Helen Perrie

Antibiotic prescription practices and their relationship to outcome in South Africa: Findings of the prevalence of infection in South African intensive care units (PISA) study

BACKGROUND The emergence of multidrug-resistant, extensively resistant and pan-resistant pathogens and the widespread inappropriate use of antibiotics is a global catastrophe receiving increasing attention by health care authorities. The antibiotic prescription practices in public and private intensive care units (ICUs) in South Africa are unknown. OBJECTIVE To document antibiotic prescription practices in public and private ICUs in South Africa and to determine their relationship to patient outcomes. METHODS A national database of public and private ICUs in South Africa was prospectively studied using a proportional probability sampling technique. RESULTS Two hundred and forty-eight patients were recruited. Therapeutic antibiotics were initiated in 182 (73.5%), and 54.9% received an inappropriate antibiotic initially. De-escalation was practised in 33.3% and 19.7% of the public and private sector patients, respectively. Antibiotic duration was inappropriate in most cases. An appropriate choice of antibiotic was associated with an 11% mortality, while an inappropriate choice was associated with a 27% mortality (p=0.01). The mortality associated with appropriate or inappropriate duration of antibiotics was 17.6% and 20.6%, respectively (p=0.42). CONCLUSION Inappropriate antibiotic prescription practices in ICUs in the public and private sectors in South Africa are common and are also associated with poor patient outcomes.

A survey of oral care practices in South African intensive care units

Objectives. The aim of this study was to describe current oral care interventions for ventilated patients in South African ICUs. The objectives of the study were to determine the knowledge, attitudes and beliefs, and training of ICU nurses who render oral care; the type and frequency of oral care delivered to ventilated patients; hospital support and supplies available; and the availability of oral care protocols in the ICU.

Microbial contamination and labelling of self-prepared, multi-dose phenylephrine solutions used at a teaching hospital

Background: Common practice at Chris Hani Baragwanath Academic Hospital (CHBAH) is to use boluses from a self-prepared, multi-dose phenylephrine solution to treat spinal anaesthesia-induced hypotension in patients undergoing a Caesarean section. The aims of this study were to determine if there was microbial contamination of the solutions and to evaluate whether healthcare workers adhered to appropriate labelling and aspiration practices. Methods: A sample was collected and the labelling data were documented from the solutions found in the two obstetric theatres at CHBAH over a three-month period. The samples were sent to a laboratory for microbial investigation. Results: Microbial contamination was identified in 6.4% of samples collected. The name of the solution was indicated on 100% of the containers and the concentration of the solution was on 96.4%. The date the solution was prepared was indicated on 74.6% of containers and the time the solution was prepared was on 57.3%. Only 8.2% of healthcare workers who prepared the solution confirmed it by placing a signature on the container. Labelling data were written directly on 100% of the containers and a spike-device was used in 64.5% of the containers. Conclusions: This study demonstrated microbial contamination of the solution and may indicate an infection hazard. Healthcare workers also did not adhere to appropriate labelling and aspiration practices. This is important for all patients from a patient safety perspective and the need to improve quality of care.

Burnout among anaesthetists in South Africa

Background: Studies have been done to determine the level of burnout in anaesthesiology internationally, but not in South Africa. Method: The Maslach Burnout Inventory-Human Services Survey was used to assess the level of burnout. The primary objectives were to estimate the level of burnout among doctors working in the Department of Anaesthesiology at the University of the Witwatersrand (Wits doctors) and to estimate the level of burnout among private anaesthetist attending an anaesthetic symposium (Private doctors). Results: High levels of burnout were identified in 21.0% of Wits doctors. Higher burnout scores were noted in female doctors (p = 0.49), less years of anaesthetic experience (p = 0.37), doctors of younger age (p = 0.07), registrars (p = 0.22) and writing examinations within three months of completing the survey (p = 0.15), but none where statistically significant. High levels of burnout were identified in 8.1% of Private doctors Conclusion: High levels of burnout were identified, especially, among anaesthetists working in the academic hospitals affiliated to Wits.

Endotracheal tube cuff pressures in adult patients undergoing general anaesthesia in two Johannesburg academic hospitals

Background: Endotracheal tube (ETT) cuff pressure commonly exceeds the recommended range of 20–30 cm H₂O during anaesthesia. A set volume of air will not deliver the same cuff pressure in each patient and the pressure exerted by the ETT cuff can lead to complications, with either over- or under-inflated cuffs. These can include a sore throat and cough, aspiration, volume loss during positive pressure ventilation, nerve palsies, tracheomalacia and tracheal stenosis. No objective means of ETT cuff pressure monitoring is available in the operating theatres of Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Chris Hani Baragwanath Academic Hospital (CHBAH). The ETT cuff pressure of patients undergoing general anaesthesia is therefore unknown. Method: ETT cuff pressure of 96 adult patients undergoing general anaesthesia without nitrous oxide at CMJAH and CHBAH was measured by one researcher. A RUSCH Endotest™ manometer was used to measure ETT cuff pressure in size 7.0 – 8.5 mm ETTs. The cuff inflation technique that was used by the anaesthetist was also documented. Results: The mean ETT cuff pressure recorded was 47.5 cm H₂O (range 10–120 cm H₂O). ETT cuff pressures exceeded 30 cm H₂O in 64.58% of patients. Only 18.75% of patients had ETT cuff pressures within the recommended range of 20–30 cm H₂O. There was no statistically significant difference between the ETT cuff pressures measured at the two hospitals. Minimal occlusive volume was the most frequent technique used to inflate the ETT cuff (37.5%); this was followed by inflating the ETT cuff with a predetermined volume of air in 31.25% of cases and palpation of the pilot balloon (27.08%). There was no statistically significant difference between the ETT cuff pressure measured and the inflation technique used by the anaesthetist. Conclusion: ETT cuff pressures of the majority of patients undergoing general anaesthesia at two academic hospitals were higher than the recommended range. ETT cuff pressure should routinely be measured using a manometer.

Paediatric dental chair sedation: An audit of current practice in Gauteng, South Africa

BACKGROUND Procedural sedation and analgesia (PSA) is often required to perform dental procedures in children. Serious adverse outcomes, while rare, are usually preventable. OBJECTIVES To determine the proportion of dental practitioners making use of paediatric dental chair PSA in Gauteng Province, South Africa, describe their PSA practice, and determine compliance with recommended safety standards. METHOD A prospective, contextual, descriptive study design was used, with 222 randomly selected dental practitioners contacted to determine whether they offered paediatric dental chair PSA. Practitioners offering PSA were then asked to complete a web-based questionnaire assessing their practice. RESULTS Of the 213 dental practitioners contacted, 94 (44.1%; 95% confidence interval 37 - 51) provided PSA to children. Most patients were 1 - 5 years old, although there were practices that offered PSA to infants. While most procedures were performed under minimal to moderate sedation, deep sedation and general anaesthesia were also administered in dental rooms. Midazolam was the most frequently used sedative agent, often in conjunction with inhaled nitrous oxide; 28.1% of PSA providers administered a combination of three or more agents. Presedation patient assessment was documented in 83.0% of cases, and informed consent for sedation was obtained in 75.6%. The survey raised several areas of concern regarding patient safety: 41.3% of dental practices did not use any monitoring equipment during sedation; the operator was responsible for the sedation and monitoring of the patient in 41.3%; 43.2% did not keep any recommended emergency drugs; and 19.6% did not have any emergency or resuscitation equipment available. Most respondents (81.8%) indicated an interest in sedation training. CONCLUSION Paediatric dental chair PSA was offered by 44.1% of dental practitioners interviewed in Gauteng. Modalities of PSA provided varied between practices, with a number of safety concerns being raised.

Anaesthetists’ knowledge of surgical antibiotic prophylaxis: a prospective descriptive study

Background: Surgical site infection (SSI) is the second most common hospital-acquired infection and results in increased morbidity and mortality and a longer hospital stay. Surgical antibiotic prophylaxis (SAP) is one component of broader strategies to reduce rates of SSI. Adherence to SAP guidelines is largely sub-optimal globally, with knowledge of appropriate SAP being an important factor that affects this. The study’s objective was to describe awareness amongst anaesthetists at university-affiliated hospitals of available SAP guidelines and to describe their knowledge on the subject. Comparisons between senior and junior anaesthetists were to be made. Methodology: A prospective descriptive study design using a self-administered questionnaire was employed. The study population was the anaesthetists in a university-affiliated Department of Anaesthesiology in Johannesburg, South Africa. Results: The analysis included 135 completed questionnaires from the department’s anaesthetists. A total of 15.6% of participants followed a specific guideline in their practice, 28% for senior anaesthetists vs. 4.2% for junior anaesthetists. The overall mean score for knowledge was 56.2%, 59.3% for senior anaesthetists vs. 53.6% for junior anaesthetists, which was statistically significant (p-value < 0.001). Overall knowledge was found to be poor and, specifically, knowledge regarding indication for prophylaxis, antibiotic re-dosing interval and duration of prophylaxis was poor. Conclusion: The anaesthetists had poor knowledge regarding SAP. While the difference in knowledge between senior and junior anaesthetists was statistically significant, is it likely that this difference would not be substantial enough to have a clinical impact. The authors recommend interventions to improve the knowledge of the anaesthetists regarding SAP as well as the development of local SAP guidelines.

The prevalence of chronic postmastectomy pain syndrome in female breast cancer survivors

Background: Breast cancer is one of the most common cancer diagnoses in women. Surgical treatment is indicated in most patients. Postmastectomy pain syndrome (PMPS) is a debilitating neuropathic pain syndrome that develops after breast surgery. A review of the literature revealed no studies determining the prevalence of PMPS conducted in South Africa. The current anecdotal perception is that the prevalence of PMPS in the African population is low. Objectives: The objectives of this study were to determine the prevalence of PMPS in adult female breast cancer patients following general anaesthesia without regional anaesthesia at the Chris Hani Baragwanath Academic Hospital (CHBAH), as well as the impact of various clinical and demographic variables on the prevalence of PMPS. Methods: The research design was a cross-sectional descriptive study. The validated DN4 pain questionnaire was used in this study. Results: The study included 92 patients. The prevalence of PMPS was found to be 38.04% (n = 35). The average duration that patients experienced neuropathic pain symptoms was 12.22 months (range 3–39 months). The average age of patients interviewed was 58.54 years (range 30–90 years). There was no statistically significant difference between age group and PMPS (p = 0.47). The study also showed that no statistically significant association existed between pain experienced and adjuvant therapy administered. Conclusion: Even though surgical procedures are becoming less invasive, the prevalence of PMPS after treatment for breast cancer remains a clinically significant problem, comparable to international literature. This necessitates the development of more effective prevention and treatment strategies to improve patients’ quality of life.

Burnout among anaesthetists in South Africa : research

Background: Studies have been done to determine the level of burnout in anaesthesiology internationally, but not in South Africa. Method: The Maslach Burnout Inventory-Human Services Survey was used to assess the level of burnout. The primary objectives were to estimate the level of burnout among doctors working in the Department of Anaesthesiology at the University ofthe Witwatersrand (Wits doctors) and to estimate the level of burnout among private anaesthetist attending an anaestheticsymposium (Private doctors). Results: High levels of burnout were identified in 21.0% of Wits doctors. Higher burnout scores were noted in female doctors(p = 0.49), less years of anaesthetic experience (p = 0.37), doctors of younger age (p = 0.07), registrars (p = 0.22) and writingexaminations within three months of completing the survey (p = 0.15), but none where statistically significant. High levels of burnout were identified in 8.1% of Private doctors Conclusion: High levels of burnout were identified, especially, among anaesthetists working in the academic hospitals affiliated to Wits.

A pilot study to determine the profile of recovery room nurses in Johannesburg hospitals

Abstract Background: Apart from anecdotal evidence, very little is known of the recovery room nurses in South Africa. Method: An exploratory, prospective, descriptive pilot study was carried out in the recovery rooms of six Johannesburg hospitals, three academic and three private hospitals, one from each of the major private hospital groups. An appointment was scheduled and data were collected from either the theatre nursing manager, sister in charge of the recovery room or the nursing manager. The data collected reflected a brief profile of the selected recovery rooms and the demographic and education profile of nurses working there in August 2011. Results: Nurse: patient ratios were difficult to determine. Agency staff was used by one recovery room. The other recovery rooms used their permanent staff to work overtime. All the hospitals used anaesthetic nurses to double up when necessary. Only one of the recovery rooms had a supernumerary anaesthetist available during the day. A total of 49 nurses were working in the six recovery rooms during August 2011. The majority, 95.9% (n = 47), of the recovery room nurses were females and 4.1% (n = 2) were males. The average age of the recovery nurses was 44 years (25–63 years), with a median of 41 years. The experience of the recovery room nurses ranged from one month to 35 years with an average of 8.6 years. The majority of nurses, 57.1% (n = 28), were professional nurses, and 42.9% (n = 21) were enrolled nurses. Of the 28 professional nurses, 32.0% (n = 9) had no postgraduate training. The remaining 19 nurses had the following postgraduate qualifications: management and operating room technique 17.9% (n = 5), critical care 14.3% (n = 4), and education 10.7% (n = 3). The six-month anaesthetic nurse qualification, that is not an official South African Nursing Council-endorsed postgraduate qualification, was held by 35.7% (n = 10) of the professional nurses and 4.8% (n = 1) of the enrolled nurses. All the recovery rooms had an in-service education programme. Conclusion: There is a need to determine the profile of recovery room nurses in South Africa and to establish an appropriately trained and competent recovery room nursing workforce.