Understanding the role of lady health workers in improving access to eye health services in rural Pakistan – findings from a qualitative study

Background
In 1994, the Lady Health Workers (LHWs) Programme was established in Pakistan to increase access to essential primary care services and support health systems at the household and community levels. In Khyber Pakhtunkhwa (KPK) province in northern Pakistan, eye care is among the many unmet needs that LHWs were trained to address, including screening and referral of people with eye conditions to health facilities. However, despite an increase in referrals by LHWs, compliance with referrals in KPK has been very low. We explored the role of LHWs in patient referral and the barriers to patient compliance with referrals.

Methods
Qualitative methodology was adopted. Between April and June 2019, we conducted eight focus group discussions and nine in-depth interviews with 73 participants including patients, LHWs and their supervisors, district managers and other stakeholders. Data were analysed thematically using NVivo software version 12.

Results
LHWs have a broad understanding of basic health care and are responsible for a wide range of activities at the community level. LHWs felt that the training in primary eye care had equipped them with the skills to identify and refer eye patients. However, they reported that access to care was hampered when referred patients reached hospitals, where disorganised services and poor quality of care discouraged uptake of referrals. LHWs felt that this had a negative impact on their credibility and on the trust and respect they received from the community, which, coupled with low eye health awareness, influenced patients’ decisions about whether to comply with a referral. There was a lack of trust in the health care services provided by public sector hospitals. Poverty, deep-rooted gender inequities and transportation were the other reported main drivers of non-adherence to referrals.

Conclusions
Results from this study have shown that the training of LHWs in eye care was well received. However, training alone is not enough and does not result in improved access for patients to specialist services if other parts of the health system are not strengthened. Pathways for referrals should be agreed and explicitly communicated to both the health care providers and the patients.

Telementoring, Surgery training, Rural surgery, Breast cancer

Abstract
Telementorship allows an expert surgeon to mentor another surgeon through an advanced procedure from a remote location via 2-way audio-visual communication. The current article was planned to review the existing literature and evaluate the utility of telementorship regarding educating rural surgeons in Pakistan about multidisciplinary breast cancer care. Publications from 2016 to 2020 were searched on PubMed and GoogleScholar and 10 most recent publications were selected. Review of literature revealed that even though telementorship in this context might be comparable to onsite mentorship, multiple concerns need to be addressed before its implementation. These include lack of concrete evidence regarding its effectiveness, legal, security and financial issues. Thus, a pilot project evaluating the efficacy of telementorship needs to be conducted for rural breast surgeons working in Pakistan. If these studies show promise and an affordable, convenient and effective method of telementorship is devised, then it may become the future of breast surgery training in far-flung regions of Pakistan.

Peer-led surgery education: A model for a surgery interest group

Abstract
We present a systematic, sustainable, student-led model for a Surgery Interest Group in a low and middle-income country setting to encourage other medical students to establish similar groups in their institutions. Our model was developed at the Aga Khan University Medical College, Karachi, and is comprised of medical students, teaching associates, residents, faculty and alumni. The group focuses on connecting medical students with an interest in surgery with opportunities to help them match in surgery training programs. The opportunities include, but are not limited to, skill development, personal development, mentorship and research. Our model has shown growth and expansion over the last four years, and can be successfully replicated in medical colleges across similar settings.

Challenges in Providing Surgical Procedures During the COVID-19 Pandemic: Qualitative Study Among Operating Department Practitioners in Pakistan

ackground: Operating Department Practitioners (ODPs) are neglected human resources for health with regard to both professional development and research for patient safety. The surgical theatre is associated with the highest mortality rates and with the onslaught of the COVID-19 pandemic. ODPs are key practitioners with respect to infection control during surgeries. Therefore, this study aims to describe challenges faced by ODPs. The secondary aim is to use empirical evidence to inform the public health sector management about both ODP professional development and improvement in surgical procedures, with a specific focus on pandemics.

Methods: A qualitative study has been conducted. Data collection was based on an interview guide with open-ended questions. Interviews with 39 ODPs in public sector teaching hospitals of Pakistan who have been working during the COVID-19 pandemic were part of the analysis. Content analysis was used to generate themes.

Results: Ten themes related to challenges faced by ODPs in delivering services during the pandemic for securing patient safety were identified: (i) Disparity in training for prevention of COVID-19; (ii) Shortcomings in COVID-19 testing; (iii) Supply shortages of personal protective equipment; (iv) Challenges in maintaining physical distance and prevention protocols; (v) Human resource shortages and role burden; (vi) Problems with hospital administration; (vii) Exclusion and hierarchy; (viii) Teamwork limitations and other communication issues; (ix) Error Management; and (x) Anxiety and fear.

Conclusions: The public health sector, in Pakistan and other developing regions, need to invest in the professional development of ODPs and improve resources and structures for surgical procedures, during pandemics and otherwis

Amid COVID-19 pandemic, are non-COVID patients left in the lurch?

Objectives: 1) To explore the possible impact of the pandemic on the health seeking behavior of the patients, 2) To explore the relation of socio-demographics on the utility of health-care facilities.

Methods: This cross-sectional study was conducted by enrolling all patients ≥15 years of age presenting to the Out-Patient-Department of three main public-hospitals after obtaining ethical committee approval. A questionnaire with validated Urdu translation was filled by each participant that included socio-demographic data, pre-Covid and Covid-19 era health seeking behaviors and the impact of the pandemic on the utilization of healthcare facilities. Data was analyzed using SPSS V.19.

Results: A total of 393 patients were enrolled with a male preponderance (72%) and a median age range of 31-45 years. Fifty-eight percent of the study population was unemployed and 47.3% were seeking follow up care. The frequency of ER and multiple (>4 times) OPD visits were significantly decreased in the Covid-19 times whereas, the laboratory and radiology services were largely unaffected. A significant number of patients were not satisfied with the current healthcare facilities that was seen irrespective of the socio-demographic status. Emergency Room and radiology services were largely unaffected whereas, elective procedures and laboratory facilities were reported to be severely affected or delayed in relation to socio-demographic variables.

Conclusions: Healthcare inequalities have widened and depression has shown a sharp rise during this pandemic. The over-burdened healthcare facilities at the verge of collapse may miss out on the chronic non-Covid patients which would ultimately lead to increased morbidity and mortality.

Epidemiological trends in community acquired acute Kidney Injury in Pakistan: 25 years Experience from a Tertiary Care Renal Unit

Background: Epidemiological studies of community acquired acute kidney injury (AKI) are sparse especially from South Asia and none has published from Pakistan. Reported incidences from different countries vary with use of different criteria of defining AKI. There is also variation found in different class of income countries, hospital based versus community based AKI.

Methods: The current study was carried out in all adult AKI patients developing community acquired AKI and coming to a tertiary care renal institution from January 1990 to December 2014. This is a retrospective data collection from patient’s records and AKI was defined according to KDIGO guidelines. Trends among different groups which are classified in medical, obstetrical and surgical were observed and presented.

Results: In medical AKI there has been found a rise in toxic rhabdomyolysis, vivax malaria and dengue infection during later part of study. In obstetrical AKI observed continuous rise in numbers contributing to total AKI during these years. Surgical AKI included obstructed cases during initial ten years and only surgical trauma during later 15 years. Older age on presentation in medical AKI, and thrombocytopenia, deranged coagulation, deranged liver function, hyperkalemia, requirement of mechanical ventilation and multi organ failure in all groups remained predictors of higher mortality.

Conclusion: From Pakistan epidemiology for community acquired AKI has never been published on a large scale and this study would remain source of great information in this regard over coming years.

Change in the spectrum of orthopedic trauma: Effects of COVID-19 pandemic in a developing nation during the upsurge; a cross-sectional study

Background: The COVID-19 pandemic has caused a great impact on orthopedic surgery with a significant curtailment in elective surgeries which is the major bread and butter for orthopedic surgeons. It was also observed that the spectrum of orthopedic trauma injuries has shifted from more severe and frequent road traffic accidents (high energy trauma) to general, low energy house-hold injuries like low energy fractures in the elderly, pediatric fractures, house-hold sharp cut injuries and nail bed lacerations. The aim of this study is to appraise the effect of the COVID-19 pandemic on orthopedic surgical practice, both inpatient and outpatient facility.

Materials and methods: This is a retrospective cross sectional study conducted in a tertiary care teaching hospital. We collected data of patients admitted from February 1, 2020 to 30th April 2020 in the orthopedic service line using non-probability consecutive sampling. This study population was divided into pre-COVID and COVID eras (6 weeks each). The data included patient demographic parameters like age, gender and site of injury, mechanism of injury, diagnosis and procedure performed and carrying out of COVID-19 Polymerase Chain Reaction (PCR) test in the COVID-era.

Results: We observed that outpatient clinical volume decreased by 75% in COVID era. Fifty percent of surgical procedures decreased in COVID era as compared to pre-COVID era. Trauma procedures reduced by 40% in COVID era. Most common mechanism of injury was household injuries like low energy falls. A significant reduction in elective surgeries by 67% was observed in the COVID era.

Conclusion: The impact of COVID-19 pandemic has significantly changed the spectrum of orthopedic injury. More household injuries have occurred and are anticipated due to the ongoing effects of lockdown.

Simulator-based ultrasound training for identification of endotracheal tube placement in a neonatal intensive care unit using point of care ultrasound

Background
Simulators are an extensively utilized teaching tool in clinical settings. Simulation enables learners to practice and improve their skills in a safe and controlled environment before using these skills on patients. We evaluated the effect of a training session utilizing a novel intubation ultrasound simulator on the accuracy of provider detection of tracheal versus esophageal neonatal endotracheal tube (ETT) placement using point-of-care ultrasound (POCUS). We also investigated whether the time to POCUS image interpretation decreased with repeated simulator attempts.

Methods
Sixty neonatal health care providers participated in a three-hour simulator-based training session in the neonatal intensive care unit (NICU) of Aga Khan University Hospital (AKUH), Karachi, Pakistan. Participants included neonatologists, neonatal fellows, pediatric residents and senior nursing staff. The training utilized a novel low-cost simulator made with gelatin, water and psyllium fiber. Training consisted of a didactic session, practice with the simulator, and practice with intubated NICU patients. At the end of training, participants underwent an objective structured assessment of technical skills (OSATS) and ten rounds of simulator-based testing of their ability to use POCUS to differentiate between simulated tracheal and esophageal intubations.

Results
The majority of the participants in the training had an average of 7.0 years (SD 4.9) of clinical experience. After controlling for gender, profession, years of practice and POCUS knowledge, linear mixed model and mixed effects logistic regression demonstrated marginal improvement in POCUS interpretation over repeated simulator testing. The mean time-to-interpretation decreased from 24.7 (SD 20.3) seconds for test 1 to 10.1 (SD 4.5) seconds for Test 10, p < 0.001. There was an average reduction of 1.3 s (β = − 1.3; 95% CI: − 1.66 to − 1.0) in time-to-interpretation with repeated simulator testing after adjusting for the covariates listed above.

Conclusion
We found a three-hour simulator-based training session had a significant impact on technical skills and performance of neonatal health care providers in identification of ETT position using POCUS. Further research is needed to examine whether these skills are transferable to intubated newborns in various health settings.

Occurrence, associated risk factors, and treatment of surgical site infections in Pakistan

Globally, surgical site infections are one of the common infections which lead to a large amount of mortality and morbidity in postsurgical care. The risk for surgical site infection is multidimensional which includes mainly; patient, surgery, and hospital-related factors. This study is aimed to determine the burden of SSIs along with contributed risk factors. A prospective observational cross-sectional study was conducted in one of the largest public-sector hospitals in Pakistan. A total of 412 patients were recruited in the study with full consent and monitored for 30 days after surgery with direct and indirect surveillance. Overall, in seven different surgical procedures the incidence (29.8%) rate of SSI was observed; in appendectomy (n = 17, 4.1%), exploratory laparotomy (n = 51, 12.6%), laparoscopic cholecystectomy (n = 12, 2.90%), mesh repair (n = 17, 4.01%), thyroidectomy (5, 1.2%), transurethral resection of the prostate (n = 11, 2.6%), and transurethral resection of the bladder (10, 2.4%). The average SSI rate in every single procedure was about 18 (4.27%) per surgical procedure out of 123 (29.85%) SSI cases. Types of SSI identified were superficial, deep incisional and organ/space (n = 76, 18.4%, n = 23, 5.5%, and n = 24, 5.7%). Incidence of SSIs during admission, at readmission, and post-surveillance cases were (n = 50, 12.1%, n = 25, 6.0% and n = 48, 11.6%). Associated risk factors found contributed to the incidence of SSI (p < 0.05). Pre-operative (n = 348, 84.5%) and 6 (1.5%) surgical patients did not received the post-operative antibiotics. The P. aeruginosa (n = 15, 12.1%) and S. aureus (13, 10.5%). Cefoperazone and sulbactam were the most prescribed antibiotics. Associated risk factors and treatment outcomes of surgical patients have a direct association with the incidence of SSI. Hospital-based antimicrobial stewardship, implementation of surgical guidelines, patient care, and education are needed to develop at wards level in hospitals.

An antibiotic stewardship program in a surgical ICU of a resource-limited country: financial impact with improved clinical outcomes

Background
Antibiotic resistance (ABX-R) is alarming in lower/middle-income countries (LMICs). Nonadherence to antibiotic guidelines and inappropriate prescribing are significant contributing factors to ABX-R. This study determined the clinical and economic impacts of antibiotic stewardship program (ASP) in surgical intensive care units (SICU) of LMIC.

Method
We conducted this pre and post-test analysis in adult SICU of Aga Khan University Hospital, Pakistan, and compared pre-ASP (September–December 2017) and post-ASP data (April–July 2018). January–March 2018 as an implementation/training phase, for designing standard operating procedures and training the team. We enrolled all the patients admitted to adult SICU and prescribed any antibiotic. ASP-team daily reviewed antibiotics prescription for its appropriateness. Through prospective-audit and feedback-mechanism changes were made and recorded. Outcome measures included antibiotic defined daily dose (DDDs)/1000 patient-days, prescription appropriateness, antibiotic duration, readmission, mortality, and cost-effectiveness.

Result
123 and 125 patients were enrolled in pre-ASP and post-ASP periods. DDDs/1000 patient-days of all the antibiotics reduced in the post-ASP period, ceftriaxone, cefazolin, metronidazole, piperacillin/tazobactam, and vancomycin showed statistically significant (p < 0.01) reduction. The duration of all antibiotics use reduced significantly (p < 0.01). Length of SICU stays, mortality, and readmission reduced in the post-ASP period. ID-pharmacist interventions and source-control-documentation were observed in 62% and 50% cases respectively. Guidelines adherence improved significantly (p < 0.01). Net cost saving is 6360US$ yearly, mainly through reduced antibiotics consumption, around US$ 18,000 (PKR 2.8 million) yearly.

Conclusion
ASP implementation with supplemental efforts can improve the appropriateness of antibiotic prescriptions and the optimum duration of use. The approach is cost-effective mainly due to the reduced cost of antibiotics with rational use. Better source-control-documentation may further minimize the ABX-R in SICU.