Adaptation and validation of the Children's Surgical Assessment Tool for Rwandan district hospitals

BACKGROUND/AIMS

Paediatric surgical care is a critical component of child health and basic universal health coverage and therefore should be included in comprehensive evaluations of surgical capacity. This study adapted and validated the Children's Surgical Assessment Tool (CSAT), a tool developed for district and tertiary hospitals in Nigeria to evaluate hospital infrastructure, workforce, service delivery, financing, and training capacity for paediatric surgery, for use in district hospitals in Rwanda.

METHODS

We used a three-round modified Delphi process to adapt the CSAT to the Rwandan context. An expert panel of surgeons, anaesthesiologists, paediatricians, and health systems strengthening experts were invited to participate based on their experience with paediatric surgical or anaesthetic care at district hospitals or with health systems strengthening in the Rwandan context. We used the Content Validity Index to validate the final tool.

RESULTS

The adapted tool had a final score of 0.84 on the Content Validity Index, indicating a high level of agreement among the expert panel. The final tool comprised 171 items across five domains: facility characteristics, service delivery, workforce, financing, and training/research.

CONCLUSION

The adapted CSAT is appropriate for use in district hospitals in Rwanda to evaluate the capacity for paediatric surgery. This study provides a framework for adapting and validating a comprehensive paediatric surgical assessment tool to local contexts in LMICs and used in similar settings in sub-Saharan Africa.

Medical interns' training in family medicine at a district hospital and primary health care clinics in Middelburg, Mpumalanga

Training of medical interns at the Middelburg district hospital has been introduced as part of the mandatory 6 months' rotation in Family Medicine department since 2021. This report provides an overview of what has been attained in 2021 and 2022. It covers various aspects of the activities medical interns have been exposed to in the Middelburg hospital and the surrounding primary health care clinics.Contribution: Sharing experiences of family medicine training for medical interns in district hospitals is essential because the 6 months' rotation is new for most family physician trainers, especially those in small hospitals and primary health care clinics. Taking into account the paucity of evidence on the topic, the report brings current information that supports that training medical interns in district hospitals and primary health care clinics prepares them to be comfortable and competent clinicians for the generalist work during the community service year ahead.

Emergency care visits at a South African hospital: Implications for healthcare services and policy

BACKGROUND

 A robust knowledge on the pattern of use of emergency care resources not only serves as an indicator of universal access to care but also provides a basis for quality improvement within the health system. This study was undertaken to describe the pattern of emergency room visits at Brits District Hospital (BDH) in North West province, South Africa. The objectives of this study were to determine the sociodemographic characteristics of emergency department (ED) users and other patterns of ED use.

METHODS

 This was a cross-sectional descriptive study that was conducted at a district hospital. All patients who reported for emergency care in the ED in 2016 were eligible for the study. Data were extracted and analysed from a systematic sample of 355 clinical notes and hospital administrative records.

RESULTS

 The age group that visited the ED most frequently (25.3%) was 25-34 years old. A high proportion of the ED users (60%) were self-referred, and only 38% were transported by the emergency medical response services (EMRS). Few (5.6%) presentations were of a non-urgent nature. Trauma-related conditions accounted for the most frequent presentation at the ED (36.5%).

CONCLUSION

 Although most ED users were self-referred, their clinical presentations were appropriate and underscore the need for policy strategies to reduce the burden of trauma in the catchment populationContribution: The study findings may have an impact on future health policies by providing decision-makers with baseline information on the pattern of use of ED resources, ensuring better resource deployment and greater access to care.

Differences in trauma care between district and regional hospitals and impact of a trauma intake form with decision support prompts in Ghana: A stepped-wedge cluster randomized trial

BACKGROUND

We sought to determine the achievement of key performance indicators (KPIs) of initial trauma care at district (first-level) and regional (second-level) hospitals in Ghana and to assess the effectiveness of a standardized trauma intake form (TIF) to improve care.

METHODS

A stepped-wedge cluster randomized trial was performed with direct observations of trauma management before and after introducing the TIF at emergency units of eight hospitals for 17.5 months. Differences in KPIs were assessed using multivariable logistic regression and generalized linear mixed regression.

RESULTS

Management of 4077 patients was observed; 30% at regional and 70% at district hospitals. Eight of 20 KPIs were performed significantly more often at regional hospitals. TIF improved care at both levels. Fourteen KPIs improved significantly at district and eight KPIs improved significantly at regional hospitals. After TIF, regional hospitals still performed better with 18 KPIs being performed significantly more often than district hospitals. After TIF, all KPIs were performed in >90% of patients at regional hospitals. Examples of KPIs for which regional performed better than district hospitals after TIF included: assessment for oxygen saturation (83% vs. 98%) and evaluation for intra-abdominal bleeding (82% vs. 99%, all p < 0.001). Mortality decreased among seriously injured patients (injury severity score ≥9) at both district (15% before vs. 8% after, p = 0.04) and regional (23% vs. 7%, p = 0.004) hospitals.

CONCLUSIONS

TIF improved care and lowered mortality at both hospital levels, but KPIs remained lower at district hospitals. Further measures are needed to improve initial trauma care at this level.

CLINICAL TRIALS REGISTRATION

Clinicaltrials.gov (NCT04547192).

Increasing access to pediatric surgical care: Assessing district hospital readiness in rural Rwanda

Introduction/Background

Safe and quality surgery is crucial for child health. In Rwanda, district hospitals serve as primary entry points for pediatric patients needing surgical care. This paper reports on the organizational readiness and facility capacity to provide pediatric surgery in three district hospitals in rural Rwanda.

Methods

We administered the Children's Surgical Assessment Tool (CSAT), adapted for a Rwandan district hospital, to assess facility readiness across 5 domains (infrastructure, workforce, service delivery, financing, and training) at three Partners in Health supported district hospitals (Kirehe, Rwinkwavu, and Butaro District Hospitals). We used the Safe Surgery Organizational Readiness Tool (SSORT) to measure perceived individual and team readiness to implement surgical quality improvement interventions across 14 domains.

Results

None of the facilities had a dedicated pediatric surgeon, and the most common barriers to pediatric surgery were lack of surgeon (68%), lack of physician anesthesiologists (19%), and inadequate infrastructure (17%). There were gaps in operating and recovery room infrastructure, and information management for pediatric outpatients and referrals. In SSORT interviews (n=47), the highest barriers to increasing pediatric surgery capacity were facility capacity (mean score=2.6 out of 5), psychological safety (median score=3.0 out of 5), and resistance to change (mean score=1.5 out of 5 with 5=no resistance).

Conclusions

This study highlights challenges in providing safe and high-quality surgical care to pediatric patients in three rural district hospitals in Rwanda. It underscores the need for targeted interventions to address facility and organizational barriers prior to implementing interventions to expand pediatric surgical capacity.

Enrollment of dengue patients in a prospective cohort study in Umphang District, Thailand, during the COVID-19 pandemic: Implications for research and policy

Background and Aims

Dengue is endemic in Thailand and imposes a high burden on the health system and society. We conducted a prospective cohort study in Umphang District, Tak Province, Thailand, to investigate the share of dengue cases with long symptoms and their duration. Here we present the results of the enrollment process during the COVID-19 pandemic with implications and challenges for research and policy.

Methods

In a prospective cohort study conducted in Umphang District, Thailand, we examined the prevalence of persistent symptoms in dengue cases. Clinically diagnosed cases were offered free laboratory testing, We enrolled ambulatory dengue patients regardless of age who were confirmed through a highly sensitive laboratory strategy (positive NS1 and/or IgM), agreed to follow-up visits, and gave informed consent. We used multivariate logistic regressions to assess the probability of clinical dengue being laboratory confirmed. To determine the factors associated with study enrollment, we analyzed the relationship of patient characteristics and month of screening to the likelihood of participation. To identify underrepresented groups, we compared the enrolled cohort to external data sources.

Results

The 150 clinical cases ranged from 1 to 85 years old. Most clinical cases (78%) were confirmed by a positive laboratory test, but only 19% of those confirmed enrolled in the cohort study. Women, who were half as likely to enroll as men, were underrepresented in the cohort.

Conclusions

The Thai physicians' clinical diagnoses at this rural district hospital had good agreement with laboratory diagnoses. By identifying underrepresented groups and disparities, future studies can ensure the creation of statistically representative cohorts to maximize their scientific value. This involves recruiting and retaining underrepresented groups in health research, such as women in this study. Promising strategies for meaningful inclusion include multi-site enrollment, offering in-home or virtual services, and providing in-kind benefits like childcare for underrepresented groups.

Quality of care of patients with type 2 diabetes mellitus at a public sector district hospital

BACKGROUND

 Globally, diabetes mellitus (DM) remains one of the leading causes of mortality, with approximately 2 million deaths in 2019, the condition also contributes significantly to adverse health conditions and costs. The study aimed to describe the quality of care (QOC) rendered to patients with type 2 DM (T2DM) seeking care at Wentworth Hospital (WWH), a district hospital in KwaZulu-Natal province, South Africa.

METHODS

 A descriptive cross-sectional design was used, and all patients living with T2DM on treatment who had accessed care for at least 1 year were included. Data were collected through structured exit interviews, and their clinical data were extracted from their medical records. Their knowledge, attitudes and practices were assessed using a 5-point Likert scale.

RESULTS

 The mean age (standard deviation [s.d.]) was 59 (13.0) years and most (65.3%) were female, of African (30.0%) and Indian (38.6%) descent, with two-thirds (69.4%) obtaining a secondary school education. Their mean glycated haemoglobin (HbA1c) (s.d.) was 8.6 (2.4%). Over 82% had one or more comorbidity, while 30% had at least one DM-related complication. Generally, participants were pleased with the care received, but their knowledge and practices related to their T2DM was suboptimal.

CONCLUSION

 This study indicates that the QOC was suboptimal due to poor efficacy indicators, poor knowledge and lack of adequate lifestyle measures, despite the frequency of medical practitioner reviews.Contributions: This study identified gaps in QOC and will aid South African public sector policy-makers in devising quality improvement initiatives.

A single-centred retrospective observational analysis on mortality trends during the COVID-19 pandemic

BACKGROUND

South Africa experienced high mortality during the COVID-19 pandemic. Resources were limited, particularly at the district hospital (DH) level. Overwhelmed healthcare facilities and a lack of research at a primary care level made the management of patients with COVID-19 challenging. The objective of this study was to describe the in-hospital mortality trends among individuals with COVID-19 at a DH in South Africa.

METHODS

Retrospective observational analysis of all adults who demised in hospital from COVID-19 between 01 March 2020 and 31 August 2021 at a DH in South Africa. Variables analysed included: background history, clinical presentation, investigations and management.

RESULTS

Of the 328 participants who demised in hospital, 60.1% were female, 66.5% were older than 60 and 59.6% were of black African descent. Hypertension and diabetes mellitus were the most common comorbidities (61.3% and 47.6%, respectively). The most common symptoms were dyspnoea (83.8%) and cough (70.1%). 'Ground-glass' features on admission chest X-rays were visible in 90.0% of participants, and 82.8% had arterial oxygen saturations less than 95% on admission. Renal impairment was the most common complication present on admission (63.7%). The median duration of admission before death was four days (interquartile range [IQR]: 1.5-8). The overall crude fatality rate was 15.3%, with the highest crude fatality rate found in wave two (33.0%).

CONCLUSION

Older participants with uncontrolled comorbidities were most likely to demise from COVID-19. Wave two (characterised by the 'Beta' variant) had the highest mortality rate.Contribution: This study provides insight into the risk factors associated with death in a resource-constrained environment.

Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania

Introduction

Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ).

Methods

Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons.

Results

Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water.

Conclusions

With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.

What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts

OBJECTIVE

To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda.

METHODS

We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers.

RESULTS

Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care.

CONCLUSION

These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

Trends in pharmaceutical expenditure in the Taiwan National Health Insurance database at different hospital levels

Aim: This study aimed to understand the medication usage among different hospitals in Taiwan. Materials & methods: The NHI claims database consisting of claims prescription drugs in Taiwan was used to determine drug prescriptions in different hospitals. Results: In the medical center, L01X showed the highest drug expenditure and the drug prescription pattern in regional hospitals was similar to that in the medical center. The highest drug expenditure in the district hospital and clinics was A10B. Conclusion: Our analysis suggests that the annual pharmaceutical expenditures from 2016 to 2018 were increasing over time in all hospitals. The generic drug usage in medical centers/regional hospitals was lower than district hospitals/clinics.

Undiagnosed Term Abdominal Pregnancy in a District-Level Hospital of a Developing Country: A Miracle Baby

Term abdominal pregnancy is a sporadic ectopic pregnancy associated with high maternal and perinatal morbidity and mortality. As symptoms are non-specific and resemble those of other ectopic pregnancies, early diagnosis is the major challenge in poor health setups. A 24-year-old primigravida at 38 weeks gestation was planned to undergo a cesarean section for the transverse lie. Abdominal pregnancy was accidentally discovered during the cesarean section, and a healthy, normal baby boy was delivered. The placenta was attached to the greater omentum, so its removal required omentectomy without compromising the blood supply to the bowels. Both patient and her baby boy were discharged on the seventh day without complications. No congenital anomalies were detected in the baby. In a term abdominal pregnancy, the most significant challenges are the control of bleeding and the decision on placenta removal, followed by prompt delivery of the fetus. Therefore, along with the gynecologist, the availability of trained personnel, such as anesthetists, pediatricians, and general surgeons, is necessary for a successful management outcome.

Perceptions of private specialist outreach services at a rural district hospital, South Africa

BACKGROUND

A major disparity exists in access to specialised healthcare between rural and urban areas. Specialist outreach programmes are one of the ways in which rural specialist healthcare inequality is being addressed. A number of rural district hospitals (RDH) employ local, private specialists (LPS) to supplement public specialist outreach. Limited research exists on private specialist outreach and support (PSOS) in sub-Saharan Africa or South Africa.

METHODS

This was a descriptive, exploratory, qualitative study using thematic analysis of semi-structured interviews. Non-probability, purposive sampling was used to obtain a sample size of 16 participants. The audio recordings were transcribed verbatim and analysed with the framework method and ATLAS.ti version 8© software.

RESULTS

Four major themes emerged, namely roles of LPS, effects, sustainability and feasibility of PSOS. Overall PSOS was considered sustainable, feasible and had positive effects in and beyond the sub-districts. The value of PSOS was supported by improved access and timeliness of services, improved competency of RDH medical practitioners, improved coordination, comprehensiveness and continuity of care. Private specialist outreach and support was, however, associated with increased burden on the RDH resources and required a basic level of RDH infrastructure to function effectively.

CONCLUSION

The perceived contribution of private specialist outreach services was positive overall. Implementation in RDHs is feasible, but should involve consideration of factors in the hospital, town, sub-district and district prior to implementation.Contribution: This paper provides evidence that private specialist outreach and support services are feasible in the state health sector, provided that certain considerations are taken into account.

Achievement of Key Performance Indicators in Initial Assessment and Care of Injured Patients in Ghanaian Non-tertiary Hospitals: An Observational Study

INTRODUCTION

We aimed to determine the level of achievement of key performance indicators (KPIs) during initial assessment and management of injured persons, as assessed by independent observers, at district and regional hospitals in Ghana.

METHODS

Trained observers were stationed at emergency units of six district (first level) and two regional (referral) hospitals, from October 2020 to February 2021, to observe management of injured patients by health service providers. Achievement of KPIs was assessed for all injured patients and for seriously injured patients (admitted for ≥ 24 h, referred, or died).

RESULTS

Management of 1006 injured patients was observed. Road traffic crash was the most common mechanism (63%). Completion of initial triage ranged from 65% for oxygen saturation to 92% for mobility assessment. For primary survey, airway was assessed in 77% of patients, chest examination performed in 66%, and internal abdominal bleeding assessed in 43%. Reassessment rates were low, ranging from 16% for respiratory rate to 23% for level of consciousness. Thirty-one percent of patients were seriously injured. Completion of KPIs was higher for these patients, but reassessment remained low, ranging from 25% for respiratory rate to 33% for level of consciousness.

CONCLUSION

KPIs were performed at a high level, but several specific elements should be performed more frequently, such as oxygen saturation and assessment for internal abdominal bleeding. Reassessment needs to be performed more frequently, especially for seriously injured patients. Overall, care for the injured at non-tertiary hospitals in Ghana could be improved with a more systematic approach.

Medical Waste Management: An Assessment of District-Level Public Health Facilities in Bangladesh

Background Due to the huge patient load and different types of services, public health facilities produce a bulk of medical waste (MW) in Bangladesh. Improper disposal of MW increases the risk of infection among healthcare service personnel, patients, and attendants. To ensure quality services, this study aimed to assess the practices of MW management and quantify those to find out the shortcomings in the specific steps of waste management. Methodology As part of a larger interventional study, a facility assessment was conducted from February to April 2016 at a District Hospital (DH) and a Mother and Child Welfare Centre (MCWC) in one district. Non-participatory observation of MW management was done using a checklist that was developed following the Guideline for Medical Waste Management of Bangladesh. Scoring was applied for various activities of MW management performed in the study facilities. Results The overall scores for bin management, segregation, and collection of waste were 64.5%, 58.1%, and 62.0% in DH and 53.1%, 41.5%, and 48.0% in MCWC, respectively. The performance of operation theater in MCWC was the lowest among different corners (16.7% to 36.0%). Reusable waste was segregated poorly (32% in DH and 0% in MCWC), and almost none was shredded (4% in DH and 0% in MCWC). Waste was transported from in-house to out-house temporary storage area in an open bin without any trolley or specific route. The storage area was accessible to unauthorized persons, for example, a waste picker in DH. While DH segregated 84% of its infectious waste at the source, it eventually got mixed up with other waste in the storage area and delivered to the municipality to be dumped. MCWC could segregate only 40% of its infectious waste at the source and disposed of them using the pit method. Both the facilities disposed of sharp MW by open-air burning and liquid waste through sewerage without any treatment. Conclusions The performance of MW management was poor in both study facilities. Advocacy to the healthcare personnel and refresher training along with supportive supervision and monitoring may improve the situation. Moreover, a larger study is needed to find out the reasons behind such poor MW management.

Demographic profile of patients and risk factors associated with suicidal behaviour in a South African district hospital

Background

Suicidal behaviour comprises self-destructive thoughts coupled with attempts at suicide, which negatively impacts the patient, family, friends, and their community. There is a paucity of data on factors influencing suicidal thoughts and behaviour in South Africa. The aim of this study was to evaluate demographic profile and risk factors associated with suicidal behaviour.

Methods

In this retrospective descriptive and observational study, 282 medical records of patients with suicidal behaviour were studied. The risk factors and age at occurrence were tabulated. Descriptive analyses were undertaken to understand how they were distributed across key socio-demographic groups.

Results

Suicidal behaviour was particularly prominent amongst the female population. The suicidal ideation, plan and non-fatal suicide were reported by 48.6%, 29.1% and 36.5%, of patients respectively. The prevalence for suicidal ideation was significantly higher in females (54.5% vs. 31.5%; p < 0.0007) but not for suicidal plan (28.7% vs. 30.1%; p < 0.81) and suicidal attempt (37.3% vs. 34.2%; p = 0.63) as compared with males. Suicidal behaviour was positively associated with depression (r = 0.56, p < 0.001) and negatively associated with age (r = −0.16, p = 0.01). Multivariate logistic regression analysis revealed that suicidal behaviour was influenced by female gender, poor social support, depression and a family history of non-fatal suicide.

Conclusion

This research has confirmed an association between female sex and factors associated with a higher risk of suicidal behaviour.

The contribution of family physicians to surgical capacity at district hospitals in South Africa

The World Health Organization states that essential, cost-effective surgical care should be delivered at district hospitals. In South Africa significant skills gap exist at district hospitals, particularly in the area of surgery and anaesthesia. These small to moderate sized hospitals are too small to support a range of full time specialists even if they could be recruited and were cost-effective. Family physicians (FPs) are trained in the clinical skills required for district hospitals and primary health care. Clinical associates have also been introduced to perform procedures at district hospitals. This report illustrates the contribution of a FP to surgical care at Zithulele Hospital in the Eastern Cape. Family physicians not only bring the necessary clinical skills set but also increase the confidence and capacity of the whole team. Outreach and support by surgeons, as well as continuing professional development, are important. Surgical and anaesthetic skills must be developed together. Family physicians also bring leadership and clinical governance skills that ensure the inputs to support surgery, such as equipment and information systems are available. The contribution of FPs to surgery and district hospitals is overlooked in both policy and practice. Human resources for health policy should recognise their contribution and increase the numbers available and FP posts at district hospitals. There is also a need to update the package of emergency and essential surgical procedures in policy.

Strengthening the Somaliland health system by integrating public and private sector family medicine

Four family physicians, who received their specialty training at Amoud University in Somaliland, organised a practice together that uses informal public–private partnerships to optimise their clinical care and teaching. Their experience offers insights into public–private partnerships that could strengthen the country’s healthcare system.

Profile and obstetric outcome of teenage pregnancies compared with pregnant adults at a district hospital in KwaZulu-Natal

Background

Teenage pregnancy remains a major public health concern and a challenge for developing countries. Young maternal age can lead to serious physical, social and psychological consequences as teenage mothers are less likely to gain full educational potential and are at higher risk of poverty and complications of pregnancy. The objective of the study was to describe the profile and obstetric outcome of teenage pregnancy compared with that of pregnant adults at a district hospital in KwaZulu-Natal.

Methods

A retrospective descriptive study utilising data obtained from randomly selected hospital records of 216 teenage mothers compared the socio-demographic profile, foetal and maternal outcomes to that of pregnant adults.

Results

The mean age of the teenage group was 17.6 and 26.0 years for the adults (control group). Both groups had a remarkable booking status (97.2% vs. 100%) and antenatal attendance (62.5% vs. 66.2% with ≥ 5 visits). No significant difference in anaemia, caesarean delivery and obstetric complications were found in both groups. There was, however, a significant risk of hypertensive disorder of pregnancy (39.8% vs. 26.4%, p = 0.030) and higher risk of episiotomy being carried out during delivery (31.5% vs. 13.0%). On the other hand, the control group had a significant higher risk of HIV infection (12.5% vs. 38.4% p = 0.000).

Conclusion

The study showed that teenage pregnancy has a similar obstetric risk to adult pregnant patients except for hypertension disorder of pregnancy. Although this study demonstrated improved antenatal attendance by pregnant teenagers, the psychosocial impact on young mothers requires further research.

Preanaesthetic assessment and management in the context of the district hospital

Preanaesthetic assessment and management allow for the systematic identification of perioperative risks and the implementation of interventions to mitigate them, such that the patient's physiological state is optimised for surgery or other procedures. This is a crucial activity for good perioperative outcomes, as patients not assessed are at a higher risk of unanticipated adverse perioperative events and are more likely to receive suboptimal management. The district hospitals in South Africa perform minor and moderately complex surgical procedures that require anaesthesia, administered mostly to healthy patients and those with stable diseases without functional limitations. A significant proportion of anaesthesia-related deaths reported in the district hospitals can be linked to poor risk assessment and management. In this article, we highlight the key clinical imperatives for optimal preanaesthetic assessment and management from the district hospital perspective.

Quality of life among district hospital nurses with multisite musculoskeletal symptoms in Vietnam

Background

Nurses are one of the population groups with the highest prevalence of musculoskeletal disorders (MSDs). At many sites, musculoskeletal symptoms (MS) represent a major health‐care burden, adversely affecting nurses' quality of life and giving rise to mental health issues.

Objectives

This study measured the prevalence of multi‐body‐site (two or more anatomical sites) musculoskeletal symptoms (MMS), and the association between MMS, a number of demographic and work characteristics, psychological distress, and the quality of life among district hospital nurses.

Material and Methods

A cross‐sectional study was performed with 1179 nurses in Haiphong City using three questionnaires: the Modified Nordic; Quality of Life Enjoyment and Satisfaction Short Form (Q‐LES‐Q‐SF); and the Kessler Psychological Distress Questionnaire (K6).

Results

Women have a higher MMS prevalence than men (57.1% in women vs 37.6% in men, P < .001). Having a higher number of anatomical sites of MS appears to be associated with a worse quality of life among nurses. Linear regression analysis found a number of other factors negatively associated with the nurses' quality of life: gender (female), age (50‐60 years old vs 19‐29 years old), and psychological distress.

Conclusions

This study shows a high prevalence of MMS and the relationship between, on the one hand, MMS, gender, age, as well as psychological distress and, on the other hand, the quality of life among nurses in Vietnam. Further in‐depth studies are needed to investigate the causal relationships between these indicators.

Emergency centre reorganization in preparation to the COVID-19 pandemic: A district hospital's dynamic adaptation response

The COVID-19 global pandemic forced healthcare facilities to put special isolation measures in place to limit nosocomial transmission. Cohorting is such a measure and refers to placing infected patients (or under investigation) together in a designated area. This report describes the physical reorganisation of the emergency centre at Khayelitsha Hospital, a district level hospital in Cape Town, South Africa in preparation to the COVID-19 pandemic. The preparation included the identification of a person under investigation (PUI) room, converting short stay wards into COVID-19 isolation areas, and relocating the paediatric section to an area outside the emergency centre. Finally, we had to divide the emergency centre into a respiratory and non-respiratory side by utilising part of the hospital’s main reception. We are positive that the preparation and reorganization of the emergency centre will limit nosocomial transmission during the expected COVID-19 surge. Our experience in adapting to COVID-19 may have useful implications for ECs throughout South Africa and in low-and-middle income countries that are preparing for this pandemic.

Stroke epidemiology based on experience from Krasnik county in eastern Poland

INTRODUCTION

Cerebrovascular diseases in Poland constitute a bigger threat to life in men than in women, especially after the age of 60. Death rates indicate higher stroke over-mortality in the rural population rather than the urban. At the same time, stroke is the main cause of long-term disability, since half of the patients are unable to independently perform daily activities, which makes them dependent on other people.

MATERIAL AND METHODS

The study was conducted in the Independent Public Healthcare Institution in Kraśnik, eastern Poland. It covered the medical records of 1,500 patients, 780 women (52%) and 720 men (48%), aged 20-100, diagnosed with cerebral infarction. The patients were hospitalised between 2011-2016 in the Neurology Ward with a Stroke Unit, the Internal Medicine Ward, and the Anaesthetics and Intensive Care Ward.

RESULTS

The stroke patients hospitalised in the Independent Public Healthcare Institution in Kraśnik were residents of urban communes (59.1% of subjects) and rural communes (40.9%). The most often diagnosed type of stroke was due to embolism of the cerebral arteries (I63.4) in women (63.48%). In men, the most most often diagnosed type was cerebral infarction due to thrombosis of the cerebral arteries (I63.3; 51.33%). Stroke in 36.15% of the female subjects resulted in death. In male subjects, death occurred in 26.11% of the cases.

CONCLUSIONS

Women aged around 78-years-old were the most likely to suffer a stroke. In men, it occurred eight years earlier. Despite residents of urban areas being hospitalised due to stroke more often, deaths caused by this disease were recorded the most frequently among rural residents. It can be concluded that primary stroke prevention is the only effective measure for reducing morbidity and premature mortality in the population.

Ventilators are not the answer in Africa

The treatment of severely ill coronavirus disease 2019 (COVID-19) patients has brought the worldwide shortage of oxygen and ventilator-related resources to public attention. Ventilators are considered as the vital equipment needed to manage these patients, who account for 3% – 5% of patients with Covid-19. Most patients need oxygen and supportive therapy. In Africa, the shortage of oxygen is even more severe and needs equipment that is simpler to use than a ventilator. Different models of generating oxygen locally at hospitals, including at provincial and district levels, are required. In some countries, hospitals have established small oxygen production plants to supply themselves and neighbouring hospitals. Oxygen concentrators have also been explored but require dependable power supply and are influenced by local factors such as ambient temperature and humidity. By attaching a reservoir tank, the effect of short power outages or high demands can be smoothed over. The local and regional energy unleashed in the citizens to respond to the COVID-19 pandemic should now be directed towards developing appropriate infrastructure for oxygen and critical care. This infrastructure is education and technology intensive, requiring investment in these areas.

Treatment Costs for Patients with Chronic Kidney Disease Who Received Multidisciplinary Care in a District Hospital in Thailand

Aim

To estimate direct medical treatment costs in patients with pre-dialysis chronic kidney disease (CKD) in a district hospital and to analyze the factors that affected the treatment costs.

Patients and Methods

Data were retrospectively retrieved from the hospital database in the period from January 2015 to December 2017. Patients who were diagnosed with CKD and had visited ambulatory care services at least two times during the index year (January to December 2015) were included. Patients' data were excluded if they had cancer, had received renal replacement therapy, or had been referred to receive treatment at other hospitals. Treatment costs based on the providers' perspectives in the first and second years after the index year were assessed. Descriptive statistics were used to analyze patients' characteristics, and multiple linear regression was used to analyze the factors in the cost model.

Results

Data of 212 patients with CKD stage G3a, G3b, or G4 who met inclusion and exclusion criteria were included for analysis. Average costs for treatment in year 1 and year 2 were not statistically different. Total cost was 5701.34 Thai Baht (THB) per year. The total cost for patients with CKD stage G4 was two times greater than for patients with CKD stage G3. Costs were increased for longer hospitalization, more frequent ambulatory visits, having diabetes mellitus or dyslipidemia as a comorbidity, and uncontrolled fasting blood glucose (FBG). A cost model with R ²=0.906 was provided. Significant predictors were length of stay, ambulatory visits, diabetes mellitus, dyslipidemia, serum creatinine, FBG, and body mass index.

Conclusion

Total annual treatment costs for the 2 years were not different. A more advanced stage of CKD, having diabetes mellitus or dyslipidemia as comorbidities, and uncontrolled FBG were significantly associated with increased costs for treatment in patients with pre-dialysis CKD.

The experiences of teleradiology end users regarding role extension in a rural district of the North West province: A qualitative analysis

Background

Teleradiology was implemented across South Africa, to provide reporting services to rural healthcare institutes without a radiologist. This is guided by standard operating procedure manuals (SOP) which standardise the quality of services provided. From observation, end users, namely, the radiographer and referring clinician, experience challenges in fulfilling the roles extending beyond the SOP.

Aim

To explore the end users’ experiences within this context and the impact it has on service delivery.

Setting

A rural district in North West province, South Africa.

Method

This was a qualitative, exploratory, descriptive study. Focus group discussions were held with radiographers and referring clinicians from the teleradiology site in the North West province. A one-on-one interview was conducted with a private radiologist at the reporting site in Gauteng. An interview guide was used to ask open-ended questions to address the aim of the study.

Results

At the teleradiology site, radiographers and referring clinicians are performing extended roles, not described in the teleradiology service-level agreement (SLA) and felt poorly equipped to fulfil these roles. They also felt that the private radiologists needed training on interprofessional collaboration to understand the challenges facing health professionals at these rural sites.

Conclusion

SLA’s should align with the clinical needs and practices of the district. This should guide the specific training needs of the end users practicing in rural areas, to support their extended roles in the teleradiology setting. Training should be in-house, ongoing and consistent to cater for the influx of health professionals entering the rural setting using teleradiology systems.

A comprehensive district-level laboratory intervention after the Ebola epidemic in Sierra Leone

Background

The 2014–2016 Ebola outbreak exposed the poor laboratory systems in Sierra Leone. Immense needs were recognised across all areas, from facilities, diagnostic capacity, supplies, trained personnel to quality assurance mechanisms.

Objective

We aimed to describe the first year of a comprehensive intervention, which started in 2015, in a public hospital’s general laboratory serving a population of over 500 000 in a rural district.

Methods

The intervention focused on (1) supporting local authorities and healthcare workers in policy implementation and developing procedures to enhance access to services, (2) addressing gaps by investing in infrastructure, supplies, and equipment, (3) development of quality assurance mechanisms via mentorship, bench-side training, and the introduction of quality control and information systems. All work was performed alongside counterparts from the Ministry of Health and Sanitation.

Results

We observed a strong increase in patient visits and inpatient and outpatient testing volumes. Novel techniques and procedures were taken up well by staff, leading to improved and expanded service and safety, laying foundations for further improvements.

Conclusion

This comprehensive approach was successful and the results suggest an increase in trust from patients and healthcare workers.

The cost of providing and scaling up surgery: a comparison of a district hospital and a referral hospital in Zambia

The lack of access to quality-assured surgery in rural parts of sub-Saharan Africa, where the numbers of trained health workers are often insufficient, presents challenges for national governments. The case for investing in scaling up surgical systems in low-resource settings is 3-fold: the potential beneficial impact on a large proportion of the global burden of disease; better access for rural populations who have the greatest unmet need; and the economic case. The economic losses from untreated surgical conditions far exceed any expenditure that would be required to scale up surgical care. We identified the resources used in delivering surgery at a rural district-level hospital and an urban based referral hospital in Zambia and calculated their cost through a combination of bottom-up costing and step-down accounting. Surgery performed at the referral hospital is ∼50% more expensive compared with the district hospital, mostly because of the higher cost of hospital stay. The low bed occupancy rates at the two hospitals suggest underutilization of the capacity, and/or missing elements of needed capacity, to conduct surgery. Nevertheless, our study confirms that scaling up district-level surgery makes sense, through bringing economies of scale, while acknowledging the need for more comprehensive assessments and costing of capacity constraints. We quantified the economies of scale under different scaling scenarios. If surgery at the district hospital was scaled up by 10, 20 or 50%, the total cost of surgery would increase proportionately less than that, i.e. by 6, 12 and 30%, respectively. If this were to lead to less demand for surgery at the referral hospital, say 10% less surgery, it would result in a reduction of 2.7% in the total cost. Although the health system as a whole would benefit, the referring hospitals would not derive the full economic benefit, unless Government increased resources for district-level surgery.

Leadership and the functioning of maternal health services in two rural district hospitals in South Africa

Maternal mortality remains high in Eastern Cape Province, South Africa, despite over 90% of pregnant women utilizing maternal health services. A recent survey showed wide variation in performance among districts in the province. Heterogeneity was also found at the district level, where maternal health outcomes varied considerably among district hospitals. In ongoing research, leadership emerged as one of the key health systems factors affecting the performance of maternal health services at facility level. This article reports on a subsequent case study undertaken to examine leadership practices and the functioning of maternal health services in two resource-limited hospitals with disparate maternal health outcomes. An exploratory mixed-methods case study was undertaken with the two rural district hospitals as the units of analysis. The hospitals were purposively selected based on their maternal health outcomes: one reported good maternal health outcomes (pseudonym: Chisomo) and the other had poor outcomes (pseudonym: Tinyade). Comparative data were collected through a facility survey, non-participant observation of management and perinatal meetings, record reviews and interviews with hospital leadership, staff and patients to elicit information about leadership practices including supervision, communication and teamwork. Descriptive and thematic data analysis was undertaken. The two hospitals had similar infrastructure and equipment. Hospital managers at Chisomo used their innovation and entrepreneurial skills to improve quality of care, and leadership style was described as supportive, friendly, approachable but 'firm'. They also undertook frequent and supportive supervisory meetings. Each department at Chisomo developed its own action plan and used data to monitor their actions. Good performers were acknowledged in group meetings. Staff in this facility were motivated and patients were happy about the quality of services. The situation was different at Tinyade hospital. Participants described the leadership style of their senior managers as authoritarian. Managers were rarely available in the office and did not hold regular meetings, leading to poor communication across teams and poor coordination to address resource constraints. This demotivated the staff. The differences in leadership style, structures, processes and work culture affected teamwork, managerial supervision and support. The study demonstrates how leadership styles and practices influence maternal health care services in resource limited hospitals. Supportive leadership manifested itself in the form of focused efforts to build teamwork, enhance entrepreneurship and in management systems that are geared to improving maternal care.

Assessing process of paediatric care in a resource-limited setting: a cross-sectional audit of district hospitals in Rwanda

BACKGROUND

Routine assessment of quality of care helps identify deficiencies which need to be improved. While gaps in the emergency care of children have been documented across sub-Saharan Africa, data from Rwanda are lacking.

OBJECTIVE

To assess the care of sick infants and children admitted to Rwandan district hospitals and the extent to which it follows currently recommended clinical practice guidelines in Rwanda.

METHODS

Data were gathered during a retrospective cross-sectional audit of eight district hospitals across Rwanda in 2012/2013. Medical records were randomly selected from each hospital and were reviewed to assess the process of care, focusing on the leading causes of under-5 mortality, including neonatal conditions, pneumonia, malaria and dehydration/diarrhoea.

RESULTS

Altogether, 522 medical records were reviewed. Overall completion of a structured neonatal admission record was above 85% (range 78.6-90.0%) and its use was associated with better documentation of key neonatal signs (median score 6/8 and 2/8 when used and not used, respectively). Deficiencies in the processes of care were identified across hospitals and there were rural/urban disparities for some indicators. For example, neonates admitted to urban district hospitals were more likely to receive treatment consistent with currently recommended guidelines [e.g. gentamicin (OR 2.52, 95% CI 1.03-6.43) and fluids (OR 2.69, 95% CI 1.2-6.2)] than those in rural hospitals. Likewise, children with pneumonia admitted to urban hospitals were more likely to receive the correct dosage of gentamicin (OR 4.47, 95% CI 1.21-25.1) and to have their treatment monitored (OR 3.75, 95% CI 1.57-8.3) than in rural hospitals. Furthermore, children diagnosed with malaria and admitted to urban hospitals were more likely to have their treatment (OR 2.7, 95% CI 1.15-6.41) monitored than those in rural hospitals.

CONCLUSIONS

Substantial gaps were identified in the process of neonatal and paediatric care across district hospitals in Rwanda. There is a need to (i) train health care professionals in providing neonatal and paediatric care according to nationally adopted clinical practice guidelines (e.g. ETAT+); (ii) establish a supervision and mentoring programme to ensure that the guidelines are available and used appropriately in district hospitals; and (iii) use admission checklists (e.g. neonatal and paediatric admission records) in district hospitals.

Laparoscopic colectomy in a district hospital: the single surgeon can be safe

BACKGROUND

Several outcome measures have been identified for colorectal surgery and published in the literature. This study sought to compare outcomes of high volume laparoscopic colectomy by a single surgeon in a district hospital with outcomes from tertiary referral centres.

METHODS

This was a retrospective review of elective laparoscopic colectomy by a single laparoscopic general surgeon in a district hospital over a 51-month period using a prospectively maintained database. The key outcome measures studied were length of hospital stay, conversion to open, anastomotic leak, wound infection, re-admission and 30-day mortality.

RESULTS

187 elective laparoscopic colectomies were performed at the Kent and Canterbury Hospital between July 2008 and October 2012. The median patient age was 69 years (range 22-90 years). Median length of hospital stay was 4 days (range 1-48 days). Anastomotic leak occurred in 4 (2.1%) patients. Seven (3.7%) patients underwent conversion to open surgery. Re-admission occurred in 4 (2.1%) patients for small bowel obstruction (1), wound infection (1), anastomotic leak (1) and colo-vaginal fistula (1). There was one post-operative death from severe chest infection (0.5%). These results are similar to those published by tertiary referral centres.

CONCLUSIONS

This study of outcomes at a district hospital shows that the outcome reported from laparoscopic colorectal surgery in tertiary referral centres is reproducible at the district hospital level by a single surgeon with a high operative volume.

[Management of suspected cases of malaria before admission to a district hospital in Burkina Faso]

After widespread use and misuse of antimalarial drugs led to the emergence of resistance, new guidelines for malaria treatment with artemisinine-based combination therapy (ACT) were introduced in Burkina Faso in 2005. To describe the management (drug therapy and other practices) of patients with suspected malaria before their admission to the district hospital of Dô, seven years later. This cross-sectional study was conducted during admission to the district hospital, during the low season for malaria, from December 2010 to May 2011. It included all patients aged 6 months or older diagnosed with suspected malaria according to the criteria of the national malaria control program, excluding those with severe comorbidities. The study included 476 suspected cases, 422 (88.7%) uncomplicated and 54 (11.3%) complicated. They accounted for 7.9% of all admissions. Their mean age was 14.4 years, and 35.3% (n = 168) were younger than 5 years. Only 23 (4.8%) had first consulted in a primary health care facility; 346 (72.7%) had used initial self-medication (or, more precisely in some cases, parental administration of medication without medical consultation). Overall, 435 (91.4%) came directly to the district hospital, 331 (76.1%) of them after self-medication; 10 (2.1%) had first consulted a traditional healer. The practice of self-medication did not differ according to age, gender, or complications (p>0.05). The drugs used for self-medication were mainly antipyretics (94.5%) and antimalarials (16.8%); the latter included ACT (39.6%), quinine (19.0%), and non-recommended antimalarial agents (41.4%). During the malaria low season, the treatment itinerary of suspected malaria cases is marked by equal use of ACT and non-recommended antimalarials for self-medication and minimal use of the primary level of care. A study underway of this management and these itineraries during the epidemic season may provide more data about use of ACT, the last armament against malaria in drug-resistant areas such as Burkina Faso.

Towards tailored teaching: using participatory action research to enhance the learning experience of Longitudinal Integrated Clerkship students in a South African rural district hospital

BACKGROUND

The introduction of Stellenbosch University's Longitudinal Integrated Clerkship (LIC) model as part of the undergraduate medical curriculum offers a unique and exciting training model to develop generalist doctors for the changing South African health landscape. At one of these LIC sites, the need for an improvement of the local learning experience became evident. This paper explores how to identify and implement a tailored teaching and learning intervention to improve workplace-based learning for LIC students.

METHODS

A participatory action research approach was used in a co-operative inquiry group (ten participants), consisting of the students, clinician educators and researchers, who met over a period of 5 months. Through a cyclical process of action and reflection this group identified a teaching intervention.

RESULTS

The results demonstrate the gaps and challenges identified when implementing a LIC model of medical education. A structured learning programme for the final 6 weeks of the students' placement at the district hospital was designed by the co-operative inquiry group as an agreed intervention. The post-intervention group reflection highlighted a need to create a structured programme in the spirit of local collaboration and learning across disciplines. The results also enhance our understanding of both students and clinician educators' perceptions of this new model of workplace-based training.

CONCLUSIONS

This paper provides practical strategies to enhance teaching and learning in a new educational context. These strategies illuminate three paradigm shifts: (1) from the traditional medical education approach towards a transformative learning approach advocated for the 21(st) century health professional; (2) from the teaching hospital context to the district hospital context; and (3) from block-based teaching towards a longitudinal integrated learning model. A programme based on balancing structured and tailored learning activities is recommended in order to address the local learning needs of students in the LIC model. We recommend that action learning sets should be developed at these LIC sites, where the relevant aspects of work-place based learning are negotiated.

Cluster analysis of medical service resources at district hospitals in Taiwan, 2007-2011

BACKGROUND

A vast amount of the annual/national budget has been spent on the National Health Insurance program in Taiwan. However, the market for district hospitals has become increasingly competitive, and district hospitals are under pressure to optimize the use of health service resources. Therefore, we employed a clustering method to explore variations in input and output service volumes, and investigate resource allocation and health care service efficiency in district hospitals.

METHODS

Descriptive and cluster analyses were conducted to examine the district hospitals included in the Ministry of Health and Welfare database during 2007-2011.

RESULTS

The results, according to the types of hospital ownership, suggested that the number of public hospitals has decreased and that of private hospitals increased; the largest increase in the number of district hospitals occurred when Taichung City was merged into Taichung County. The descriptive statistics from 2007 to 2011 indicated that 43% and 36.4% of the hospitals had 501-800 occupied beds and 101-200 physicians, respectively, and > 401 medical staff members. However, the number of outpatients and discharged patients exceeded 6001 and 90,001, respectively. In addition, the highest percentage of hospitals (43.9%) had 30,001-60,000 emergency department patients. In 2010, the number of patients varied widely, and the analysis of variance cluster results were nonsignificant (p > 0.05).

CONCLUSION

District hospitals belonging to low-throughput and low-performance groups were encouraged to improve resource utilization for enhancing health care service efficiency.

Improving quality through performance-based financing in district hospitals in Rwanda between 2006 and 2010: a 5-year experience

INTRODUCTION

Since 2000 performance-based financing (PBF) made its way to sub-Saharan health systems in an attempt to improve service delivery. In Rwanda initial experiences in 2001 and 2002 led to a scaling up of the initiative to all health centres (HC) and district hospitals (DH). In 2008 PBF became national strategy.

METHODS

PBF was introduced in Rwanda in 2006 at the DH level. Evaluation on their service delivery was carried out quarterly in the following areas: hospital management, support to the health centres and clinical activities. We studied four DHs.

RESULTS

After 5 years, an improvement in the quantity of clinical activities was observed, as well as quality in hospital management, in HC support and in clinical activities.

CONCLUSION

PBF proves to be a promising approach in strengthening and maintaining quality service delivery in the sub-Saharan district hospitals.

Survey of safety practices among hospital laboratories in Oromia Regional State, Ethiopia

BACKGROUND

Unsafe working practices, working environments, disposable waste products, and chemicals in clinical laboratories contribute to infectious and non-infectious hazards. Staffs, the community, and patients are less safe. Furthermore, such practices compromise the quality of laboratory services. We conducted a study to describe safety practices in public hospital laboratories of Oromia Regional State, Ethiopia.

METHOD

Randomly selected ten public hospital laboratories in Oromia Regional State were studied from Oct 2011- Feb 2012. Self-administered structured questionnaire and observation checklists were used for data collection. The respondents were heads of the laboratories, senior technicians, and safety officers. The questionnaire addressed biosafety label, microbial hazards, chemical hazards, physical/mechanical hazards, personal protective equipment, first aid kits and waste disposal system. The data was analyzed using descriptive analysis with SPSS version16 statistical software.

RESULT

All of the respondents reported none of the hospital laboratories were labeled with the appropriate safety label and safety symbols. These respondents also reported they may contain organisms grouped under risk group IV in the absence of microbiological safety cabinets. Overall, the respondents reported that there were poor safety regulations or standards in their laboratories. There were higher risks of microbial, chemical and physical/mechanical hazards.

CONCLUSION

Laboratory safety in public hospitals of Oromia Regional State is below the standard. The laboratory workers are at high risk of combined physical, chemical and microbial hazards. Prompt recognition of the problem and immediate action is mandatory to ensure safe working environment in health laboratories.

Management of gastrointestinal carcinoid tumours - 10 years experience at a district general hospital

BACKGROUND

There is paucity of guidelines regarding management of gastrointestinal carcinoid tumours in district hospitals.

METHODS

This study was undertaken at a district hospital to analyse the management pathway of gastrointestinal carcinoid tumours.

RESULTS

Over a period of 10 years there were 35 patients, with an estimated annual incidence of 2.5 per 100,000 population. After a median follow up of 24 months, 22 (63%) patients were alive and disease free. Only 56% patients were referred to the regional neuro-endocrine multidisciplinary team.

CONCLUSIONS

Management of patients with carcinoid tumours in district hospitals needs streamling with increased utilisation of regional neuroendocrine multidisciplinary teams.