Improving the emergency services using quality improvement project and Donabedian model in a quaternary teaching hospital in South India.

INTRODUCTION: The primary goal of quality improvement is to enhance patient outcomes, particularly in the emergency department (ED). Timely and effective care is crucial in these situations. By comprehending the challenges, evaluating current performance and implementing quality improvement projects, areas in need of enhancement can be pinpointed and addressed, resulting in better outcomes. METHODOLOGY: This interventional study explores the implementation of quality improvement in the ED of a quaternary care teaching hospital in South India. It follows the Plan-Do-Check-Act (PDCA) cycle guided by the Donabedian model. Descriptive statistics were employed to measure changes in outcomes before and after implementation. To improve processes, Donabedian principles were applied, and a performance audit was conducted based on patient feedback and stakeholder input. Various ED indicators were measured. To address identified issues, formal root cause analysis was performed, leading to the generation of PDCA rapid change cycles. These cycles were implemented over 6 months, with two cycles executed, followed by postimplementation evaluation. RESULTS: Post implementation, improvements were observed in several aspects of ED operations. These included reduced ED average length of stay, decreased time to analgesia, shorter cross-consultation time, faster transfer time from ED and improved investigation turnaround time (TAT). Additionally, there was a reduction in revisits to ED within 72 hours and a decrease in patients who left without being seen. These positive changes demonstrate the effectiveness of the quality improvement intervention using the PDCA cycle. CONCLUSION: A comprehensive understanding of patient profile in the ED and factors influencing care is essential for the hospital to ensure sufficient resources and skilled emergency medicine physicians are available 24/7. By enhancing services in the ED, reducing patient waiting times and improving TAT, the overall efficiency of services can be improved. This leads to provision of timely quality care to patients and ultimately improves their outcomes.

Precision nephrotoxicity testing using 3D in vitro models.

Nephrotoxicity is a significant concern during the development of new drugs or when assessing the safety of chemicals in consumer products. Traditional methods for testing nephrotoxicity involve animal models or 2D in vitro cell cultures, the latter of which lack the complexity and functionality of the human kidney. 3D in vitro models are created by culturing human primary kidney cells derived from urine in a 3D microenvironment that mimics the fluid shear stresses of the kidney. Thus, 3D in vitro models provide more accurate and reliable predictions of human nephrotoxicity compared to existing 2D models. In this review, we focus on precision nephrotoxicity testing using 3D in vitro models with human autologous urine-derived kidney cells as a promising approach for evaluating drug safety.

Assessing Barriers to Human Papillomavirus (HPV) Vaccination in At-Risk Rural Communities of Western North Carolina, United States.

Human papillomavirus (HPV) vaccination among adolescents in rural, western North Carolina (NC) remains suboptimal. Data are needed to understand the barriers to HPV vaccination in these communities. We conducted a cross-sectional pilot study of parental attitudes and provider practices regarding HPV vaccination in rural western NC counties with lower HPV vaccination rates. Eight health department clinics were enrolled in the study. Further, 29 provider and 32 parent surveys were analyzed along with environmental scans. Median provider comfort regarding knowledge of HPV-associated diseases was 85% (IQR = 75-95), on a scale of 0-100% (100% representing complete comfort). Median parental comfort level regarding knowledge of HPV-associated diseases and the HPV vaccine was 75% (IQR = 50-89) and 75% (IQR = 49-96), respectively. Less than 25% of parents rated the HPV vaccine as 'extremely effective' against genital (16.7%) and anal cancers (17.9%). Parents were more likely to rate the vaccine as 'extremely effective' to 'very effective' if their child was female. There was no significant difference between parental- and provider-reported comfort with knowledge about HPV-associated diseases (p = 0.0725) and the HPV vaccine (p = 0.167). This study identified multiple opportunities to increase HPV vaccine coverage among unvaccinated adolescents at parental, provider, and clinic levels. Health education of rural NC residents and providers in public health settings may identify future interventions to increase HPV vaccine uptake.

Preventing Risks of Infections and Medication Errors in IV therapy (PRIME): a patient safety initiative.

BACKGROUND: Two major avoidable reasons for adverse events in hospital are medication errors and intravenous therapy-induced infections or complications. Training for clinical staff and compliance to patient safety principles could address these. METHODS: Joint Commission International (JCI) consultants created a standardised, 6-month training programme for clinical staff in hospitals. Twenty-one tertiary care hospitals from across south-east Asia took part. JCI trained the clinical consultants, who trained hospital safety champions, who trained nursing staff. Compliance and knowledge were assessed, and monthly audits were conducted. RESULTS: There was an overall increase of 29% in compliance with parameters around medication preparation and vascular access device management. CONCLUSION: The programme improved safe practice around preparing medications management and managing vascular access devices. The approach could be employed as a continuous quality improvement initiative for the prevention of medication errors and infusion-associated complications.

Effect of Educational Intervention on Knowledge and Level of Adherence among Hemodialysis Patients: A Randomized Controlled Trial.

Purpose: The purpose of the study was to assess the impact of an educational intervention on the level of knowledge and adherence to the treatment regimen among hemodialysis (HD) patients as well as to describe the association between these variables. Methods: In this randomized controlled trial, 160 HD patients at an HD centre of a 2030-bed tertiary teaching hospital in Southern India were randomly assigned into intervention (N = 80, received education and a booklet) and control (N = 80, received standard care) groups. Knowledge and adherence were measured preintervention and postintervention using a validated questionnaire for knowledge and the ESRD-AQ (End-Stage Renal Disease Questionnaire) for the level of adherence. The statistical analysis of the data was performed with the help of the Statistical Program SPSS version 19.0. The statistical significance level was set at 0.05. Results: The increase in knowledge on disease management, fluid adherence, and dietary adherence in the intervention group was significantly higher compared to the control group. There was no significant correlation between knowledge and adherence. Adherence improved for all the domains, i.e., dialysis attendance, episodes of shortening, adherence to medication, fluid restriction, and dietary restriction. Adherence to fluid and dietary restriction was statistically significant. This trail is registered with https://clinicaltrials.gov/ct2/show/CTRI/2018/05/014166.

Clinical Correlates of Cerebellar Injury in Preterm Infants with Surgical Necrotizing Enterocolitis.

Objective: Determine the risk factors of cerebellar injury in infants with surgical necrotizing enterocolitis (NEC). Methods: Retrospective study compared clinical/pathological information between surgical NEC infants with and those without cerebellar injury. Results: Infants with cerebellar injury (21/65, 32.3%) had significantly more hemorrhagic and the reparative lesions on the intestinal histopathology, had patent ductus arteriosus (PDA) more often, received red cell transfusion frequently, had blood culture positive sepsis and grew gram positive organisms more often and had cholestasis frequently following NEC than those without cerebellar injury. On multilogistic regression, the positive blood culture sepsis (OR 3.9, CI 1.1-13.7, p = 0.03), PDA (OR 4.5, CI 1.0-19.9, p = 0.04) and severe hemorrhage (grade 3-4)(OR 16.9, CI 2.1-135.5, p = 0.007) were independently associated with higher risk of cerebellar injury. Conclusion: The cerebellar injury was most likely associated with positive blood culture sepsis following NEC, PDA, and severe hemorrhage lesions (grade 3-4) in infants with surgical NEC.

Global monkeypox case hospitalisation rates: A rapid systematic review and meta-analysis.

Background: Estimates of the case hospitalization rate and case fatality rate when hospital care is available for monkeypox (MPX) infections have not been well defined. This rapid systematic review and meta-analysis aimed to estimate the case hospitalisation rate and case fatality rate where hospital care is available. Methods: We systematically searched PubMed, Embase, the Lancet Preprints, and MedRxiv for studies published between Jan 1, 1950 and Aug 2, 2022. We included documents which contained both the number of cases and associated hospitalisations of MPX infections. From eligible studies we extracted the country, the year of the study, the study design type, the clade of MPX, the participant characteristics, transmission type, any treatments used, number of cases (including suspected, probable, or laboratory confirmed diagnosis), number of hospitalizations, hospitalized patient outcomes, and case definition. Case hospitalization rate (CHR) was defined as the proportion of cases that were admitted to hospital care while case fatality rate (CFR) was defined as the proportion of cases that died. CHR and CFR were analysed in a fully Bayesian meta-analytic framework using random effects models, including sub-group analysis with heterogeneity assessed using I2. Findings: Of the 259 unique documents identified, 19 studies were eligible for inclusion. Included studies represented 7553 reported cases among which there were 555 hospitalizations. Of the 7540 cases for which outcomes were available, there were 15 recorded deaths. The median age of cases was 35 years (interquartile range 28-38, n = 2010) and primarily male (7339/7489, 98%) in studies where age or sex were available. Combined CHR was estimated to be 14.1% (95% credible interval, 7.5-25.0, I2 97.4%), with a high degree of heterogeneity. Further analysis by outbreak period indicates CHRs of 49.8% (28.2-74.0, I2 81.4%), 21.7% (7.2-52.1, I2 57.7%), and 5.8% (3.2-9.4, I2 92.4%) during the pre-2017, 2017-2021, and 2022 outbreaks, respectively, again with high levels of heterogeneity. CFR was estimated to be 0.03% (0.0-0.44, I2 99.9%), with evidence of large heterogeneity between the studies. Interpretation: There is limited data for MPX hospitalization rates in countries where MPX has been traditionally non-endemic until the current outbreak. Due to substantial heterogeneity, caution is needed when interpreting these findings. Health care organizations should be cognizant of the potential increase in healthcare utilization. Rapid identification of infection and use of appropriate therapies such as antivirals play a role reducing the CHR and associated CFR. Funding: None.

COVID-19 Palliative and End-of-Life Care Plan: Development and Audit of Outcomes.

Objectives: Palliative care (PC) referral in serious and critical COVID-19 improves decision-making, health resource utilisation, end-of-life symptom management and family support. In this study, we explored developing a systematic decision-making matrix for PC referral in COVID-19 and audited its outcomes. Materials and Methods: A team of interdisciplinary experts developed a hospital COVID-19 PC plan. PC referral and outcomes of PC referral in hospitalised COVID-19 patients were audited. Results: Out of 1575 inpatients, 1066 (67.7%) had mild and 509 (32.3%) had serious and critical COVID-19 illness. Among 50 (3.1%) referred to PC, 5 (0.4%) had mild and 45 (8.8%) had serious and critical COVID-19 illness. Out of 45 serious and critical COVID-19 patients referred to PC, 38 (84%) received end-of-life care (EOLC), 4 (9%) self-discharged against medical advice and 3 (7%) recovered. Forty-seven (94%) were referred for goals-of-care discussion. About 78% received opioids, 70% benzodiazepines and 42% haloperidol for symptom management. Among 45 serious and critical COVID-19 patients referred to PC, foregoing life-sustaining treatment was documented in 43 (96%) but implemented only in 23 (53%). Out of 38 who received EOLC, ICU was the place of death in 31 (82%) and ward in 7 (18%). Conclusion: Despite interdisciplinary experts developing a hospital COVID-19 PC, low referral of serious and critical COVID-19 patients to PC was observed. PC referral enabled access to management of end-of-life symptoms and facilitated limitation of life-sustaining treatment in some COVID-19 patients with serious illness. Educating critical care physicians about the scope of PC in the COVID-19 setting might improve PC referral.

Knowledge, Attitudes, Risk Perception, Preparedness and Vaccine Intent of Health Care Providers towards the Nipah Virus in South India.

Nipah virus (NiV) disease (NVD) remains a re-emerging public health threat in India. We assessed the knowledge, attitudes, and risk perception of NVD and future vaccine intent among a convenience sample of health care providers (HCP). The primary outcome measures were the knowledge, attitudes, and risk perception scores. Of 261 participants surveyed, 203 (77.8%) had heard of NiV and associated symptoms. The majority (248, 95%) identified the fruit bat as a primary NiV reservoir and 205 (79.8%) were aware of human-to-human transmission via droplets. Only 101 (38.7%) participants were aware that drinking date palm sap is a risk factor for transmission. Most HCP either agreed (117 (44.8%)) or strongly agreed (131 (50.2%)) that NiV is a serious illness. Less than half (121 (46.4%)) were aware of any institutional protocol for NiV; 235 (90.7%) of HCP stated that they need more information about prevention and treatment options. Knowledge scores were significantly higher among physicians compared to nurses whereas nurses and academic providers were more likely to have higher attitudes scores. A majority of respondents (20,779.9%) were willing to be vaccinated and willing to recommend the NiV vaccine to their patients (21,682.8%). Future strategies include education of HCP to bridge the knowledge gaps and enhance preparedness through disease-specific training for NiV infection.

Knowledge, Attitudes and HPV Vaccine Intention Among Women in India.

In India, cervical cancer associated with human papillomavirus (HPV) infection is a leading cause of cancer-related mortality among women. However, uptake of the vaccine in India is low. We assessed knowledge and attitudes towards HPV, assess participants' willingness to accept the vaccination for themselves and their children, and determine factors associated with intention to receive the HPV vaccine among women in Mangalore, India. This cross-sectional study surveyed a convenient sample of 237 women aged 18-45 years using a semi-structured questionnaire. All respondents reported being aware of HPV infection. However, 22.36% (n = 53) of the respondents have never heard about genital warts and 18.57% (n = 44) have never heard about HPV vaccine. Participants displayed good general knowledge of HPV infection (median score, 1.26; Interquartile Range (IQR): 1.04-1.52) and average knowledge of HPV vaccine (e.g., median score, 1.18; IQR: 0.73-1.45). HPV general knowledge and vaccine knowledge were associated with intention to receive the HPV vaccine and recommend it to children. Participant awareness of the HPV vaccine predicted vaccine intent for themselves. Participants' willingness to recommend the vaccine for their children was associated with older age, married status, having one or more children, and having a college education. Lack of awareness about genital warts was strongly associated with participants' refusal to get the HPV vaccine or recommend it for their own children (Relative Risk Ratio RRR: 12.21; 95% C.I.: 2.33-63.99). Our study validated the questionnaire as a reliable tool for assessing HPV and HPV vaccine knowledge, attitudes, awareness, and vaccine intentions in women aged 18-45 years. Public health education should focus on increasing awareness of genital warts as a sequela of HPV, as well as promote awareness of role and safety of HPV vaccination in -children.

Critical COVID-19 Complicating Recovery From Surgical Repair of Congenital Heart Disease.

This case highlights the need for accurate and rapid testing for severe acute respiratory syndrome coronavirus 2 and also underscores the need for caregivers to remain vigilant for coronavirus disease 2019 in the postoperative setting despite negative preoperative testing.

An exploratory study of undergraduate healthcare student perspectives regarding human papillomavirus and vaccine intent in India.

OBJECTIVE: Safe and effective human papillomavirus vaccines are available against cervical cancer and other human papillomavirus-associated diseases. Vaccine uptake is low in India given lack of universal vaccination programme. This exploratory study describes the medical, dental and nursing undergraduate student perspectives about human papillomavirus and intentions to receive the vaccine. METHODS: Using a cross-sectional, explorative study design, we conducted two focus group discussions among a convenience sample of male (n = 11) and female (n = 9) student group aged ⩾18 years, respectively, at a medical college in South India. The focus group discussion sessions were recorded, transcribed and analysed using thematic content analysis. RESULTS: Over half of the students showed adequate knowledge of cervical cancer and human papillomavirus. Medical students had much in-depth knowledge of cervical cancer, vaccine cost and its side effects compared to dental and nursing students. Human papillomavirus vaccine knowledge was relatively less among males compared to females; most male participants were unaware of the availability of the human papillomavirus vaccine. Intention to receive the vaccine was higher among females than males. All the participants had positive attitude in creating awareness in the community and making the vaccine cost-effective. Cultural concerns and high vaccine cost were cited major barriers for vaccine uptake. Suggestion of physician recommendation in promotion of human papillomavirus vaccine uptake was an emerging theme. CONCLUSION: Educating male students and those enrolled in dental and nursing courses about human papillomavirus vaccine, addressing cultural concerns and advocating provider recommendation for promoting vaccine uptake are potential strategies to improve future human papillomavirus vaccine intent among students and recommendations to patients in their role as future healthcare provider.

Challenges to Human Papillomavirus Vaccine Acceptability among Women in South India: An Exploratory Study.

Cervical cancer is the second leading cause of cancer and one of the leading causes of cancer-related death in women in India. Human papillomavirus (HPV) vaccine uptake in India is low due to cost, low awareness of HPV, social stigma, and other factors. We assessed the awareness, attitudes, and beliefs regarding HPV and HPV vaccination and explored the barriers and challenges to HPV vaccine intent among women in Mangalore, India. An exploratory study was conducted using two focus group discussions (FGDs) and six in-depth one-on-one interviews. FGD-1 comprised nine women aged 18 to 26 years, and FGD-2 comprised seven women aged 27 to 45 years. The FGDs were recorded, transcribed, and analyzed using thematic content analysis. Themes identified were limited knowledge of HPV and vaccine, stigma associated with receiving HPV vaccine, vaccine safety concerns, and cost as a barrier to receiving vaccine. Participants expressed desire for physician and government recommendation of the HPV vaccine to validate vaccine intent. Contrasting themes between the two FGDs include support for vaccination at a younger age and lower perception of stigma and judgment in the 18- to 26-year-old group; however, participants in the 27- to 45-year-old group support vaccination at an older age and endorse greater fear of stigma and judgment associated with obtaining vaccination. Education regarding HPV-associated diseases and the HPV vaccine for the general public, physicians, and government officials in conjunction with lowering vaccine cost, improving vaccine access, and encouraging strong physician recommendations are key strategies to scale up HPV vaccine implementation in India.

Antibiotic resistance and random amplified polymorphic DNA typing of Klebsiella pneumoniae isolated from clinical and water samples.

The study aimed to screen for the presence of multidrug-resistant Klebsiella pneumoniae from diarrheal stool and environmental water samples and to check the epidemiological link between the two categories. Isolates obtained after culturing on different media were tested for antibiotic resistance and extended-spectrum beta-lactamase (ESBL) production. Polymerase chain reaction (PCR) analysis was done for important ß-lactamase encoding genes. Random amplified polymorphic DNA (RAPD) typing was done using two primers. Results showed a high prevalence of K. pneumoniae from fish market effluents compared with stool and well water. Stool isolates showed high resistance to ceftazidime (80.0%) and cefepime (80.0%), fish market effluent isolates to cefoperazone-sulbactam (92.1%), and erythromycin (78.9%), while well water isolates to erythromycin (72.7%) and cefuroxime (54.4%). The ESBL genes blaCTX , blaSHV , and blaTEM were detected in 22.85%, 14.28%, and 42.85% of K. pneumoniae isolates, respectively. The results of RAPD-PCR showed high genetic similarities between the isolates from different sources. PRACTITIONER POINTS: Detection of multi-drug resistant Klebsiella strains in hospital wastewater and drinking water sources has progressively increased since its emerging resistance to third-generation cephalosporins and carbapenems. Detection of beta-lactamase encoding genes by molecular techniques and typing by random amplified polymorphic DNA (RAPD) can be useful in identifying the genetic fingerprints for epidemiological study. Implementation of effective antimicrobial stewardship program and infection control policy thereby helps assess the risk factors associated with infections.

Cannabis induced thermal epiglottitis in a pediatric patient.

Acute epiglottitis is an airway emergency presenting with edema and inflammation of the epiglottis and aryepiglottic folds [1]. Infectious and other non-infectious etiologies may cause significant airway injury presenting with similar clinical symptoms and radiographic findings [1]. While many causes of thermal epiglottitis have been described in the pediatric and young adult population, we describe an unusual case of an adolescent patient with cannabis induced thermal epiglottitis. A 17-year-old previously healthy, vaccinated adolescent male presented to the pediatric emergency department with dysphagia, odynophagia, drooling, and muffled voice with fever, tachypnea, and leukocytosis. Lateral plain film imaging and computed tomography (CT) scan showed significant edema of the epiglottitis. Urinary drug screen in the emergency department was positive for benzodiazepine, opiates, and cannabinoids. Transnasal flexible laryngoscopy and direct laryngoscopy demonstrated significant erythema, edema, and copious secretions. Culture of the epiglottis culture showed normal oropharyngeal flora. The patient was diagnosed with thermal induced epiglottitis secondary to cannabinoid use based on positive substance use history, urinary drug screen, and negative bacterial cultures. Clinicians must consider thermal injury of the epiglottitis due to substance use, specifically marijuana in vaccinated adolescent patients presenting with positive substance use history, progressive dysphagia, odynophagia, and drooling with a muffled voice. It is essential to obtain a thorough history and physical examination and urinary drug screen in the pediatric emergency department since the clinical and radiographic findings are similar in epiglottitis due to infectious and non-infectious etiologies. Prompt management with intubation should occur to protect and maintain airway integrity.

A comparison of nutritional status between children with and without disabilities: A community-based study.

BACKGROUND: Children with disabilities are expected to have poor nutritional status in comparison to children without disabilities. However, limited data on nutritional status of children with and without disabilities in rural settings in India. OBJECTIVE: To assess and compare the nutritional status of children with and without disability. METHODS: A cross-sectional study among children aged 5-15 years was conducted in the rural practise area of a medical college in Karnataka. 290 children (145 with and 145 children without disability) of similar age and sex were studied. Age and sex-specific World Health Organization (WHO) BMI centiles, 24 h dietary calorie and protein intakes were assessed and compared. Median and interquartile ranges were calculated for quantitative variables. Mann-Whitney U test was used to assess the differences in quantitative variables among the two groups. RESULTS: As per WHO BMI centiles, 33.1% with and 37.20% without disabilities were undernourished. The median calorie consumed by children with disabilities was 1169.0 (946.5-1586.0) significantly lower compared to that of children without disability, that is, 1362.0 (1167.0-1641.0). The median protein consumed by children with disabilities was 28.0 (22.5-38.0) significantly lower compared to that of children without disability, that is, 32.0 (28.0-40.0). CONCLUSIONS: Children with disabilities had similar rates of undernutrition as that of their non-disabled peers and their lesser dietary intake in terms of calories and proteins.

Unremitting Pain and Fever in a 15-Year-Old Boy With Osteomyelitis.

A previously healthy 15-year-old boy from a rural county in the southeastern United States was evaluated in the emergency department with fever and worsening toe pain in the absence of trauma. He initially presented to his primary care physician 4 weeks before with upper respiratory symptoms and was treated with corticosteroids for presumed reactive airway disease. His respiratory symptoms resolved. One week after this presentation, he developed fever and right great toe pain and presented to an outside hospital. Inflammatory markers were elevated. MRI confirmed a diagnosis of osteomyelitis with associated periosteal abscess. He was treated with intravenous antibiotics and drainage of the abscess. Ten days after his discharge from the outside hospital, he developed fever and had increasing drainage of the toe and pain refractory to oral pain medications. He presented to our facility for further evaluation. Repeat MRI and inflammatory markers corroborated his worsening disease, and he was admitted to the hospital for intravenous antibiotics and underwent serial surgical debridement. He developed painful subcutaneous nodules on his lower extremities and was found to have lung abnormalities on chest radiograph. A multispecialty team collaborated in the management of this patient and unveiled a surprising diagnosis.

Healthcare Delivery through Telemedicine during the COVID-19 Pandemic: Case Study from a Tertiary Care Center in South India.

The Coronavirus disease 2019 (COVID-19) pandemic has necessitated medical centers across the world to deliver healthcare through telemedicine. We discuss the adoption, delivery of telemedicine services at a tertiary care center and patient satisfaction involving 456 patients in south India. Most respondents had sought telemedicine care at the department of Medicine (16.23%). The maximum satisfaction was reported by patients in OBG (100%). The responses were generally positive across all the age groups. The paper offers insights on best practices adopted at the center, lessons learnt, and provides recommendations for health care systems offering telemedicine during COVID-19 times.