A point prevalence survey of health associated infections and antimicrobial use in a public health institution in Trinidad

Objective: The point prevalence survey is a validated tool for measuring the quality of prescribing in the hospital setting. The objectives were to estimate the prevalence of hospital acquired infections, to assess the antimicrobial agent prescribed and determine if prescribers followed existing evidence-based antimicrobial policies subsequent to diagnosis of infection in patients. Design and Methodology: Day-of-survey records of patients in the intensive care unit and medical/surgical wards were examined at the institution, retrospectively. The extracted clinical data were recorded on the standardized data collection instruments (hospital, ward and patient forms) and analysed. Results: Of the 130 patients surveyed, 30 had an infection which occurred within 48 hours of admission. The most commonly reported infection type was urinary tract infections, evident in 9 (30.0%) patients, caused by Escherichia coli in 7 patients and Klebsiella pneumonia in 2 patients. Out of the 30 patients, 10 (33.3%) were awaiting laboratory reports at the time of the survey. Resistance was noted for Staphylococcus aureus and Escherichia coli, both of which were seen in 2 patients and Enterococcus spp. in 1 patient. The antimicrobial agent selected to treat these microorganisms should have been queried. Conclusions: Results of this survey imply that public health surveillance and prevention activities should be implemented to address appropriate treatment of hospital acquired infections. Recommendations to minimize the risk of resistance include: improving the availability of alcohol-based hand rub, the provision of single room and isolation capacity, antimicrobial guidelines for treatment of infection, judicious prescribing and proper surveillance of prescribed antimicrobials.

Evaluative research on pharmacist managed diabetes care: focus on self-monitoring of blood glucose

Diabetes, especially Type 2 Diabetes (90%) is an ongoing problem for many nations. The world-wide prevalence of diabetes estimated by World Health Organization was approximately 175 million in 2000 and is predicted to be at least 366 million by 2030 among adults ≥ 20 years of age. The WHO estimate for Trinidad and Tobago in 2000 was 60,000 and is projected to increase to 125,000 if current trends prevail. Recent data (unpublished) from the Ministry of Health indicate that the Chronic Disease Assistance Programme, since its inception in 2003 to 2009, has provided medicines for approximately 226,435 diabetic patients. The National Insurance Property Development Company procures and manages the distribution of medicines for Chronic Disease Assistance Programme on behalf of the Ministry of Health. The total cost of diabetes treatment amounted to 285 million USD, representing approximately 38% of the total patient population receiving treatment through the progamme in this period. Objective: The primary objective was to demonstrate that pharmacists can assist patients to achieve at least a 1% decrease in HbA1c. Methods: A randomized controlled Pharmacist Evaluative Research Study compared the efficacy of pharmacist managed care (the intervention), and routine standard management (control) of poorly controlled (abnormal glycosylated haemoglobin, blood pressure, blood glucose and lipid panel) adult diabetic patients. Participants in the intervention group met with the pharmacist at their respective primary care sites on a regular basis for an assessment of adherence to medications, barriers to adherence and education. Control group participants consisted of patients receiving routine care by their primary physician but, with no direct intervention by the pharmacist except for the filling of prescriptions. Results: Seventy-five (75) patients were initially recruited, of these forty-eight (48) [20 interventions and 28 control] met the inclusion criteria. It was only possible to analyse the result from twenty (20) patients: 14 (70%) intervention and 6 (21.4%) control because of incomplete collected data. A minimum decrease of at least 1% HbA1c was obtained by eight (57%) intervention participants compared to two (33%) in the control group; while HbA1c remained unchanged for two participants each in the intervention and control groups (14% and 33%, respectively). The patient cohort was too small, therefore better methods for recruitment needed to be explored. The failure of patients to document key measurements (SMGB, BP), as requested by the pharmacist, was responsible for the exclusion of these patients in the statistical analysis. All of these factors reinforced the importance of preventing patients from absconding in order to reduce the high attrition rate. Conclusion: The data supports the hypothesis that the use of pharmacists as adjunctive healthcare practitioners achieves better patient outcomes than the non-use of pharmacists.

Confidence in Prescription Writing among Junior Physicians in Trinidad and Tobago.

BACKGROUND: A fundamental skill in the practice of medicine is the ability to safely and rationally prescribe drugs. This research aims to estimate the percentage of newly registered medical officers who reported confidence in writing prescriptions. METHODS: A questionnaire was distributed to 200 medical officers employed at public health tertiary institutions throughout Trinidad and Tobago. These comprised medical interns (provisionally registered) and house officers (fully registered). Participants indicated their confidence or reluctance to prescribe with or without supervision. Estimates and comparisons between the two groups were obtained using Fisher's exact and Chi-squared tests. RESULTS: The response rate was 73.5%. More medical interns (68%; n = 41) than house officers (56%; n = 42) stated that they were 'Confident' or 'Very Confident' (p = 0.126) to prescribe. Approximately eighty-four per cent (83.6%; n = 51) of medical interns and 89.2% (n = 66) of house officers felt confident to prescribe antibiotics (p = 0.465). A greater percentage of medical interns (84.2%; n = 50) than house officers (66.7%; n = 49) agreed that undergraduate training equipped them to write prescriptions safely and rationally (c² = 6.17, df = 1; p = 0.012). CONCLUSIONS: While most recent medical graduates felt confident about their prescription writing, there is a need to objectively measure this ability.

Integrating an evidence-based intervention into clinical practice: 'transitional relationship model'.

The transitional relationship model (TRM) facilitates the discharge process by providing peer support and hospital staff involvement until a therapeutic relationship has been established with a community care provider. A quasi-experimental, action-oriented research design was employed in which psychiatric wards at six hospital sites implemented the model in three waves. Helpful strategies were identified by each wave of wards for consideration by subsequent wards. Using an ethnographic approach, qualitative data were examined to uncover experiences and perceptions of TRM implementation and to help identify key issues that were supporting or hampering implementation. Specific strategies that facilitate the implementation of TRM include: (1) the use of educational modules for on-ward hospital staff training and peer training; (2) presence of on-site champions; and (3) supportive documentation systems. Issues identified as barriers to implementation included: (1) feeling drowned, swamped and overwhelmed; (2) death by process; (3) team dynamics; and (4) changes in champions. Staged large-scale implementation of the TRM allowed for iterative improvements to the model leading to positive outcomes. This study highlights the need to address work environment issues, particularly interprofessional teams.

The impact of micafungin on the cellular integrity of mg63 osteoblastlike cells in vitro a preliminary study.

Fungal osteomyelitis is a rare and possibly life-threatening condition. Factors that increase the risk of bone infection include the use of indwelling catheters, immunosuppressive agents (cyclosporine) in organ transplantation, aggressive anticancer chemotherapy, total parenteral nutrition, and broad spectrum antibiotics; immunocompromised hosts (human immunodeficiency virus) and individuals who have suffered burns, have diabetes mellitus or have undergone abdominal surgery. Treatment involves the use of intravenously administered antifungal agents, such as micafungin (MFG), initially, followed by long term oral suppressive therapy. The purpose of this study was to assess the impact of MFG at low (0.128 microg/mL), medium (64 microg/mL) and high (125 microg/mL) concentrations on MG-63 osteoblast-like cells (MOCs) on cell growth and viability. Apoptosis, glutathione and malondialdehyde assays, hematoxylin and eosin stains, and the proliferation rate were used to characterize MOCs (1 x 104 cells/well) for growth and viability after exposure to low, medium and high concentrations of MFG at 24, 48 and 72 hours in tissue culture. Micafungin at 0.128 and 64 microg/mL had a stimulatory effect on bone cell proliferation as early as 24 hours and was maintained for the duration of the study. Micafungin at high concentration showed suppressive effects on cell number after 72 hours and markedly decreased glutathione levels at 24 hours. Cell membrane damage was less than that observed in controlled untreated cells. Cell morphology and apoptosis evaluation of cells treated with MFG at high concentration showed a greater potential towards cell damage. Micafungin, at low and medium concentrations, minimally affected the integrity of MOCs relative to the control at 24, 48 and 72 hours in tissue culture medium.

Diabetic admissions at the Queen Elizabeth Hospital, Barbados - does the timing of primary care contact make a difference? - abstract

The Queen Elizabeth Hospital (QEH) is the major secondary and tertiary health care facility in Barbados, and patients who reach this hospital either present directly to the Accident and Emergency Department (A+E), or are referred by physicians. Over a six-month period all diabetic admissions to the hospital were identified, each patient was interviewed and examined, and hospital progress and outcome recorded. Of the 539 patients identified, 201 (37 percent) came directly to the A+E, while 338 (63 percent) had been referred to hospital. Three hundred and sixty-two (69 percent) had seen a physician within three months of admission. The main reasons for admission were the diabetic septic foot (33 percent), followed by heart failure (13 percent) and acute myocardial infarct 12.5 percent. Because the diabetic septic foot is considered a largely preventable problem, the high admission rate suggests that preventive care, assessment and management at the primary care level are inadequate. Patients who visited their primary care physicians within three months of admission, but nevertheless ended up in hospital, had lower mortality rates but prolonged hospital stays (AU)

HIV seroprevalence in antenatal women in Barbados - abstract

Barbados has reported, up to the end of September 1991, a total of 231 cases of the acquired immune deficiency syndrome (AIDS), with 162 deaths from the disease. This is one of the highest incidences reported by countries to the World Health Organization. In order to bring the disease under control, one has to estimate the gravity of the problem in at-risk groups within the society. This calls for an organized programme of counselling and testing of individuals and groups who have been exposed, knowingly or unknowingly, to the human immunodeficiency virus - the causitive agent of AIDS. In pursuance of the above objective, the Ministry of Health in Barbados has launched a programme whereby pregnant women are being screened for the virus after they have been counselled, and informed consent obtained. This programme was commenced early in 1991 at the Winston Scott Polyclinic, which serves a catchment area with an estimated population of 58,000 which compares with the total population of 256,000. In addition, a questionnaire, covering the basic demographic and sexual behaviour patterns of the women was completed for each of the participants. During the first ten months of 1991 a total of 401 antenatal women were counselled and 400 tested for HIV. Six (6) were found to be HIV-positive, giving a prevalence rate of 1.5 per cent. One woman refused to be tested. The findings of the questionnaire showed that a large number of respondents were unmarried and had had multiple sexual contacts. Their partners were occasional users of condoms. The findings support the need for more health educaton in relation to the practise of safe sex in the population of women attending the polyclinic (AU)