Investigating the cultural and contextual determinants of antimicrobial stewardship programmes across low-, middle- and high-income countries—A qualitative study

Background Most of the evidence on antimicrobial stewardship programmes (ASP) to help sustain the effectiveness of antimicrobials is generated in high income countries. We report a study investigating implementation of ASP in secondary care across low-, middle- and high-income countries. The objective of this study was to map the key contextual, including cultural, drivers of the development and implementation of ASP across different resource settings. Materials and methods Healthcare professionals responsible for implementing ASP in hospitals in England, France, Norway, India, and Burkina Faso were invited to participate in face-to face interviews. Field notes from observations, documentary evidence, and interview transcripts were analysed using grounded theory approach. The key emerging categories were analysed iteratively using constant comparison, initial coding, going back the field for further data collection, and focused coding. Theoretical sampling was applied until the categories were saturated. Cross-validation and triangulation of the findings were achieved through the multiple data sources. Results 54 participants from 24 hospitals (England 9 participants/4 hospitals; Norway 13 participants/4 hospitals; France 9 participants/7 hospitals; India 13 participants/ 7 hospitals; Burkina Faso 8 participants/2 hospitals) were interviewed. Across Norway, France and England there was consistency in ASP structures. In India and Burkina Faso there were country level heterogeneity in ASP. State support for ASP was perceived as essential in countries where it is lacking (India, Burkina Faso), and where it was present, it was perceived as a barrier (England, France). Professional boundaries are one of the key cultural determinants dictating involvement in initiatives with doctors recognised as leaders in ASP. Nurse and pharmacist involvement was limited to England. The surgical specialty was identified as most difficult to engage with in each country. Despite challenges, one hospital in India provided the best example of interdisciplinary ASP, championed through organisational leadership. Conclusions ASP initiatives in this study were restricted by professional boundaries and hierarchies, with lack of engagement with the wider healthcare workforce. There needs to be promotion of interdisciplinary team work including pharmacists and nurses, depending on the available healthcare workforce in different countries, in ASP. The surgical pathway remains a hard to reach, but critical target for ASP globally. There is a need to develop contextually driven ASP targeting the surgical pathway in different resource settings

Model to Reduce HIV Related Stigma Among Indonesian Nurses

Stigmatization of persons living with HIV (PLWH) did by health professionals including nurses. Stigma was a barrier of nurses to implement nursing care to PLWH patients. The purpose of this study was to make model of reducing stigma among nurses particularly in the hospital, district of Banyuwangi, Indonesia. Design used in this study was analytical observational. The population was all nurses who worked in 4 hospitals in Banyuwangi of Indonesia. Total sample recruited were 77 respondents. Data were collected by questionnaire and analyzed by using Smart PLS (Partial Least Squares). The result showed that stigma existed among nurses particularly on labelling and stereotyping to PLWH patient. Transcultural components had influence to nurses' stigma on HIV and AIDS patients; there were jobs factor, facilities factor, values factor, and knowledge factor. Stigmatizing attitudes were found among nurses with quite satisfied. It can be concluded to reduce the stigma of nurses by intervening on transcultural components among other factors affecting jobs factor, facilities factor, values factor and knowledge factor. Further research should apply this model in nursing care

Long-term follow-up of patients undergoing resection of tnm stage i colorectal cancer: an analysis of tumour and host determinants of outcome

Background Screening for colorectal cancer improves cancer-specific survival (CSS) through the detection of early-stage disease; however, its impact on overall survival (OS) is unclear. The present study examined tumour and host determinants of outcome in TNM Stage I disease. Methods All patients with pathologically confirmed TNM Stage I disease across 4 hospitals in the North of Glasgow between 2000 and 2008 were included. The preoperative modified Glasgow Prognostic Score (mGPS) was used as a marker of the host systemic inflammatory response (SIR). Results There were 191 patients identified, 105 (55 %) were males, 91 (48 %) were over the age of 75 years and 7 (4 %) patients underwent an emergency operation. In those with a preoperative CRP result (n = 150), 35 (24 %) patients had evidence of an elevated mGPS. Median follow-up of survivors was 116 months (minimum 72 months) during which 88 (46 %) patients died; 7 (8 %) had postoperative deaths, 15 (17 %) had cancer-related deaths and 66 (75 %) had non-cancer-related deaths. 5-year CSS was 95 % and OS was 76 %. On univariate analysis, advancing age (p < 0.001), emergency presentation (p = 0.008), and an elevated mGPS (p = 0.012) were associated with reduced OS. On multivariate analysis, only age (HR = 3.611, 95 % CI 2.049–6.365, p < 0.001) and the presence of an elevated mGPS (HR = 2.173, 95 % CI 1.204–3.921, p = 0.010) retained significance. Conclusions In patients undergoing resection for TNM Stage I colorectal cancer, an elevated mGPS was an objective independent marker of poorer OS. These patients may benefit from a targeted intervention

From the Chair

Jefferson and Change-Redux “Laws and institutions must go hand in hand with the progress of the human mind…” – Thomas Jefferson, July 12, 1810 Our American health care system is under pressure to change from many directions: the government, the media, the economists, and others. In a recent Surgical Grand Rounds, I discussed my Baker’s Dozen list of key topics: (1) health care spending is flattening out, (2) physicians and hospitals will be paid less for what they do, (3) payers are getting aggressive on cost and quality, (4) hospitals are targets for cost cuts, (5) cost reduction will entail standardization and elimination of variations, (6) waste control will be crucial, (7) current payment systems are mal-aligned with quality, health and wellness improvement, (8) Accountable Care Organizations exist, (9) the 5-50 rule reigns (the sickest 5% of the population consume 50% of the resources), (10) hospital systems will necessarily morph to Total Care systems, (11) physician elements are under transition, (12) physician integration (and leadership) will be crucial, (13) aspirational items for hospital corporate leaders have evolved. We have much to do. The mantras will no longer be – “business as usual” or “increase volume to cover expenses”. The focus needs to be on individual health, wellness and population health… We’re working toward a new paradigm – “Livewell Jefferson” – a cooperative venture of Thomas Jefferson University Hospital, Thomas Jefferson University, Jefferson Medical College, the Jefferson Women’s Board, Jefferson Health System and our communities: eliminate unhealthy cafeteria and vending choices, expand our non-smoking perimeter, increase wellness services, institute a maximum 30-minute meeting rule and mandate daily 30-minute on-the-job treadmill walking, freshen our stairways and label them “vertical exercise corridors”, track BMI quarterly, and work with the city to design and maintain safe, measured walking routes around our campus. We have much to do to effect change! To view Dr. Yeo’s recent mini-Grand Rounds lecture on this topic visit: www.jefferson.edu/surgerylecture

Characterising Kenyan hospitals' suitability for medical officer internship training: a secondary data analysis of a cross-sectional study

Objective To characterise the capacity of Kenya internship hospitals to understand whether they are suitable to provide internship training for medical doctors. Design A secondary data analysis of a cross-sectional health facility assessment (Kenya Harmonized Health Facility Assessment (KHFA) 2018). Setting and population We analysed 61 out of all 74 Kenyan hospitals that provide internship training for medical doctors. Outcome measures Comparing against the minimum requirement outlined in the national guidelines for medical officer interns, we filtered and identified 166 indicators from the KHFA survey questionnaire and grouped them into 12 domains. An overall capacity index was calculated as the mean of 12 domain-specific scores for each facility. Results The average overall capacity index is 69% (95% CI 66% to 72%) for all internship training centres. Hospitals have moderate capacity (over 60%) for most of the general domains, although there is huge variation between hospitals and only 29 out of 61 hospitals have five or more specialists assigned, employed, seconded or part-time-as required by the national guideline. Quality and safety score was low across all hospitals with an average score of 40%. As for major specialties, all hospitals have good capacity for surgery and obstetrics-gynaecology, while mental health was poorest in comparison. Level 5 and 6 facilities (provincial and national hospitals) have higher capacity scores in all domains when compared with level 4 hospitals (equivalent to district hospitals). Conclusion Major gaps exist in staffing, equipment and service availability of Kenya internship hospitals. Level 4 hospitals (equivalent to district hospitals) are more likely to have a lower capacity index, leading to low quality of care, and should be reviewed and improved to provide appropriate and well-resourced training for interns and to use appropriate resources to avoid improvising

Stress in nurses : stress-related affect and its determinants examined over the nursing day

Peer reviewedPostprin

Distributed simulation with COTS simulation packages: A case study in health care supply chain simulation

The UK National Blood Service (NBS) is a public funded body that is responsible for distributing blood and asso-ciated products. A discrete-event simulation of the NBS supply chain in the Southampton area has been built using the commercial off-the-shelf simulation package (CSP) Simul8. This models the relationship in the health care supply chain between the NBS Processing, Testing and Is-suing (PTI) facility and its associated hospitals. However, as the number of hospitals increase simulation run time be-comes inconveniently large. Using distributed simulation to try to solve this problem, researchers have used techniques informed by SISO’s CSPI PDG to create a version of Simul8 compatible with the High Level Architecture (HLA). The NBS supply chain model was subsequently divided into several sub-models, each running in its own copy of Simul8. Experimentation shows that this distri-buted version performs better than its standalone, conven-tional counterpart as the number of hospitals increases

Elective Open Suprarenal Aneurysm Repair in England from 2000 to 2010 an Observational Study of Hospital Episode Statistics

Background: Open surgery is widely used as a benchmark for the results of fenestrated endovascular repair of complex abdominal aortic aneurysms (AAA). However, the existing evidence stems from single-centre experiences, and may not be reproducible in wider practice. National outcomes provide valuable information regarding the safety of suprarenal aneurysm repair. Methods: Demographic and clinical data were extracted from English Hospital Episodes Statistics for patients undergoing elective suprarenal aneurysm repair from 1 April 2000 to 31 March 2010. Thirty-day mortality and five-year survival were analysed by logistic regression and Cox proportional hazards modeling. Results: 793 patients underwent surgery with 14% overall 30-day mortality, which did not improve over the study period. Independent predictors of 30-day mortality included age, renal disease and previous myocardial infarction. 5-year survival was independently reduced by age, renal disease, liver disease, chronic pulmonary disease, and known metastatic solid tumour. There was significant regional variation in both 30-day mortality and 5-year survival after risk-adjustment. Regional differences in outcome were eliminated in a sensitivity analysis for perioperative outcome, conducted by restricting analysis to survivors of the first 30 days after surgery. Conclusions: Elective suprarenal aneurysm repair was associated with considerable mortality and significant regional variation across England. These data provide a benchmark to assess the efficacy of complex endovascular repair of supra-renal aneurysms, though cautious interpretation is required due to the lack of information regarding aneurysm morphology. More detailed study is required, ideally through the mandatory submission of data to a national registry of suprarenal aneurysm repair

Comparing conventional and distributed approaches to simulation in complex supply-chain health systems

Decision making in modern supply chains can be extremely daunting due to their complex nature. Discrete-event simulation is a technique that can support decision making by providing what-if analysis and evaluation of quantitative data. However, modelling supply chain systems can result in massively large and complicated models that can take a very long time to run even with today's powerful desktop computers. Distributed simulation has been suggested as a possible solution to this problem, by enabling the use of multiple computers to run models. To investigate this claim, this paper presents experiences in implementing a simulation model with a 'conventional' approach and with a distributed approach. This study takes place in a healthcare setting, the supply chain of blood from donor to recipient. The study compares conventional and distributed model execution times of a supply chain model simulated in the simulation package Simul8. The results show that the execution time of the conventional approach increases almost linearly with the size of the system and also the simulation run period. However, the distributed approach to this problem follows a more linear distribution of the execution time in terms of system size and run time and appears to offer a practical alternative. On the basis of this, the paper concludes that distributed simulation can be successfully applied in certain situations

Knowledge, attitude and practice of staff of 4 hospitals in Yaoundé on the prevention of vertical transmission of hepatitis B

Introduction: Hepatitis B virus infection is a public health concern in Cameroon and worldwide. With hepatitis C virus, it is the first cause of liver cancer in Cameroon. The high prevalence of 11.9% in Cameroon is associated with the premature contamination at the perinatal period, due to vertical transmission, from mother-to-child. To put into practice the preventives measures, actors need a good knowledge on premature contamination of a baby. The general objective of this study was to evaluate the influence of level of knowledge on the attitudes and the professional practices concerning prevention of mother-to-child transmission of hepatitis B (PMTCT/HBV) in Yaoundéhospitals and environs.Methods: We carried out a cross sectional multicentric, KAP study from 10th March to 15th December 2015 in the obstetrics services of 4 hospitals in Yaoundéand environs. For each health care provider who gave his consent, we used a pretested questionnaire to collect socio-demographics and professional data as well as their knowledges, attitudes and practices on PMTCT/HBV. After given a grade to each item, we proceeded to a quantitative analysis of data using SPSS software and Epi info 7th version.Results: 105 health care provider took part in the study, made up of 82 women (79%) and 22 men (21%). The ages were between 23 and 60 years, with a mean age of 40.9 ± 9.2 years. Only 21% of the participants had good knowledges on HBV/PMCT. This knowledge had a significant link with the profession, the professional experience and the duration in the same service. All the nurseaids had inadequate knowledges as well as the elders in the profession. Most of the participants (64.4%) had favorableattitude on PMTCT/HBV and that was significantly associated to good knowledges. (OR:5.34; CI 95% [1.47-19.47], p = 0.006). The practices on PMTCT/HBV were inappropriate in 57.1% of the participants. There were no significant relation between good knowledge and the practices (OR: 1.818, CI 95% [0.705-4.68]; p = 0.213) as well as between good attitudes and practices on PMTCT/HBV (OR: 0.932; CI 95% [0.423-2.058]; p = 0.862).Conclusion: The healthcare provider in hospitals in Yaoundé and its environs are old. Their knowledge on PMTCT/HBV is inadequate and their practices inappropriate. Good knowledge doesn't always lead to good practices of PMTCT/HBV. There exist some obstacles or intermediate variables between good knowledge, good attitudes and appropriate practices of PMTCT/HBV.Keywords: PMTCT/HBV, hepatitis B, healthcare providers, knowledges, attitudes and practice