Quality of asthma care : Western Cape Province, South Africa

ArticleThe original publication is available at http://www.samj.org.zaBackground. Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. The Asthma Guidelines Implementation Project (AGIP) was established to improve the impact of the South African guidelines for chronic asthma in adults and adolescents in the Western Cape. One strategy was an audit tool to assist with assessing and improving the quality of care. Methods. The audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape province. The usual steps in the quality improvement cycle were followed. Results. Data were obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% were given a self-management plan; 81% of medication was in stock, and the controller/reliever dispensing ratio was 0.6. Only 31.5% of patients were well controlled, 16.3% of all visits were for exacerbations, and 17.6% of all patients had been hospitalised in the previous year. Conclusion. The availability of medication and prescription of inhaled steroids is reasonable, yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique, and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care.Publishers' versio

Quality of asthma care: Western Cape Province, South Africa

Asthma is the eighth leading contributor to the burden of disease in South Africa, but has received less attention than other chronic diseases. The Asthma Guidelines Implementation Project (AGIP) was established to improve the impact of the South African guidelines for chronic asthma in adults and adolescents in the Western Cape. One strategy was an audit tool to assist with assessing and improving the quality of care. Methods. The audit of asthma care targeted all primary care facilities that managed adult patients with chronic asthma within all six districts of the Western Cape province. The usual steps in the quality improvement cycle were followed. Results. Data were obtained from 957 patients from 46 primary care facilities. Only 80% of patients had a consistent diagnosis of asthma, 11.5% of visits assessed control and 23.2% recorded a peak expiratory flow (PEF), 14% of patients had their inhaler technique assessed and 11.2% were given a self-management plan; 81% of medication was in stock, and the controller/reliever dispensing ratio was 0.6. Only 31.5% of patients were well controlled, 16.3% of all visits were for exacerbations, and 17.6% of all patients had been hospitalised in the previous year. Conclusion. The availability of medication and prescription of inhaled steroids is reasonable, yet control is poor. Health workers do not adequately distinguish asthma from chronic obstructive pulmonary disease, do not assess control by questions or PEF, do not adequately demonstrate or assess the inhaler technique, and have no systematic approach to or resources for patient education. Ten recommendations are made to improve asthma care

The effect of an automated integrated management of childhood illness guideline on the training of professional nurses in the Western Cape, South Africa

CITATION: Rhode, H. W. J. & Mash, B. 2015. The effect of an automated integrated management of childhood illness guideline on the training of professional nurses in the Western Cape, South Africa. South African Family Practice, 57(2):100–105, doi:10.1080/20786190.2014.995914.The original publication is available at http://www.tandfonline.comBackground: Reducing under-five mortality rates is a global priority. Although under-five mortality has decreased in South Africa, it is still unacceptably high. The implementation of the Integrated Management of Childhood Illness (IMCI) guideline is a key World Health Organization intervention aimed at reducing under-five mortality. Most primary care consultations are with professional nurses and they are usually trained in IMCI in a year-long primary healthcare diploma, which qualifies them to be a clinical nurse practitioner. This study aimed to evaluate the effect on training outcomes of introducing an automated IMCI guideline. Methods: Thirty professional nurses enrolled for the diploma course were purposively allocated in a quasi-experimental design to train with either paper-based or automated versions of the guideline. Their knowledge of IMCI was evaluated before and after the initial 12 hours of classroom teaching. Data on assessment, classification and management of children was extracted from the medical records of their consultations during supervised clinical training. Results: Both groups improved their knowledge of IMCI, but were not significantly different at the end of classroom teaching. Nurses in the automated group performed significantly better in use of the IMCI guideline (p < 0.05): checking immunisations (68% vs. 93%), making a complete assessment (62% vs 100%), prescribing correct medication (50% vs 85%) and correct dose (42% vs 85%). Conclusion: Use of automated IMCI guidelines showed potential for improved training outcomes. The potential for improved quality of care and clinical outcomes needs to be further studied along with a cost–benefit analysis.http://www.tandfonline.com/doi/full/10.1080/20786190.2014.995914Publisher's versio

The use of automated integrated management of childhood illness guidelines in primary health care in the Western Cape in South Africa

Thesis (MPhil)--Stellenbosch University, 2012.Introduction Under-5 year mortality in South Africa is increasing and effectiveness of primary care is a key factor. Adherence to IMCI guidelines by primary care nurses is critical. The IMCI guidelines provide a standardized integrated approach to delivering quality care. Nurses in South Africa are currently using a paper-based guideline. The automated guideline in the format of a convertible personalised computer tablet aimed to improve training in IMCI and the quality of clinical decision making. The automated guideline was designed to systematically guide the nurse through the algorithms thus reducing errors and making care more effective. This study evaluated the use of automated guidelines in improving the training of nurses. Methods A sample size of thirty Professional Registered Nurses (PNs) was selected from the one year Postgraduate Diploma in Clinical Nursing Science at Stellenbosch University. Observational study design compared 15 PNs who used and 15 who did not use the automated guidelines during training. Nurses were compared in terms of their knowledge of IMCI after classroom based teaching and adherence to IMCI in clinical training practices. Results Both groups improved their knowledge of IMCI, but were not significantly different at the end of the classroom teaching. Nurses in the automated group showed significant improvement in their clinical practice (p<0.05): gathering information on HIV risk (50% vs. 93%) or immunisations (68% vs. 93%); making a complete assessment of the patient (61% vs. 100%), prescribing correct medication (50% vs. 85%), correct dose (42% vs. 85%) and safety netting (78% vs. 96%). Conclusion The use of automated guidelines showed potential for improving adherence to IMCI in the Western Cape. Further research is needed to determine if the widespread use of the automated version by PNs translates into better quality of care and improved health outcomes

[Editorial]: Symposium on the Ethics and Regulation of Lawyers in the United States of America

This special issue of Legal Ethics is indeed special. Alexis de Tocqueville’s description of the American legal profession as the Republic’s ‘privileged body’ or ‘aristocracy’ reminds us how the lawyer’s prominent place in the United States is deeply rooted in its national identity, its public culture and its devotion to law.1 Like many of the contributors to this special issue, de Tocqueville found much about this American aristocracy both to admire and criticise. But this aristocracy makes the US ‘a nation under lawyers’.2 And it is entirely consistent with this that, as an academic discipline, legal ethics was pioneered by American scholars. American scholars continue to be leaders in the field. At the same time, their prominence has often encouraged a lack of attention to international developments that could inform US regulatory norms and policies. A special issue of Legal Ethics devoted exclusively to American scholarship was therefore long overdue, and we are pleased that it includes contributions from scholars who are pre-eminent in the field. Organised by Deborah Rhode, Professor at Stanford University and President of the International Association of Legal Ethics, the Symposium features a rich cross-section of American scholarship on ethics and the legal profession

Evaluating the effect of the practical approach to Care Kit on teaching medical students primary care : quasi-experimental study

CITATION: Mash, R., Pather, M., Rhode, H & Fairall, L. 2017. Evaluating the effect of the Practical Approach to Care Kit on teaching medical students primary care: Quasi-experimental study. African Journal of Primary Health care & Family Medicine, 9(1):a1602. doi:10.4102/phcfm.v9i1.1602.The original publication is available at https://phcfm.org/index.php/phcfmBackground: South Africa is committed to health reforms that strengthen primary health care. Preparing future doctors to work in primary care teams with other professionals is a priority, and medical schools have shifted towards community-based and decentralised training of medical students. Aim: To evaluate the effect on student performance of the Practical Approach to Care Kit (PACK) (an integrated decision-making tool for adult primary care) during the final phase of medical student training at Stellenbosch University. Setting: Clinical rotations in family medicine at clinics in the Western Cape. Methods: Mixed methods involving a quasi-experimental study and focus group interviews. Student examination performance was compared between groups with and without exposure to the PACK during their clinical training. Student groups exposed to PACK were interviewed at the end of their rotations. Results: Student performance in examinations was significantly better in those exposed to the PACK. Students varied from using the PACK overtly or covertly during the consultation to checking up on decisions made after the consultation. Some felt that the PACK was more suitable for nurses or more junior students. Although tutors openly endorsed PACK, very few modelled the use of PACK in their clinical practice. Conclusion: The use of PACK in the final phase of undergraduate medical education improved their performance in primary care. Students might be more accepting and find the tool more useful in the earlier clinical rotations. Supervisors should be trained further in how to incorporate the use of the PACK in their practice and educational conversations.publishers versio

Evaluating the effect of the Practical Approach to Care Kit on teaching medical students primary care: Quasi-experimental study

Background: South Africa is committed to health reforms that strengthen primary health care. Preparing future doctors to work in primary care teams with other professionals is a priority, and medical schools have shifted towards community-based and decentralised training of medical students. Aim: To evaluate the effect on student performance of the Practical Approach to Care Kit (PACK) (an integrated decision-making tool for adult primary care) during the final phase of medical student training at Stellenbosch University. Setting: Clinical rotations in family medicine at clinics in the Western Cape. Methods: Mixed methods involving a quasi-experimental study and focus group interviews. Student examination performance was compared between groups with and without exposure to the PACK during their clinical training. Student groups exposed to PACK were interviewed at the end of their rotations. Results: Student performance in examinations was significantly better in those exposed to the PACK. Students varied from using the PACK overtly or covertly during the consultation to checking up on decisions made after the consultation. Some felt that the PACK was more suitable for nurses or more junior students. Although tutors openly endorsed PACK, very few modelled the use of PACK in their clinical practice. Conclusion: The use of PACK in the final phase of undergraduate medical education improved their performance in primary care. Students might be more accepting and find the tool more useful in the earlier clinical rotations. Supervisors should be trained further in how to incorporate the use of the PACK in their practice and educational conversations