Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis.

Asthma is the most common chronic paediatric disease treated in the emergency department (ED). Rapid corticosteroid administration is associated with improved outcomes, but our busy ED setting has made it challenging to achieve this goal. Our primary aim was to decrease the time to corticosteroid administration in a large, academic paediatric ED. We conducted an interrupted time series analysis for moderate to severe asthma exacerbations of one to 18 year old patients. A multidisciplinary team designed the intervention of a bedside nurse initiated administration of oral dexamethasone, to replace the prior system of a physician initiated order for oral prednisone. Our baseline and intervention periods were 12 month intervals. Our primary process measure was the time to corticosteroid administration. Other process measures included ED length of stay, admission rate, and rate of emesis. The balance measures included rate of return visits to the ED or clinic within five days, as well as the proportion of discharged patients who were admitted within five days. No special cause variation occurred in the baseline period. The mean time to corticosteroid administration decreased significantly, from 98 minutes in the baseline period to 59 minutes in the intervention period (p \u3c 0.01), and showed special cause variation improvement within two months after the intervention using statistical process control methodology. We sustained the improvement and demonstrated a stable process. The intervention period had a significantly lower admission rate (p\u3c0.01) and emesis rate (p\u3c0.01), with no unforeseen harm to patients found with any of our balance measures. In summary, the introduction of a nurse initiated, standardized protocol for corticosteroid therapy for asthma exacerbations in a paediatric ED was associated with decreased time to corticosteroid administration, admission rates, and post-corticosteroid emesi

Epidemiology of patients presenting to the emergency centre of Princess Marina Hospital in Gaborone, Botswana

Emergency medicine is a newly recognized specialty in Botswana and the country launched an emergency medicine residency in January 2011. Data regarding the practice of emergency medicine in Botswana are limited. This study reviewed 1 year of patient presentations to the emergency centre of Princess Marina Hospital, the country’s main referral hospital located in the capital city, Gaborone. Methods: Epidemiologic data of all patients presenting to the emergency centre between May 2010 and April 2011 were extracted into a database. The diagnoses of a random sample of patient presentations were coded using the categories outlined by the Clinical Classifications Software (CCS) for ICD-10. For ease of analysis, several CCS categories were grouped together for subsequent analysis. Results: 24,905 patient encounters were recorded during the study period. A large proportion of patients were aged between 25 and 50 years old. 20% of patients presented with a traumatic injury. The most common diagnoses across all ages included trauma, pregnancy complications, gastrointestinal disorders, and pneumonia. Conclusion: These results can inform the development of emergency medicine education and acute care systems in Botswana

A Global Health Research Checklist for clinicians.

Global health research has become a priority in most international medical projects. However, it is a difficult endeavor, especially for a busy clinician. Navigating the ethics, methods, and local partnerships is essential yet daunting.To date, there are no guidelines published to help clinicians initiate and complete successful global health research projects. This Global Health Research Checklist was developed to be used by clinicians or other health professionals for developing, implementing, and completing a successful research project in an international and often low-resource setting. It consists of five sections: Objective, Methodology, Institutional Review Board and Ethics, Culture and partnerships, and Logistics. We used individual experiences and published literature to develop and emphasize the key concepts. The checklist was trialed in two workshops and adjusted based on participants\u27 feedback

The impact of training non-physician clinicians in Malawi on maternal and perinatal mortality : a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project

Background: Maternal mortality in much of sub-Saharan Africa is very high whereas there has been a steady decline in over the past 60 years in Europe. Perinatal mortality is 12 times higher than maternal mortality accounting for about 7 million neonatal deaths; many of these in sub-Saharan countries. Many of these deaths are preventable. Countries, like Malawi, do not have the resources nor highly trained medical specialists using complex technologies within their healthcare system. Much of the burden falls on healthcare staff other than doctors including non-physician clinicians (NPCs) such as clinical officers, midwives and community health-workers. The aim of this trial is to evaluate a project which is training NPCs as advanced leaders by providing them with skills and knowledge in advanced neonatal and obstetric care. Training that will hopefully be cascaded to their colleagues (other NPCs, midwives, nurses). Methods/design: This is a cluster randomised controlled trial with the unit of randomisation being the 14 districts of central and northern Malawi (one large district was divided into two giving an overall total of 15). Eight districts will be randomly allocated the intervention. Within these eight districts 50 NPCs will be selected and will be enrolled on the training programme (the intervention). Primary outcome will be maternal and perinatal (defined as until discharge from health facility) mortality. Data will be harvested from all facilities in both intervention and control districts for the lifetime of the project (3–4 years) and comparisons made. In addition a process evaluation using both quantitative and qualitative (e.g. interviews) will be undertaken to evaluate the intervention implementation. Discussion: Education and training of NPCs is a key to improving healthcare for mothers and babies in countries like Malawi. Some of the challenges faced are discussed as are the potential limitations. It is hoped that the findings from this trial will lead to a sustainable improvement in healthcare and workforce development and training. Trial registration: ISRCTN6329415

HIV management by nurse prescribers compared with doctors at a paediatric centre in Gaborone, Botswana

Objectives. To compare compliance with national paediatric HIV treatment guidelines between nurse prescribers and doctors at a paediatric referral centre in Gaborone, Botswana. Methods. A cross-sectional study was conducted in 2009 at the Botswana-Baylor Children’s Clinical Centre of Excellence (COE), Gaborone, Botswana, comparing the performance of nurse prescribers and physicians caring for HIV-infected paediatric patients. Selected by stratified random sampling, 100 physician and 97 nurse prescriber encounters were retrospectively reviewed for successful documentation of eight separate clinically relevant variables: pill count charted; chief complaint listed; social history updated; disclosure reviewed; physical exam; laboratory testing; World Health Organization (WHO) staging documented; paediatric dosing. Results. Nurse prescribers and physicians correctly documented 96.0% and 94.9% of the time, respectively. There was a trend towards a higher proportion of social history documentation by the nurses, but no significant difference in any other documentation items. Conclusions. Our findings support the continued investment in programmes employing properly trained nurses in southern Africa to provide quality care and ART services to HIV-infected children who are stable on therapy. Task shifting remains a promising strategy to scale up and sustain adult and paediatric ART more effectively, particularly where provider shortages threaten ART rollout. Policies guiding ART services in southern Africa should avoid restricting the delivery of crucial services to doctors, especially where their numbers are limited

DETECT schools study protocol: A prospective observational cohort surveillance study investigating the impact of COVID-19 in Western Australian schools

Introduction: Amidst the evolving COVID-19 pandemic, understanding the transmission dynamics of the SARS-CoV-2 virus is key to providing peace of mind for the community and informing policy-making decisions. While available data suggest that school-aged children are not significant spreaders of SARS-CoV-2, the possibility of transmission in schools remains an ongoing concern, especially among an aging teaching workforce. Even in low-prevalence settings, communities must balance the potential risk of transmission with the need for students\u27 ongoing education. Through the roll out of high-throughput school-based SARS-CoV-2 testing, enhanced follow-up for individuals exposed to COVID-19 and wellbeing surveys, this study investigates the dynamics of SARS-CoV-2 transmission and the current psychosocial wellbeing impacts of the pandemic in school communities. Methods: The DETECT Schools Study is a prospective observational cohort surveillance study in 79 schools across Western Australia (WA), Australia. To investigate the incidence, transmission and impact of SARS-CoV-2 in schools, the study comprises three “modules”: Module 1) Spot-testing in schools to screen for asymptomatic SARS-CoV-2; Module 2) Enhanced surveillance of close contacts following the identification of any COVID-19 case to determine the secondary attack rate of SARS-CoV-2 in a school setting; and Module 3) Survey monitoring of school staff, students and their parents to assess psycho-social wellbeing following the first wave of the COVID-19 pandemic in WA. Clinical Trial Registration: Trial registration number: ACTRN1262000092297

Linking the sectoral employment structure and household poverty in the United Kingdom

Structural changes in the labour markets of developed economies, and changes in their institutional characteristics, have led to growing unease about the nature of low-paid employment. Related concerns have been expressed about the persistence of low-pay, the fragmentation of work and the growth of under-employment. While all these factors have potential implications for individuals’ earnings, less is known about the connection between labour market change, patterns of sectoral growth and decline and household poverty outcomes. This article shows distinct patterns of poverty outcomes by sector of employment, after controlling for other factors. However, household characteristics, in particular the presence of a second earner, do strongly mitigate the poverty risk. Overall, the findings demonstrate that policymakers need to develop a coherent policy towards poverty that recognises the nature of jobs growth and the distribution of ‘good jobs’ across households

The state of the Martian climate

60°N was +2.0°C, relative to the 1981–2010 average value (Fig. 5.1). This marks a new high for the record. The average annual surface air temperature (SAT) anomaly for 2016 for land stations north of starting in 1900, and is a significant increase over the previous highest value of +1.2°C, which was observed in 2007, 2011, and 2015. Average global annual temperatures also showed record values in 2015 and 2016. Currently, the Arctic is warming at more than twice the rate of lower latitudes

Causes of Pediatric Meningitis in Botswana: Results From a 16-Year National Meningitis Audit.

BACKGROUND: Central nervous system infections are an important cause of childhood morbidity and mortality in high HIV-prevalence settings of Africa. We evaluated the epidemiology of pediatric meningitis in Botswana during the rollout of antiretroviral therapy, pneumococcal conjugate vaccine and Haemophilus influenzae type B (HiB) vaccine. METHODS: We performed a cross-sectional study of children (<15 years old) evaluated for meningitis by cerebrospinal fluid (CSF) examination from 2000 to 2015, with complete national records for 2013-2014. Clinical and laboratory characteristics of microbiologically confirmed and culture-negative meningitis were described and incidence of Streptococcus pneumoniae, H. influenzae and cryptococcal meningitis was estimated for 2013-2014. RESULTS: A total of 6796 unique cases were identified. Median age was 1 year [interquartile range 0-3]; 10.4% (435/4186) of children with available HIV-related records were known HIV-infected. Overall, 30.4% (2067/6796) had abnormal CSF findings (positive microbiologic testing or CSF pleocytosis). Ten percent (651/6796) had a confirmed microbiologic diagnosis; including 26.9% (175/651) Cryptococcus, 18.9% (123/651) S. pneumoniae, 20.3% (132/651) H. influenzae and 1.1% (7/651) Mycobacterium tuberculosis. During 2013-2014, national cryptococcal meningitis incidence was 1.3 cases per 100,000 person-years (95% confidence interval, 0.8-2.1) and pneumococcal meningitis incidence 0.7 per 100,000 person-years (95% confidence interval, 0.3-1.3), with no HiB meningitis diagnosed. CONCLUSIONS: Following HiB vaccination, a marked decline in microbiologically confirmed cases of H. influenzae meningitis occurred. Cryptococcal meningitis remains the most common confirmed etiology, demonstrating gaps in prevention-of-mother-to-child transmission and early HIV diagnosis. The high proportion of abnormal CSF samples with no microbiologic diagnosis highlights limitation in available diagnostics

Motivational determinants among physicians in Lahore, Pakistan

Introduction: Human resource crises in developing countries have been identified as a critical aspect of poor quality and low accessibility in health care. Worker motivation is an important facet of this issue. Specifically, motivation among physicians, who are an important bridge between health systems and patients, should be considered. This study aimed to identify the determinants of job motivation among physicians, a neglected perspective, especially in developing countries. Methods: A stratified random sample of 360 physicians was selected from public primary, public secondary and public and private tertiary health facilities in the Lahore district, Pakistan. Pretested, semi-structured, self-administered questionnaires were used. For the descriptive part of this study, physicians were asked to report their 5 most important work motivators and demotivators within the context of their current jobs and in general. Responses were coded according to emergent themes and frequencies calculated. Of the 30 factors identified, 10 were classified as intrinsic, 16 as organizational and 4 as socio-cultural. Results: Intrinsic and socio-cultural factors like serving people, respect and career growth were important motivators. Conversely, demotivators across setups were mostly organizational, especially in current jobs. Among these, less pay was reported the most frequently. Fewer opportunities for higher qualifications was a demotivator among primary and secondary physicians. Less personal safety and poor working conditions were important in the public sector, particularly among female physicians. Among private tertiary physicians financial incentives other than pay and good working conditions were motivators in current jobs. Socio-cultural and intrinsic factors like less personal and social time and the inability to financially support oneself and family were more important among male physicians. Conclusion: Motivational determinants differed across different levels of care, sectors and genders. Nonetheless, the important motivators across setups in this study were mostly intrinsic and socio-cultural, which are difficult to affect while the demotivators were largely organizational. Many can be addressed even at the facility level such as less personal safety and poor working conditions. Thus, in resource limited settings a good strategic starting point could be small scale changes that may markedly improve physicians' motivation and subsequently the quality of health care