Knowledge acquisition and retention following Saving Children's Lives course for healthcare providers in Botswana: a longitudinal cohort study.

OBJECTIVES: Millions of children die every year from serious childhood illnesses. Most deaths are avertable with access to quality care. Saving Children's Lives (SCL) includes an abbreviated high-intensity training (SCL-aHIT) for providers who treat serious childhood illnesses. The objective of this study was to examine the impact of SCL-aHIT on knowledge acquisition and retention of providers. SETTING: 76 participating centres who provide primary and secondary care in Kweneng District, Botswana. PARTICIPANTS: Doctors and nurses expected by the District Health Management Team to provide initial care to seriously ill children, completed SCL-aHIT between January 2014 and December 2016, submitted demographic data, course characteristics and at least one knowledge assessment. METHODS: Retrospective, cohort study. Planned and actual primary outcome was adjusted acquisition (change in total knowledge score immediately after training) and retention (change in score at 1, 3 and 6 months), secondary outcomes were pneumonia and dehydration subscores. Descriptive statistics and linear mixed models with random intercept and slope were conducted. Relevant institutional review boards approved this study. RESULTS: 211 providers had data for analysis. Cohort was 91% nurses, 61% clinic/health postbased and 45% pretrained in Integrated Management of Childhood Illness (IMCI). A strong effect of SCL-aHIT was seen with knowledge acquisition (+24.56±1.94, p<0.0001), and loss of retention was observed (-1.60±0.67/month, p=0.018). IMCI training demonstrated no significant effect on acquisition (+3.58±2.84, p=0.211 or retention (+0.20±0.91/month, p=0.824) of knowledge. On average, nurses scored lower than physicians (-19.39±3.30, p<0.0001). Lost to follow-up had a significant impact on knowledge retention (-3.03±0.88/month, p=0.0007). CONCLUSIONS: aHIT for care of the seriously ill child significantly increased provider knowledge and loss of knowledge occurred over time. IMCI training did not significantly impact overall knowledge acquisition nor retention, while professional status impacted overall score and lost to follow-up impacted retention.

Promoting Health Equity Through Purposeful Design and Professionalization of Resident Global Health Electives in Obstetrics and Gynecology.

OBJECTIVE: To design an Obstetrics and Gynecology (OBGYN) residency elective in global health that meets ACGME standards and simultaneously promotes health equity. DESIGN: A 4-week elective was established for US residents in a high-volume African district hospital that served as a site for OBGYN rotations for the national internship training program. Clear clinical, operative, and teaching requirements were delineated for US OBGYN residents. Resident formal didactic outputs were incorporated into the intern OBGYN curriculum. The program was evaluated through assessment of resident experience and contribution to local training, as well as assessment of intern competency in OBGYN. SETTING: Scottish Livingstone Hospital, a public district hospital in Molepolole, Botswana. PARTICIPANTS: Second- to fourth-year OBGYN residents from US training programs, working with Batswana medical interns under on-site faculty supervision. RESULTS: From May 2016 to June 2018, 18 residents from 9 US OBGYN residency programs participated in the elective. Under supervision, US residents performed 116 major and 77 minor gynecologic surgeries, and teach-assisted Batswana interns and medical officers in 76 cesarean deliveries. Residents led or contributed significantly to 25 didactic education sessions as part of the formal intern OBGYN curriculum. During this period, 24 Batswana interns rotated through the hospital's department of OBGYN, and all 24 trainees met required OBGYN competencies prior to completing their internship. CONCLUSIONS: Matching US resident demand for global health experiences to equitable global health programming while maintaining ACGME training guidelines poses a challenge to OBGYN residency training programs. This elective provides a model OBGYN global health elective that addresses host-identified needs, broadens residents' skills, and meets standards for postgraduate OBGYN training. Purposeful global health electives for US residents embedded in longitudinal programs provide an opportunity for residents to contribute to broader global health efforts that promote health equity.

Audit of Early Mortality among Patients Admitted to the General Medical Ward at a District Hospital in Botswana.

BACKGROUND: Mortality among adult general medical admissions has been reported to be high across sub-Saharan Africa, yet there is a paucity of literature on causes of general medical inpatient mortality and quality-related factors that may contribute to the high incidence of deaths. Based on a prior study at our hospital as well as our clinical experience, death early in the hospitalization is common among patients admitted to the adult medical wards. OBJECTIVE: Quantify early inpatient mortality and identify factors contributing to early in-hospital mortality of medical patients in a resource-limited hospital setting in Botswana. METHODS: Twenty-seven cases of patients who died within 48 hours of admission to the general medical wards at Scottish Livingstone Hospital in Molepolole, Botswana from December 1, 2015-April 25, 2016 were retrospectively reviewed through a modified root cause analysis. FINDINGS: Early in-hospital mortality was most frequently attributed to septic shock, identified in 20 (74%) of 27 cases. The most common care management problems were delay in administration of antibiotics (15, 56%), inappropriate fluid management (15, 56%), and deficient coordination of care (15, 56%). The most common contributing factors were inadequate provider knowledge and skills in 25 cases (93%), high complexity of presenting condition in 20 (74%), and inadequate communication between team members in 18 (67%). CONCLUSIONS: Poor patient outcomes in low-and middle-income countries like Botswana are often attributed to resource limitations. Our findings suggest that while early in-hospital mortality in such settings is associated with severe presenting conditions like septic shock, primary contributors to lack of better outcomes may be healthcare-provider and system-factors rather than lack of diagnostic and therapeutic resources. Low-cost interventions to improve knowledge, skills and communication through a focus on provider education and process improvement may provide the key to reducing early in-hospital mortality and improving hospitalization outcomes in this setting.

Pilot of an International Collaboration to Build Capacity to Provide Gynecologic Oncology Surgery in Botswana.

OBJECTIVES: Gynecologic malignancies are the leading cause of cancer death among women in Botswana. Twenty-five percent of cervical cancers present at a stage that could be surgically cured; however, there are no gynecologic oncologists to provide radical surgeries. A sustainable model for delivery of advanced surgery is essential to advance treatment for gynecologic malignancies. METHODS/MATERIALS: A model was developed to provide gynecologic oncology surgery in Botswana, delivered by US-based gynecologic oncologists in four 2-week blocks per year. A pilot gynecologic oncology campaign was planned at a district hospital. Eligible patients were identified through the gynecologic oncology multidisciplinary clinic at the regional referral hospital, where gynecologic oncology treatment planning is provided. Local providers were invited to participate to build local surgical capacity. RESULTS: One US-based gynecologic oncologist, 2 gynecologists, and 2 surgeons working in Botswana participated in the pilot campaign. Sixteen operations were performed over 7 days. Indications included cervical cancer (4), ovarian cancer (3), vulvar cancer (1), complex atypical hyperplasia (1), pre-invasive cervical disease (2), and benign disease (3), as well as 2 obstetric emergencies. The only gynecologic oncology complication was a case of bleeding requiring transfusion and postoperative intensive care unit admission. Follow-up care was coordinated through the gynecologic oncology multidisciplinary clinic. CONCLUSIONS: Periodic gynecologic oncology campaigns in settings otherwise lacking local capacity to perform advanced surgery are a feasible model to create access and build local capacity. Strong local collaboration is essential. Future strategies to increase impact include recruitment of more gynecologic oncologists to increase service and training availability.

HIV-related mortality at a district hospital in Botswana.

We reviewed mortality data among medical inpatients at a tertiary hospital in Botswana to identify risk factors for adverse inpatient outcomes. This review was a prospective analysis of inpatient admissions. All medical admissions to male and female medical wards were recorded over a six-month period between 1 November 2011 and 30 April 2012. Data collected included patient demographics, HIV status (positive, negative, unknown), HIV testing history, HIV related treatment and serological history, admission and discharge diagnoses, and mortality status at final discharge or transfer. Of 972 patients admitted during the surveillance period, 427 (43.9%) were known to be HIV-positive on admission, 144 (14.8%) were known to be HIV-negative, and 401 (41.3%) had an unknown HIV status. Of those with unknown status, 131 (32.7%) were tested for HIV during admission and among these 35 (27.5%) were HIV-positive. Including patients with known mortality status following transfer, 172 (17.9%) patients died during the hospitalization. Death occurred in 105 (23%) of known HIV-positive patients, compared with 31 (13%) of known HIV-negative patients (p = 0.002, HR = 1.56 in adjusted analyses). Among HIV-positive patients who died, a low CD4 cell count (<200 cells/mm3) was associated with death. Overall, patients who died had significantly more neurological and respiratory-related presenting complaints than patients who survived. In conclusion, we identified higher overall mortality among HIV-positive patients at a tertiary hospital in Botswana, and low rates of in-hospital HIV testing and antiretroviral therapy initiation. These data demonstrate that despite available antiretroviral therapy in the population for over a decade, HIV continues to add excess burden to the hospital system and adds to inpatient mortality in Botswana.