Amit Chandra

Adopting an ethical approach to global health training: the evolution of the Botswana - University of Pennsylvania partnership.

Global health training opportunities for medical students and residents have proliferated in recent years. These short-term elective rotations allow trainees to learn about global health issues by participating in various aspects of education and health care in resource-limited settings. Recently published consensus-based ethical guidelines have suggested considerations for the design of international electives that address the activities of host and sending sites, visiting students and residents, and sponsors.The authors analyze the value of global health training opportunities for medical students, residents, faculty, host and sending institutions, and other stakeholders from the perspective of the Botswana-University of Pennsylvania Partnership, a program that has provided global health experiences for health care trainees for more than 10 years. Drawing from the Working Group on Ethics Guidelines for Global Health Training framework, they illustrate the ethical and logistical challenges faced by the programs organizers and the solutions that they implemented alongside their host site partners. They conclude with a summary of recommendations to guide implementation of ethically sound international health electives in resource-limited settings.

Reduced overtriage and undertriage with a new triage system in an urban accident and emergency department in Botswana: a cohort study

Background Improvements in triage have demonstrated improved clinical outcomes in resource-limited settings. In 2009, the Accident and Emergency (A&E) Department at the Princess Marina Hospital (PMH) in Botswana identified the need for a more objective triage system and adapted the South African Triage Scale to create the PMH A&E Triage Scale (PATS). Aim The primary purpose was to compare the undertriage and overtriage rates in the PATS and pre-PATS study periods. Methods Data were collected from 5 April 2010 to 1 May 2011 for the PATS and compared with a database of patients triaged from 1 October 2009 to 24 March 2010 for the pre-PATS. Data included patient disposition outcomes, demographics and triage level assignments. Results 14 706 (pre-PATS) and 25 243 (PATS) patient visits were reviewed. Overall, overtriage rates improved from 53% (pre-PATS) to 38% (PATS) (p<0.001); likewise, undertriage rates improved from 47% (pre-PATS) to 16% (PATS) (p<0.001). Statistically significant decreases in both rates were found when paediatric and adult cases were analysed separately. PATS was more predictive of inpatient admission, Intensive Care Unit (ICU) admission and death rates in the A&E than was the pre-PATS. The lowest acuity category of each system had a 0.6% (pre-PATS) and 0% (PATS) chance of death in the A&E or ICU admission (p<0.001). No change in death rate was seen between the pre-PATS and PATS, but ICU admission rates decreased from 0.35% to 0.06% (p<0.001). Conclusions PATS is a more predictive triage system than pre-PATS as evidenced by improved overtriage, undertriage and patient severity predictability across triage levels.

Tuberculosis among individuals with community-acquired pneumonia presenting to emergency in Gaborone, Botswana.

Delays in diagnosing Tuberculosis (TB) are associated with increased transmission. TB may present as a clinical syndrome that mimics community-acquired pneumonia (CAP). The aim of this paper was to determine frequency of TB among patients with CAP at a referral hospital in Gaborone, Botswana. We performed a retrospective study of adults presenting with CAP from April 2010-October 2011 to the Emergency Department (ED); we matched this cohort to the National Botswana Tuberculosis Registry (NBTR) to identify individuals subsequently diagnosed with TB. We assessed demographics, time to TB diagnosis, clinical outcomes and performed logistic regressions to identify factors associated with TB diagnosis. We identified 1305 individuals presenting with CAP; TB was subsequently diagnosed in 68 (5.2%). The median time to TB diagnosis was 9.5 days. Forty percent were AFB sputum smear positive and 87% were identified as being HIV-positive. Subsequent diagnosis of TB is common among individuals with CAP at our ED, suggesting that TB may be present at the time of CAP presentation. Given the lack of distinguishing clinical factors between pulmonary TB and CAP, adults presenting with CAP should be evaluated for active TB in Botswana.