Multiple challenges of antibiotic use in a large hospital in Ethiopia - a ward-specific study showing high rates of hospital-acquired infections and ineffective prophylaxis.

BACKGROUND: This project aims to study the use of antibiotics in three clinical wards in the largest tertiary teaching hospital in Ethiopia for a period of 1 year. The specific aims were to assess the prevalence of patients on antibiotics, quantify the antibiotic consumption and identify the main indications of use. METHOD: The material was all the medical charts (n = 2231) retrieved from three clinical wards (internal medicine, gynecology/obstetrics and surgery) in Tikur Anbessa Specialized Hospital (TASH) in Addis Ababa between September 2013 and September 2014. Data collection was performed manually by four pharmacists. RESULTS: Each medical chart represented one patient. About 60% of the patients were admitted to internal medicine, 20% to each of the other two wards. The number of bed days (BD) was on average 16.5. Antibiotics for systemic use were prescribed to 73.7% of the patients (on average: 2.1 antibiotics/patient) of whom 86.6% got a third or fourth generation cephalosporin (mainly ceftriaxone). The average consumption of antibiotics was 81.6 DDD/100BD, varying from 91.8 in internal medicine and 71.6 in surgery to 47.6 in gynecology/obstetrics. The five most frequently occurring infections were pneumonia (26.6%), surgical site infections (21.5%), neutropenic fever (6.9%), sepsis (6.4%) and urinary tract infections (4.7%). About one fourth of the prescriptions were for prophylactic purposes. Hospital acquired infections occurred in 23.5% of the patients (353 cases of surgical site infection). The prescribing was based on empirical treatment and sensitivity testing was reported in only 3.8% of the cases. CONCLUSIONS: In the present study from three wards in the largest tertiary teaching hospital in Ethiopia, three out of four patients were prescribed antibiotics, primarily empirically. The mean antibiotic consumption was 81.6 DDD/100BD. Surgical site infections constituted a large burden of the infections treated in the hospital, despite extensive prescribing of prophylaxis. The findings show the need to implement antibiotic stewardship programs in Ethiopian hospitals with focus on rational prescribing, increased sensitivity testing and better procedures to prevent hospital acquired infections.

[Current issues in pancreatic surgery]. / Aktual'nye voprosy khirurgii podzheludochnoi zhelezy.

AIM: To present own experience of pancreatic surgery and to analyze literature data for this issue. MATERIAL AND METHODS: We have analyzed work of abdominal surgery department over the last 5 years. Moreover, MEDLINE and RSCI databases regarding surgical treatment of pancreatic diseases were assessed. RESULTS: There were 456 pancreatectomies. Postoperative complications arose in 176 (38.6%) patients, 11 patients died (2.4%). According to world data, mortality after pancreatectomy reaches 10%. Only creation of specialized centers is proven way to improve the outcomes. CONCLUSION: Current medical assistance for pancreatic disease may be only achieved in specialized centers with large number of various pancreatic procedures. The organization of such centers is required throughout the country and certain accreditation criteria should be developed for this purpose. Targeted routing of patients to specialized pancreatology centers will be able to reduce incidence of diagnostic, tactical and technical errors.

Exploring interhospital transfers and partnerships in the hospital sector in New South Wales, Australia.

Objective The aim of the present study was to explore characteristics of interhospital transfers (IHT) and sharing of care among hospitals in New South Wales (NSW), Australia. Methods Data were extracted from patient-level linked hospital administrative datasets for separations from all NSW acute care hospitals from 1 July 2013 to 30 June 2015. Patient discharge and arrival information was used to identify IHTs. Characteristics of patients and related hospitals were then analysed. Results Transfer-in patients accounted for 3.9% of all NSW admitted patients and, overall, 7.3% of NSW admissions were associated with transfers (IHT rate). Patients with injuries and circulatory system diseases had the highest IHT rate, accounting for one-third of all IHTs. Patients were more often transferred to larger than smaller hospitals (61% vs 29%). Compared with private hospitals, public hospitals had a higher IHT rate (8.4% vs 5.1%) and a greater proportion of transfer-out IHTs (52% vs 28%). Larger public hospitals had lower IHT rates (3-8%) compared with smaller public hospitals (13-26%). Larger public hospitals received and retransferred higher proportions of IHT patients (52-58% and 11% respectively) than their smaller counterparts (26-30% and 2-3% respectively). Less than one-quarter of IHTs were between the public and private sectors or between government health regions. The number of interacting hospitals and their interactions varied across hospital peer groups. Conclusion NSW IHTs were often to hospitals with greater speciality services. The patterns of interhospital interactions could be affected by organisational and regional preferences. What is known about the topic? IHTs aim to provide efficient and effective care. Nonetheless, information on transfers and the sharing of care among hospitals in an Australian setting is lacking. Studies of transfers and hospital partnership patterns will inform efforts to improve patient-centred transfers and hospital accountability in terms of end outcomes for patients. What does this paper add? Transfer-in patients accounted for 3.9% of all NSW admissions; they were often (61%) transferred to hospitals with greater speciality services. The number of IHTs and sharing of care among hospitals varied across hospital peer groups, and could have been affected by organisational and regional preferences. What are the implications for practitioners? The findings of the present study suggest that different patterns of IHTs may not only have resulted from clinical priorities, but that organisational and regional preferences are also likely to be influential factors. Patient-centred IHTs and the development of guidelines need to be pursued to enhance the care and functionality of healthcare. Patient sharing should be acknowledged in hospital and regional performance profiling.

Evaluation of a center of excellence program for spine surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services and many private health plans are encouraging patients to seek orthopedic care at hospitals designated as centers of excellence. No evaluations have been conducted to compare patient outcomes and costs at centers of excellence versus other hospitals. The objective of our study was to assess whether hospitals designated as spine surgery centers of excellence by a group of over 25 health plans provided higher quality care. METHODS: Claims representing approximately 54 million commercially insured individuals were used to identify individuals aged 18-64 years with 1 of 3 types of spine surgery in 2007-2009: 1-level or 2-level cervical fusion (referred to as cervical simple fusion), 1-level or 2-level lumbar fusion (referred to as lumbar simple fusion), or lumbar discectomy and/or decompression without fusion. The primary outcomes were any complication (7 complications were captured) and 30-day readmission. The multivariate models controlled for differences in age, sex, and comorbidities between the 2 sets of hospitals. RESULTS: A total of 29,295 cervical simple fusions, 27,214 lumbar simple fusions, and 28,911 lumbar discectomy/decompressions were identified, of which 42%, 42%, and 47%, respectively, were performed at a hospital designated as a spine surgery center of excellence. Designated hospitals had a larger number of beds and were more likely to be an academic center. Across the 3 types of spine surgery (cervical fusions, lumbar fusions, or lumbar discectomies/decompressions), there was no difference in the composite complication rate [OR 0.90 (95% CI, 0.72-1.12); OR 0.98 (95% CI, 0.85-1.13); OR 0.95 (95% CI, 0.82-1.07), respectively] or readmission rate [OR 1.03 (95% CI, 0.87-1.21); OR 1.01 (95% CI, 0.89-1.13); OR 0.91 (95%, CI 0.79-1.04), respectively] at designated hospitals compared with other hospitals. CONCLUSIONS: On average, spine surgery centers of excellence had similar complication rates and readmission rates compared with other hospitals. These results highlight the importance of empirical evaluations of centers of excellence programs.

Health care utilization in medically complex people living with HIV before and after admission to an HIV-specific community facility: a pre-post comparison study.

BACKGROUND: People living with HIV and multiple comorbidities have high rates of health service use. This study evaluates system usage before and after admission to a community facility focused on HIV care. METHODS: We used Ontario administrative health databases to conduct a pre-post comparison of rates and costs of hospital admissions, emergency department visits, and family physician and home care visits among medically complex people with HIV in the year before and after admission to Casey House, an HIV-specific hospital in Toronto, for all individuals admitted between April 2009 and March 2015. Negative binomial regression was used to compare rates of health care utilization. We used Wilcoxon rank sum tests to compare associated health care costs, standardized to 2015 Canadian dollars. To contextualize our findings, we present rates and costs of health service use among Ontario residents living with HIV. RESULTS: During the study period, 268 people living with HIV were admitted to Casey House. Emergency department use declined from 4.6 to 2.5 visits per person-year (p = 0.02) after discharge from Casey House, and hospitalization rates declined from 1.4 to 1.1 admissions per person-year (p = 0.05). Conversely, home care visits increased from 24.3 to 35.6 visits per person-year (p = 0.01) and family physician visits increased from 18.3 to 22.6 visits per person-year (p < 0.001) in the year after discharge. These changes were associated with reduced overall costs to the health care system. The reduction in overall costs was not significant (p = 0.2); however, costs of emergency department visits (p < 0.001) and physician visits (p < 0.001) were significantly less. INTERPRETATION: Health care utilization by people with HIV was significantly different before and after admission to a community hospital focused on HIV care. This has implications for health care in other complex patient populations.

Stroke Center Care and Outcome: Results from the CSPPC Stroke Program.

The aim of this study was to assess the association between admission to stroke centers for acute ischemic stroke and complications and mortality during hospitalization in a Chinese population by means of an observational study using data from the China Stroke Center Data-Sharing Platform. We compared in-hospital complications and mortality for patients admitted with acute ischemic stroke (N = 13,236) between November 1, 2018 and December 31, 2018 at stroke center (SH) and non-stroke center (CH) hospitals using distance to hospitals as an instrumental variable to adjust for potential prehospital selection bias. The results showed that complication rates during hospitalization among ischemic stroke patients who received thrombolytic therapy (n = 11,203) were lower in the SH group than in the CH group: 11.1% vs 15.7% (absolute difference, - 5.11% [95% CI, - 6.05 to - 3.99%], odds ratio [OR] 0.85 [95% CI, 0.74 to 0.92]). The incidence of intracranial hemorrhage was reduced from 4.2 to 3.2%: SH group vs CH group, 3.2% vs 4.2% (absolute difference, - 1.24% [95% CI, - 1.65 to - 0.82%], OR 0.83 [95% CI, 0.69 to 0.0.98]). Furthermore, the total mortality rate in the SH group was also lower than in the CH group: SH group vs CH group, 2.2% vs 3.0% (absolute difference, - 0.92% [95% CI, - 1.48 to - 0.53%], OR 0.85 [95% CI, 0.73 to 0.96]). The data showed that admission to SH hospitals was associated with a lower risk of treatment complications and death for patients with an acute ischemic stroke receiving thrombolytic therapy.

Do specialized centers and specialists produce better outcomes for patients with chronic diseases than primary care generalists? A systematic review.

PURPOSE: Although specialized centers are generally accepted for treatment of relatively uncommon diseases, such as cystic fibrosis, statements regarding the amount of expertise or minimum number of patients treated are increasingly included in guidelines for the treatment of other chronic diseases such as rheumatoid arthritis and diabetes mellitus. DATA SOURCES: Medline and Embase from 1987 through March 2008 were searched. STUDY SELECTION: Studies reporting the effect of treatment in a specialized or high-volume center or by subspecialists on a clinically relevant outcome. Data extraction Two reviewers extracted the data independently and assessed the methodological quality. RESULTS OF DATA SYNTHESIS: We included 22 articles. Two randomized-controlled trials and a quasi-experimental study compared the effect of outpatient team care with traditional outpatient care for patients with rheumatoid arthritis. These studies showed no difference or were inconsistent. Studies on the outcomes of care for diabetic patients (5 prospective or historical cohort studies and 10 retrospective cohort studies) were generally of poor quality. Studies comparing the subspecialist care with the care provided by general internists or primary care providers produced inconsistent results. Similar inconsistency and poor quality were found for three observational studies on cystic fibrosis. CONCLUSION: The available literature suggests that among patients with rheumatoid arthritis, diabetes mellitus or cystic fibrosis, outcomes are not superior in specialized centers or with subspecialists compared with other forms of chronic illness care.

The impact of physician-owned specialty orthopaedic hospitals on surgical volume and case complexity in competing hospitals.

Published studies of physician-owned specialty hospitals have typically examined the impact of these hospitals on disparities, quality, and utilization at a national level. Our objective was to examine the impact of newly opened physician-owned specialty orthopaedic hospitals on individual competing general hospitals. We used Medicare Part A administrative data to identify all physician-owned specialty orthopaedic hospitals performing total hip arthroplasty (THA) and total knee arthroplasty (TKA) between 1991 and 2005. We identified newly opened specialty hospitals in three representative markets (Durham, NC, Kansas City, and Oklahoma City) and assessed their impact on surgical volume and patient case complexity for the five competing general hospitals located closest to each specialty hospital. The average general hospital maintained THA and TKA volume following the opening of the specialty hospitals. The average general hospital also did not experience an increase in patient case complexity. Thus, based on these three markets, we found no clear evidence that entry of physician-owned specialty orthopaedic hospitals resulted in declines in THA or TKA volume or increases in patient case complexity for the average competing general hospital.

The effect of patient institutional transfer during the interstage period of two-stage treatment for prosthetic knee infection.

AIMS: The aim of this study was to assess the effects of transferring patients to a specialized arthroplasty centre between the first and second stages (interstage) of prosthetic joint infection (PJI) of the knee. PATIENTS AND METHODS: A search of our institutional database was performed to identify patients having undergone two-stage revision total knee arthroplasty (TKA) for PJI. Two cohorts were created: continuous care (CC) and transferred care (TC). Baseline characteristics and outcomes were collected and compared between cohorts. RESULTS: A total of 137 patients were identified: 105 in the CC cohort (56 men, 49 women; mean age 67.9) and 32 in the TC cohort (17 men, 15 women; mean age 67.8 years). PJI organism virulence was greater in the CC cohort (36.2% vs 15.6%; p = 0.030). TC patients had a higher rate of persisting or recurrent infection (53.6% vs 13.4%; p < 0.001), soft-tissue complications (31.3 vs 14.3%; p = 0.030), and reduced requirement for porous metal augments (78.1% vs 94.3%; p = 0.006). Repeat first stage debridement after transfer led to greater need for plastic surgical procedures (58.3% vs 0.0%; p < 0.001). CONCLUSION: Patient transfer during the interstage of treatment for infected TKA leads to poorer outcomes compared with patients receiving all their treatment at a specialized arthroplasty centre. Cite this article: Bone Joint J 2019;101-B:1087-1092.

Short-term Outcomes of Total Knee Arthroplasty Performed at an Orthopedic Specialty Hospital.

This study compared perioperative outcomes for total knee arthroplasty (TKA) at an orthopedic specialty hospital and a tertiary referral center. The authors identified all primary TKA procedures performed in 2014 at the 2 facilities. Each patient at the orthopedic specialty hospital was manually matched to a patient at the tertiary referral center according to demographic and clinical variables. Matching was blinded to outcomes. Outcomes were 90-day readmission, mortality rate, reoperation, length of stay, and use of inpatient rehabilitation. Each group had 215 TKA patients. The 2 groups of patients were similar in age (66.8 years, P=.98), body mass index (30.4 kg/m2, P=.99), age-adjusted Charlson Comorbidity Index (3.4, P=1.00), and sex (46.0% male, P=1.00). Mean length of stay was 1.47±0.62 days at the orthopedic specialty hospital vs 1.87±0.75 days (P<.01) at the tertiary referral center. There were 3 readmissions at the orthopedic specialty hospital and 6 readmissions at the tertiary referral center (P=.31). There were 6 reoperations at the orthopedic specialty hospital and 5 at the tertiary referral center (P=.76). In addition, 8 patients at the orthopedic specialty hospital used inpatient rehabilitation vs 15 patients at the tertiary referral center (P=.08). One patient who was treated at the orthopedic specialty hospital required transfer to a tertiary referral center. This study found that perioperative outcomes were similar for matched patients who underwent primary TKA at an orthopedic specialty hospital and a tertiary referral center. Patients treated at the orthopedic specialty hospital spent 0.4 fewer days in the hospital compared with matched patients who were treated at the tertiary referral center. This equals 2 fewer hospital nights for every 5 TKA patients. [Orthopedics. 2018; 41(1):e84-e91.].

Population-level surgical outcomes for infantile hypertrophic pyloric stenosis.

OBJECTIVES: Determine national outcomes for pyloromyotomy; how these are affected by: (i) surgical approach (open/laparoscopic), or (ii) centre type/volume and establish potential benchmarks of quality. METHODS: Hospital Episode Statistics data were analysed for admissions 2002-2011. Data presented as median (IQR). RESULTS: 9686 infants underwent pyloromyotomy (83% male). Surgery was performed in 22 specialist (SpCen) and 39 nonspecialist centres (NonSpCen). The proportion treated in SpCen increased linearly by 0.4%/year (r=0.76, p=0.01). Annual case volume in SpCen vs. NonSpCen was 40 (24-53) vs. 1 (0-3). Time to surgery was shorter in SpCen (1day [1, 2] vs. 2 [1-3]), but total stay equal (4days [3-6]). 137 (1.4%) had complications requiring reoperation (wound problem 0.6%; repeat pyloromyotomy 0.5% and perforation, bleeding or obstruction 0.2%): pooled rates were similar between SpCen and NonSpCen (1.4% vs. 1.6%, p=0.52). Three NonSpCen had >5% reoperations (within 99.8% C.I. as small denominators). There was no relationship between reoperation and centre volume. Laparoscopic pyloromyotomy had increased risk of repeat pyloromyotomy (OR 2.28 [1.14-4.57], p=0.029). CONCLUSIONS: Pyloric stenosis surgery shifted from centres local to patients, but outcomes were unaffected by centre type/volume. Modest reported benefits of laparoscopy appear offset by increased reoperations. Quality benchmarks could be set for reoperation <4%. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.

Examination of first-degree relatives of patients with glaucoma: a randomized trial of strategies to increase use in an eye hospital in Africa.

OBJECTIVE: To determine the best approach to examine first-degree relatives (FDR) of glaucoma patients in a rural African setting. METHODS: Randomized controlled trial of FDR aged 40 years and older of (index) open angle glaucoma patients who presented to KCMC Hospital. Two strategies of uptake were tested. The main outcome measure was FDR presentation for examination for glaucoma. RESULTS: From 182 index cases, 484 FDR were enrolled in the study, 256 randomized to free examination, and 228 randomized to standard (pay) examination. Overall, 8.1% (95% CI: 5.7-10.5) came for examination. FDR who were offered examination free of charge were 1.87 times (95% CI: 0.94-3.73) more likely to present than those offered standard examination. Among those offered free examination, living near the hospital was associated with presentation (OR=2.85; 95% CI: 1.10-7.36) whereas among those offered standard examination the association with residence was weak (OR=2.27; 95% CI: 0.72-7.15). CONCLUSIONS: Providing good quality counseling of index cases and offering glaucoma examination free of charge is not sufficient to reach those at risk of glaucoma, suggesting that the indirect costs of accessing services are significant barriers to use of examination services. Other means of encouraging FDR to come for glaucoma examination should be investigated.

Emerging aspects of psychosocial risks: violence and harassment at work.

In the last twenty years, psychosocial risks have become crucial in Occupational Health. Particularly, there is an increasing interest about psychological and physical violence at the workplaces. Psychological violence (mobbing or workplace bullying) is described as a situation in which the person has been the victim of negative acts directed to the person and work, with offences, discriminations and isolation. Physical violence at work, still underestimated in many parts of the world, is becoming a topical subject both for its frequency and its pathogenic potential and consist of violence among workers (internal violence) and between workers and external persons (external violence). Examples of external violence are bank robberies, which are prevalent in many European countries, particulary in Italy. The costs of psychological and physical workplace violence are very high at all levels; individual, for the implication of violence for health and quality of life as well as organizational, for the increase of absenteeism, turnover and health care demands and claims. The Medical Centre for Occupational Stress and Harassment (CDL) of the "Clinica de Lavoro Luigi Devoto" was set up in 1996 with a day-hospital service for the diagnosis, rehabilitation and prevention of work related psychological diseases. From its opening, about 5000 patients have been examined.

The effect of decentralisation on tuberculosis services in three states of Sudan.

SETTING: Referral hospitals and primary health care (PHC) facilities in Khartoum, Red Sea and Gadaref States. OBJECTIVES: To measure the effect of the decentralisation of the tuberculosis (TB) services on the clinical profile and treatment outcome of tuberculosis. DESIGN: A cohort study of case detection and treatment outcome using information routinely collected comparing patients attending PHC facilities and referral hospitals in selected locations in Sudan. RESULTS: Two-thirds of all TB patients were diagnosed in referral hospitals and one-third in PHC facilities. In PHC facilities, women represented 46% of notified cases, compared to 37.9% in referral hospitals (OR 1.398, 95%CI 1.343-1.455). Older age groups were more likely to prefer PHC facilities to referral hospitals. In referral hospitals, 38% were cured, 29.3% completed treatment without smear examination and 17.3% defaulted, while in PHC facilities 58% were cured, 17.8% completed treatment without smear examination and 11.6% defaulted. CONCLUSION: PHC facilities provide care for a higher proportion of women and older age groups of tuberculosis patients, suggesting a higher level of accessibility for these groups. A higher cure rate and a lower default rate were noted in PHC facilities, possibly reflecting better conditions for directly observed treatment and follow-up.

Making better use of scarce resources: the Palestinian experience, 1995-1999.

Until August 2, 1997, The Eye Hospital-Gaza (EH) provided both primary and secondary eye services to almost 1 million inhabitants in Gaza. This exerted a tremendous load on the hospital's facilities and prevented the hospital from performing its main role as a secondary eye care provider. The training and guidance of primary health care (PHC) providers are essential in order that they can do their share in eye care. A prevention of blindness awareness campaign, training, workshops, and practical instruction took place in Gaza over a three-year span. A new purpose designed referral system was started on August 2, 1997, that resulted in a great change and improvement of the services in the hospital. Primary eye care is an integral part of ophthalmic services. Proper continuous training of PHC providers is essential, not only for providing service to patients near their residence in the shortest time possible, but also to facilitate the smooth, effective, and efficient functioning of the hospital as a secondary and tertiary eye care provider. We believe the system and methodology used is efficient and reproducible in many developing countries.

Pediatric day-care surgery: a 30-year hospital experience.

Over a 30-year period (may 1955 to December 1985), day care surgery was performed on 39,654 patients at the Winnipeg Children's Hospital (WCH). Up to 51% of all pediatric surgical cases and 59% of elective pediatric cases, involving more than 50 different procedures, were performed annually on a day-care basis. The overall incidence of postoperative problems and admission to hospital was 1.5% and 1.1%, respectively. A unique preoperative home visiting program by nurses was demonstrably effective in reducing late cancellations by 75%. The WCH experience adds further evidence that day-care surgery in a pediatric hospital is safe and effective for a large proportion of infants and children requiring operation.

Pathways to long-term geriatric hospital care.

This paper describes the pathways that are taken to long-term geriatric hospital care. Information was collected for 160 people currently receiving such care, and it was found that 110 different pathways were taken to a long-term geriatric bed. The most commonly experienced accommodation settings were acute hospital care, and living in the community with some form of disability but no domiciliary services, which were also the most frequent ways of beginning the pathways. The ends of the pathways were characterized by acute hospital care, short-term geriatric or convalescent care and rest or residential care. Domiciliary services had been used by less than half of the sample, and many of these appeared to have been receiving only a minimal level of support. This paper also examines the role of the assessment and rehabilitation unit, and seeks to comment on how services designed to reduce the demand for long-term geriatric care have been used.

General practitioner referrals to an eye hospital: a standard referral form.

To assess general practitioner (GP) referrals to an eye hospital, 500 consecutive referral letters were analysed for content, diagnosis, ocular examination, and medical and drug history. Inadequate information was provided. Visual acuity was measured by general practitioners in only 3.7% of referrals. The standard of ocular examination compared unfavourably with that of ophthalmic opticians. A standard ophthalmic referral form is proposed, and referral protocols are desirable. Undergraduate education in ophthalmology is inadequate and requires more curricular time.