β-lactamases-producing Acinetobacter baumannii among hospitalized orthopedic patients at a tertiary referral hospital in Tanzania. Swabs were also taken from patients' caretakers, healthcare workers, and the neighboring inanimate environment. A total of 26 confirmed β-lactamases producing Acinetobacter baumannii were isolated, of which 4 representative isolates (two from patients and two from hospital environment) underwent whole-genome sequencing (WGS) to detect sequence types (ST), β-lactamases genes, plasmid replicon types, and virulence genes. All four isolates harbored multiple β-lactamases genes including blaADC-25(3), blaOXA(4), blaCTX-M-15(2) and blaNDM-1(2). Furthermore, isolates harbored virulence genes encoding outer membrane protein (ompA), curli protein (csg), siderophore biosynthesis systems (enterobactin [entABCDEFS, fepABCDG, fes]; yersiniabactin [ybtAEPQSTUX, irp1, irp2, fyuA] and aerobactin [iucABCD, iutA]), transport secretion system type II (T2SS) and type III (T3SS), E. coli common pilus (ecpRABCDE operon), type 1 fimbriae (fim), arylsulfatase (aslA) and adhesions (fedC). Only isolates from patients harbored 4 plasmid replicons each, with the most common plasmid replicons being IncFIA_1; IncY_1 and IncFIB(AP001918)_1. Admitted orthopedic patients and the hospital environment act as a reservoir of multiple β-lactamases producing Acinetobacter baumannii (including those against carbapenems like blaOXA and blaNDM-1) endowed with virulence genes, highlighting the necessity to routinely screening of orthopedic patients with open fractures on admission as well as reinforcing infection prevention and control measures to reduce the dissemination of nosocomial infection within the hospital environment.

862: FEASIBILITY TRIAL OF ADAPTIVE ELECTRONIC LEARNING FOR PEDIATRIC HEALTHCARE WORKERS IN TANZANIA

Introduction: Gaps in provider education contribute to millions of pediatric deaths in low- and middle-income countries (LMICs). Conventional education in LMICs is limited by reach, sustainability, and inability to scale. Adaptive electronic learning (AEL) is superior to conventional education in high-income countries and may overcome existing barriers in LMICs. In order to address the existing limitations of current provider education in LMICs, we developed an AEL curriculum based on evidence-based guidelines for the management of acutely-ill children. We undertook a feasibility trial of this curriculum among a cohort of medical interns at a tertiary referral hospital in Tanzania. Methods: We developed and tested our 11-module curriculum in a convenience sample of clinical interns at a zonal academic hospital in Mwanza, Tanzania. Following enrollment, participants accessed PACE for up to 10 weeks. RE-AIM is an established framework to assist in translating research into implementation. Using 3 of RE-AIM’s 5 evaluative dimensions, we defined feasibility as > 15% mean knowledge increase (efficacy), > 75% providers initiating PACE (adoption), and > 60% completing all modules (maintenance). These percentages reflect thresholds found in similar educational interventions. Results: 21 clinical interns participated. Overall efficacy was 24% (95% CI 3.06, 45.74), adoption was 81% (17/21) and maintenance was 33% (7/21). No differences in demographics, job satisfaction, motivation, or data usage were detected between those who completed maintenance and those who did not. Sixty-five percent (13/20) had previous conventional pediatric training and twenty percent (5/20) used electronic media as a primary learning source for continuing medical education. For those who maintained PACE, median number of learning episodes was 9 and time to completion was 181 minutes. Nine of eleven modules required < 30 minutes to complete. Conclusions: In its current implementation strategy, PACE was feasible for efficacy and adoption, but not maintenance. Our cohort reported high levels of previous training, but low use of electronic media as a learning source. Provider usage characteristics suggest that module size and content were appropriate for this cohort. Refinement of our implementation strategy is needed to increase maintenance.

Performance in mortality prediction of SAPS 3 And MPM-III scores among adult patients admitted to the ICU of a private tertiary referral hospital in Tanzania: a retrospective cohort study.

BackgroundIllness predictive scoring systems are significant and meaningful adjuncts of patient management in the Intensive Care Unit (ICU). They assist in predicting patient outcomes, improve clinical decision making and provide insight into the effectiveness of care and management of patients while optimizing the use of hospital resources. We evaluated mortality predictive performance of Simplified Acute Physiology Score (SAPS 3) and Mortality Probability Models (MPM0-III) and compared their performance in predicting outcome as well as identifying disease pattern and factors associated with increased mortality.MethodsThis was a retrospective cohort study of adult patients admitted to the ICU of the Aga Khan Hospital, Dar- es- Salaam, Tanzania between August 2018 and April 2020. Demographics, clinical characteristics, outcomes, source of admission, primary admission category, length of stay and the support provided with the worst physiological data within the first hour of ICU admission were extracted. SAPS 3 and MPM0-III scores were calculated using an online web-based calculator. The performance of each model was assessed by discrimination and calibration. Discrimination between survivors and non–survivors was assessed by the area under the receiver operator characteristic curve (ROC) and calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test.ResultsA total of 331 patients were enrolled in the study with a median age of 58 years (IQR 43-71), most of whom were male (n = 208, 62.8%), of African origin (n = 178, 53.8%) and admitted from the emergency department (n = 306, 92.4%). In- hospital mortality of critically ill patients was 16.1%. Discrimination was very good for all models, the area under the receiver-operating characteristic (ROC) curve for SAPS 3 and MPM0-III was 0.89 (95% CI [0.844–0.935]) and 0.90 (95% CI [0.864–0.944]) respectively. Calibration as calculated by Hosmer-Lemeshow goodness-of-fit test showed good calibration for SAPS 3 and MPM0-III with Chi- square values of 4.61 and 5.08 respectively and P–Value > 0.05.ConclusionBoth SAPS 3 and MPM0-III performed well in predicting mortality and outcome in our cohort of patients admitted to the intensive care unit of a private tertiary hospital. The in-hospital mortality of critically ill patients was lower compared to studies done in other intensive care units in tertiary referral hospitals within Tanzania.

Prevalence and Risk Factors for Acute Postoperative Pain After Elective Orthopedic and General Surgery at a Tertiary Referral Hospital in Tanzania.

BackgroundIn Africa, postoperative pain management is still a major problem with a prevalence of postoperative pain in up to 95.2% of the patients. There are little data on the prevalence and potential risk factors for postoperative pain in Tanzania. Therefore, we aimed to investigate these at Kilimanjaro Christian Medical Centre in Northern Tanzania. Our goal is to optimize pain management.MethodsA prospective cohort study was carried out from December 2016 to April 2017. Patients ≥18 years admitted for elective general or orthopedic surgery were included in the study. Demographic data were collected during a pre-operative visit, and pain was assessed with a numerical rating scale (NRS 0–10) at 4, 24, 36 and 48 hours postoperatively. A NRS >3 was considered as moderate to severe postoperative pain. Potential risk factors for postoperative pain were identified using univariate and multivariable binary logistic regression analyses.ResultsA total of 281 patients were included in the study. The prevalence of postoperative pain was 61%, 73%, 67% and 58% at 4, 24, 36 and 48 hours after surgery, respectively. Pethidine was the most frequently prescribed analgesic for postoperative pain management (85.1%) in the first 24 hours postoperatively; only 1% received paracetamol or diclofenac, and 13% received tramadol. In the multivariable model, general anesthesia and intra-operative analgesia (OR = 3.70, 95% CI 1.70–8.04) were significant risk factors for postoperative pain.ConclusionPain is still inadequately managed at Kilimanjaro Christian Medical Centre leading to a high prevalence (73% on the first day after surgery) of reported postoperative pain in this study. It reflects the need for adequate postoperative analgesia, especially in low- and middle-income countries. Further research identifying risk factors in larger cohorts can be performed if adequate analgesia is given.

Undernourished children presenting to an urban emergency department of a tertiary hospital in Tanzania: a prospective descriptive study

Background: Childhood undernutrition causes significant morbidity and mortality in low- and middle-income countries (LMICs). In Tanzania, the in-hospital prevalence of undernutrition in children under five years of age is approximated to be 30% with a case fatality rate of 8.8%. In Tanzania, the burden of undernourished children under five years of age presenting to emergency departments (EDs) and their outcomes are unknown. This study describes the clinical profiles and outcomes of this population presenting to the emergency department of Muhimbili National Hospital (ED-MNH), a large, urban hospital in Dar es Salaam, Tanzania.MethodsThis was a prospective descriptive study of children aged 1–59 months presenting to the ED-MNH over eight weeks in July and August 2016. Enrolment occurred through consecutive sampling. Children less than minus one standard deviation below World Health Organization mean values for Weight for Height/Length, Height for Age, or Weight for Age were recruited. Structured questionnaires were used to document primary outcomes of patient demographics and clinical presentations, and secondary outcomes of 24-h and 30-day mortality. Data was summarised using descriptive statistics and relative risks (RR).ResultsA total of 449 children were screened, of whom 34.1% (n = 153) met criteria for undernutrition and 95.4% (n = 146) of those children were enrolled. The majority of these children, 56.2% (n = 82), were male and the median age was 19 months (IQR 10–31 months). They presented most frequently with fever 24.7% (n = 36) and cough 24.0% (n = 35). Only 6.7% (n = 9) were diagnosed with acute undernutrition by ED-MNH physicians. Mortality at 24 h and 30 days were 2.9% (n = 4) and 12.3% (n = 18) respectively. A decreased level of consciousness with Glasgow Coma Scale below fifteen on arrival to the ED and tachycardia from initial vital signs were found to be associated with a statistically significant increased risk of death in undernourished children, with mortality rates of 16.1% (n = 23), and 24.6% (n = 35), respectively.ConclusionsIn an urban ED of a tertiary referral hospital in Tanzania, undernutrition remains under-recognized and is associated with a high rate of in-hospital mortality.

Feasibility and yield of HIV screening among adult trauma patients presenting to an urban emergency department of a tertiary referral hospital in Tanzania

BackgroundThe World Health Organization and Tanzanian National Guidelines for HIV and AIDS management, recommends provider initiated testing and counseling for HIV at any point of health care contact. In Tanzania, over 45% of people living with HIV are unaware of their HIV positive status. We determine the feasibility and yield of HIV screening among otherwise healthy adult trauma patients presenting to the first full-capacity Emergency Department in Tanzania.MethodsThis was a prospective cohort study of consecutive adult trauma patients presenting to Emergency Medicine Department at Muhimbili National Hospital (EMD-MNH) in Dar es Salaam, from March 2017 to September 2017. Eligible patients provided informed consent, pre and post-test counseling was done. Structured case report forms were completed, documenting demographics, acceptance of testing, results and readiness to receive results. Outcomes were the proportion of patients accepting testing, proportion of positive tests, readiness of the patient to receive the results, and proportion of patients who had an HIV test ordered as part of care.ResultsWe screened 2848 trauma patients, and enrolled 326 (11.5%) eligible patients. Median age was 33 (IQR 25–42 years), and 248 (76.0%) of participants were male. Of those enrolled, 250 (76.7%) patients accepted testing for HIV, and among them 247 (98.8%) were ready to receive their test results. Of those tested, 14 (5.6%) were found to be HIV positive and 12 were ready to receive results. Two months post hospital discharge 6 (50%), of those who were informed of positive results had visited Care and Treatment Clinics (CTC) for HIV treatment. Three additional patients had not yet attended and three could not be reached. The treating ED physician tested none of the enrolled patients for HIV as part of their regular treatment.ConclusionsIn our cohort of adult trauma patients presenting to ED, routine HIV screening for unrelated reason, was feasible and acceptable. The yield is sufficient to warrant an on-going program and superior to having physicians choose which patients to test. Future studies should focus on factors affecting the linkage to CTC among HIV positive patients identified at the ED.

Pre-referral stabilization and compliance with WHO guidelines for trauma care among adult patients referred to an urban emergency department of a tertiary referral hospital in Tanzania

BackgroundThe outcomes of trauma are considered to be time dependent. Efficient and timely pre-referral stabilization of trauma patients has been shown to impact survival. Tanzania has no formal pre-hospital or trauma system. World Health Organisation has provided a set of standards for initial stabilization of trauma patients according to the level of the hospitals. We aimed to describe pre-referral stabilization provided to adult trauma patient referred to the national referral hospital and compliance with World Health Organisation guidelines.MethodsThis prospective observational cross-sectional study was conducted at the Emergency Medicine Department of Muhimbili National Hospital (EMD-MNH), between July 2017 and December 2017. Eligible patients were adults with head injury and extremity injury ≥18 years who were referred from a peripheral hospital and had a referral note. Research assistant enrolled patients using structured case report form clinical information, and initial stabilization received at the referring hospital. Primary outcome was the proportion of patients who had initial stabilization performed according to World Health Organisation recommendation.ResultsWe enrolled 368 (29% of eligible patients), the median age was 34 years (Interquartile range 26–44 years), and 281 (76%) were male. Overall 69% of referred patients arrived at the EMD more than 24 h after injury. Of those enrolled, 50 (13.6%) patients had received at least one stabilization intervention prior to transfer to MNH. Among 206 patients with extremity injuries, splinting was inadequate or missing in all cases; No patients with head injury received cervical spine protection. Among patients referred from a health center, 26.9% received an initial stabilization, while stabilization procedures were administered to 13.2% of those from district hospitals, and 10% of those from regional hospitals.ConclusionsIn this urban public emergency department in Tanzania, majority of trauma patients were referred from lower health facilities after 24-h of injury. Most did not receive initial trauma stabilization as recommended by the World Health Organisation guidelines. Future studies should identify barriers to pre-referral stabilization of adult trauma patients.

The spectrum of oral and maxillofacial surgical procedures at the National Referral Hospital in Tanzania from 2013 to 2017

Background: The scope of oral and maxillofacial surgery includes the diagnosis and treatment of diseases affecting the mouth, jaws, face and neck. This study aims at reporting on the indications, pattern and types of oral and maxillofacial surgical procedures carried out under general anaesthesia in a tertiary referral hospital in Tanzania, in a period of 5 years. Methods: A retrospective study of operation records of all patients who had undergone oral and maxillofacial surgeries under general anaesthesia at Muhimbili National Hospital from January 2013 to November 2017 was done. Descriptive statistics such as bio-data, indication for surgery and type of surgery were recorded and analysed using the IBM SPSS statistics for windows version 20 (Armonk, NY: IBM Corp) software. Results: A total of 1,110 patients with oral and maxillofacial conditions were managed during the study period. The male to female ratio was 1.1:1, and the mean age of patients was 31.1±17.1 years. The predominant indications for surgery were benign neoplastic conditions (36.8%, n=409), traumatic conditions (22.3%, n=248) and malignant neoplastic conditions (18.4%, n=204). Open reduction and internal fixation (21.0%, n=233) and mandibulectomy (18.3%, n=203) were the most common surgical procedures performed under general anaesthesia. Conclusions: There is a high need for the government and appropriate authorities to invest in reconstructive surgeries as the most commonly operated individuals are those in productive age, and the ablative surgeries do affect not only their general well-being but also social aspect of life.

Use of a criteria-based audit to optimize uptake of cesarean delivery in a low-resource setting.

To evaluate the impact of a criteria-based audit (CBA) of obstructed labor and fetal distress on cesarean delivery and perinatal outcomes. A cross-sectional study was performed at a tertiary referral hospital in Tanzania. Data were collected before and after CBA (January 2013-November 2013 and July 2015-June 2016). Outcomes of fetal distress (baseline CBA, n=248; re-audit, n=251) and obstructed labor (baseline CBA, n=260; re-audit n=250) were assessed using a checklist. Additionally, 27960 parturients were assessed using the Robson classification. Perinatal morbidity and mortality decreased from 42 of 260 (16.2%) to 22 of 250 (8.8%) among patients with obstructed labor after CBA (P=0.012). Cesarean delivery rate decreased for referred term multiparas with induced labor or prelabor cesarean delivery (odds ratio [OR] 0.28, 95% confidence interval [CI] 0.09-0.82). Cesarean delivery rate for preterm pregnancies increased among both referred (OR 1.28, 95% CI 1.02-1.63) and non-referred (OR 2.78, 95% CI 1.98-3.90) groups. Neonatal distress rate decreased for referred term multiparas (OR 0.72, 95% CI 0.56-0.92), referred preterm pregnancies (OR 0.32, 95% CI 0.25-0.39), and non-referred preterm pregnancies (OR 0.26, 95% CI 0.18-0.36). Use of CBA reduced poor perinatal outcomes of obstructed labor and increased uptake of cesarean delivery.

Assessment of cardiopulmonary resuscitation knowledge and skills among healthcare providers at an urban tertiary referral hospital in Tanzania

BackgroundEarly and effective CPR increases both survival rate and post-arrest quality of life. In limited resource countries like Tanzania, there is scarce data describing the basic knowledge of CPR among Healthcare providers (HCP). This study aimed to determine the current level of knowledge on, and ability to perform, CPR among HCP at Muhimbili National Hospital (MNH).MethodsThis was a descriptive cross sectional study of a random sample of 350 HCP from all cadres and departments at MNH from October 2015 to March 2016. Each participant completed a with 25 question multiple choice and fill-in-the-blank CPR test and a practical test using a CPR manikin where the participant was videotaped for 1–2 min. Two expert observers independently viewed the videos and rated participant performance on a structured data form. The primary outcome of interest was staff member overall performance on the written and practical CPR testing.ResultsWe enrolled 350 HCPs from all 12 MNH clinical departments. The median participant age was 35 (IQR 29–43) years, 225 (64%) were female and 138 (39%) had clinical experience of less than 5 years. Only 57 (16%) and 88 (25%) scored above 50% in written and practical tests, respectively according to local minimum passing test score and 13(4%) and 30 (9%) scored above 75% in written and practical tests, respectively according to international minimum passing test score on CPR. The 233(67%) HCP who reported prior experience performing CPR on an adult patient scored higher on testing than those without; 40% (IQR 28–54) versus 26% (IQR 16–42) respectively, but both groups had median scores <50%.ConclusionThe level of CPR knowledge and skills displayed by all cadres and in all departments was poor despite the fact that most providers reported having performed CPR in the past. Since MNH is a tertiary referral hospital, it may reflect the performance of resuscitation status of other local health centers in Tanzania and other low-income countries to employ a formal system of training every HCP in CPR. Staff should be certified and assessed regularly to ensure retention of resuscitation knowledge and skills.

Profile of patients with hypertensive urgency and emergency presenting to an urban emergency department of a tertiary referral hospital in Tanzania

BackgroundHypertensive crises are clinical syndromes grouped as hypertensive urgency and emergency, which occur as complications of untreated or inadequately treated hypertension. Emergency departments across the world are the first points of contact for these patients. There is a paucity of data on patients in hypertensive crises presenting to emergency departments in Tanzania. We aimed to describe the profile and outcome of patients with hypertensive crisis presenting to the Emergency Department of Muhimbili National Hospital in Tanzania.MethodsThis was a descriptive cohort study of adult patients aged 18 years and above presenting to the emergency department with hypertensive urgency or emergency over a four-month period. Trained researchers used a structured data sheet to document demographic information, clinical presentation, management and outcome. Descriptive statistics with 95% confidence intervals (CIs) are presented as well as comparisons between the groups with hypertensive urgency vs. emergency.ResultsWe screened 8002 patients and enrolled 203 (2.5%). The median age was 55 (interquartile range 45–67 years) and 51.7% were females. Overall 138 (68%) had hypertensive emergency; and 65 (32%) had hypertensive urgency, for an overall rate of 1.7% (95% CI: 1.5 to 2.0%) and 0.81% (95% CI: 0.63 to 1.0%), respectively. Altered mental status was the most common presenting symptom in hypertensive emergency [74 (53.6%)]; low Glasgow Coma Scale was the most common physical finding [61 (44.2%)]; and cerebrovascular accident was the most common final diagnosis [63 (31%)]. One hundred twelve patients with hypertensive emergency (81.2%) were admitted and three died in the emergency department, while 24 patients with hypertensive urgency (36.9%) were admitted and none died in the emergency department. In-hospital mortality rates for hypertensive emergency and urgency were 37 (26.8%) and 2 (3.1%), respectively.ConclusionIn our cohort of adult patients with elevated blood pressure, hypertensive crisis was associated with substantial morbidity and mortality, with the most vulnerable being those with hypertensive emergency. Further research is required to determine the aetiology, pathophysiology and the most appropriate strategies for prevention and management of hypertensive crisis.

Identification of delirium and dementia in older medical inpatients in Tanzania: A comparison of screening and diagnostic methods

BackgroundIn sub-Saharan Africa, there are no validated screening tools for delirium in older adults. This study assesses clinical utility of two instruments, the IDEA cognitive screen and the Confusion Assessment Method (CAM) for identification of delirium in older adults admitted to medical wards of a tertiary referral hospital in Tanzania. MethodThe IDEA cognitive screen and CAM were administered to a consecutive cohort of older individuals on admission to Kilimanjaro Christian Medical Centre using a blinded protocol. Consensus diagnosis for delirium was established against DSM-5 criteria and dementia by DSM-IV criteria. ResultsOf 507 admission assessments, 95 (18.7%) had DSM-5 delirium and 95 (18.7%) had DSM-IV dementia (33 (6.5%) delirium superimposed on dementia). The CAM and IDEA cognitive screen had very good diagnostic accuracy for delirium (AUROC curve 0.94 and 0.87 respectively). However, a number of participants (10.5% and 16.4% respectively) were unable to complete these screening assessments due to reduced consciousness, or other causes of reduced verbal response and were excluded from this analysis; many of whom met DSM-5 criteria for delirium. Secondary analysis suggests that selected cognitive and observational items from the CAM and IDEA cognitive screen may be as effective as the full screening tools in identifying delirium even in unresponsive patients. ConclusionBoth instruments appeared useful for delirium screening in this inpatient setting, but had significant limitations. The combination of assessment items identified may form the basis of a brief, simple delirium screening tool suitable for use by non-specialist clinicians. Further development work is needed.

The test characteristics of physician clinical gestalt for determining the presence and severity of anaemia in patients seen at the emergency department of a tertiary referral hospital in Tanzania

ObjectivesTo evaluate the test characteristics of clinical gestalt for detecting the presence and severity of anaemia in emergency department patients at a tertiary referral hospital in Tanzania.MethodsThis prospective study enrolled...

Trends in stroke admissions to a Tanzanian hospital over four decades: a retrospective audit.

The aim of this study was to record stroke admissions to a tertiary referral hospital in Tanzania over four decades. We audited the medical records held at a large teaching and tertiary referral hospital in northern Tanzania over four decades. We collected records for the years 1974-1976, 1984-1986, 1994-1995 and 2008. All patients admitted as inpatients with a primary diagnosis of stroke were included in the study. Data collected included age, sex, stroke subtype, predominant side of symptoms and survival to discharge. The number of stroke admissions rose from just four in the three-year period 1974-1976 (mean 1.3 cases annually) to 153 cases annually in 2008. The mean age of those admitted rose steadily during this period, as did the proportion of females admitted. The burden of stroke on health services in Tanzania appears to have increased rapidly. If this increase is to be slowed, then sustainable primary preventative measures to target known stroke risk factors will be required.