Emergency care capabilities in the Kingdom of Swaziland, Africa.

INTRODUCTION: Emergency care is available in many forms in Swaziland, and to our knowledge there has never been a systematic study of emergency centres (ECs) in the country. The purpose of this study was to describe the characteristics, resources and capacity of emergency centres in the Kingdom. METHODS: The National Emergency Department Inventory (NEDI)-International survey instrument (www.emnet-nedi.org) was used to survey all Swaziland ECs accessible to the general public 24/7. EC staff were asked about calendar year 2014. Data were entered directly into Lime Survey, a free, web-based, open-source survey application. Responses were analysed using descriptive statistics, including proportions and medians with interquartile ranges (IQR). RESULTS: Sixteen of 17 ECs participated (94% response rate). Participating ECs were either in hospitals (69%) or health centres (31%). ECs had a median of 53,399 visits per year (IQR 15,000-97,895). Fourteen (88%) ECs had a contiguous layout, and the other two (12%) were non-contiguous. Overall, eight (53%) had access to cardiac monitors and 11 (69%) had a 24/7 clinical laboratory available. Only 1 (6%) EC had a dedicated CT scanner, while 2 (13%) others had limited access through their hospital. The typical EC length-of-stay was between 1 and 6 h (44%). The most commonly available specialists were general surgeons, with 9 (56%) ECs having them available for in-person consultation. No ECs had a plastic surgeon or psychiatrist available. Overall, 75% of ECs reported running at overcapacity. DISCUSSION: Swaziland ECs were predominantly contiguous and running at overcapacity, with high patient volumes and limited resources. The limited access to technology and specialists are major challenges. We believe that these data support greater resource allocation by the Swaziland government to the emergency care sector.

INTRODUCTION: Les soins d'urgence sont disponibles sous de nombreuses formes au Swaziland, et à notre connaissance, aucune étude systématique des services d'urgence (SU) n'a jamais été réalisée dans le pays. L'objet de cette étude était de décrire les caractéristiques, ressources et capacités des services d'urgences dans le Royaume. MÉTHODES: L'Inventaire national des services d'urgences (NEDI) - Instrument d'enquête international (www.emnet-nedi.org) a été utilisé pour recenser tous les SU swazis accessibles au grand public 24 h/24, 7 j/7. Le personnel des SU a été interrogé sur l'année civile 2014. Les données ont été directement entrées dans Lime Survey, une application de recensencement en open source gratuite et disponible sur internet. Les réponses ont été analysées à l'aide de statistiques descriptives, en incluant les proportions et médianes, et les intervalles interquartiles (IIQ). RÉSULTATS: Seize des 17 SU ont participé (taux de réponse de 94%. Les SU participants se trouvaient soit dans des hôpitaux, soit dans des centres médicaux (31%). Les SU totalisaient une médiane de 53 399 visites par an (IIQ compris entre 15 000 et 97 895). Quatorze (88%) SU étaient attenants à une structure de soins, les deux autres (12%) ne l'étaient pas. Au total, huit (53%) avaient accès à des moniteurs cardiaques et 11 (69%) disposaient d'un laboratoire clinique disponible 24 h/24, 7 j/7. Un seul (6%) SU disposait d'un CAT scan, et deux autres (13%) n'y avaient qu'un accès limité par l'intermédiaire de l'hôpital auquel ils étaient rattachés. La durée moyenne de séjour au SU variait entre une et six heures (44%). Les spécialistes les plus fréquement disponibles étaient les chirurgiens généralistes, neuf (56%) SU les ayant à disposition pour des consultations individuelles. Aucun SU ne disposait de chirurgien esthétique ou de psychiatre. Globalement, 75% des SU indiquaient fonctionner en surcapacité. DISCUSSION: Les SU au Swaziland étaient essentiellement attenants à une structure de soins et fonctionnaient en surcapacité, avec un volume élevé de patients et des ressources limitées. L'accès limité à la technologie et aux spécialistes constituaient des défis majeurs. Nous considérons que ces données viennent appuyer une allocation plus importante de ressources par le gouvernement swazi au secteur des soins d'urgence.

Feasibility and validity of telephone triage for adverse events during a voluntary medical male circumcision campaign in Swaziland.

BACKGROUND: Voluntary medical male circumcision (VMMC) reduces HIV acquisition among heterosexual men by approximately 60%. VMMC is a surgical procedure and some adverse events (AEs) are expected. Swaziland's Ministry of Health established a toll-free hotline to provide general information about VMMC and to manage post-operative clinical AEs through telephone triage. METHODS: We retrospectively analyzed a dataset of telephone calls logged by the VMMC hotline during a VMMC campaign. The objectives were to determine reasons clients called the VMMC hotline and to ascertain the accuracy of telephone-based triage for VMMC AEs. We then analyzed VMMC service delivery data that included date of surgery, AE type and severity, as diagnosed by a VMMC clinician as part of routine post-operative follow-up. Both datasets were de-identified and did not contain any personal identifiers. Proportions of AEs were calculated from the call data and from VMMC service delivery data recorded by health facilities. Sensitivity analyses were performed to assess the accuracy of phone-based triage compared to clinically confirmed AEs. RESULTS: A total of 17,059 calls were registered by the triage nurses from April to December 2011. Calls requesting VMMC education and counseling totaled 12,492 (73.2%) and were most common. Triage nurses diagnosed 384 clients with 420 (2.5%) AEs. According to the predefined clinical algorithms, all moderate and severe AEs (153) diagnosed through telephone-triage were referred for clinical management at a health facility. Clinicians at the VMMC sites diagnosed 341 (4.1%) total clients as having a mild (46.0%), moderate (47.8%), or severe (6.2%) AE. Eighty-nine (26%) of the 341 clients who were diagnosed with AEs by clinicians at a VMMC site had initially called the VMMC hotline. The telephone-based triage system had a sensitivity of 69%, a positive predictive value of 83%, and a negative predictive value of 48% for screening moderate or severe AEs of all the AEs. CONCLUSIONS: The use of a telephone-based triage system may be an appropriate first step to identify life-threatening and urgent complications following VMMC surgery.

"Othering" the health worker: self-stigmatization of HIV/AIDS care among health workers in Swaziland.

BACKGROUND: HIV is an important factor affecting healthcare workforce capacity in high-prevalence countries, such as Swaziland. It contributes to loss of valuable healthcare providers directly through death and absenteeism and indirectly by affecting family members, increasing work volume and decreasing performance. This study explored perceived barriers to accessing HIV/AIDS care and prevention services among health workers in Swaziland. We asked health workers about their views on how HIV affects Swaziland's health workforce and what barriers and strategies health workers have for addressing HIV and using healthcare treatment facilities. METHODS: Thirty-four semi-structured, in-depth interviews, including a limited set of quantitative questions, were conducted among health workers at health facilities representing the mixture of facility type, level and location found in the Swaziland health system. Data were collected by a team of Swazi nurses who had received training in research methods. Study sites were selected using a purposive sampling method while health workers were sampled conveniently with attention to representing a mixture of different cadres. Data were analyzed using Nvivo qualitative analysis software and Excel. RESULTS: Health workers reported that HIV had a range of negative impacts on their colleagues and identified HIV testing and care as one of the most important services to offer health workers. They overwhelmingly wanted to know their own HIV status. However, they also indicated that in general, health workers were reluctant to access testing or care as they feared stigmatization by patients and colleagues and breaches of confidentiality. They described a self-stigmatization related to a professional need to maintain a HIV-free status, contrasting with the HIV-vulnerable general population. Breaching of this boundary included feelings of professional embarrassment and fear of colleagues' and patients' judgements. CONCLUSIONS: While care is available and relatively accessible, Swaziland health workers still face unique usage barriers that relate to a self-stigmatizing process of boundary maintenance--described here as a form of "othering" from the HIV-vulnerable general population--and a lack of trust in privacy and confidentiality. Interventions that target health workers should address these issues.