Background: Vietnam has encountered difficulties in ensuring an adequate and equitable distribution of health workforce. The traditional staffing norms stated in the Circular 08/TT-BYT issued in 2007 based solely on population or institutional size and do not adequately take into consideration the variations of need such as population density, mortality and morbidity patterns. To address this problem, more rigorous approaches are needed to determine the number of personnel in health facilities. One such approach is Workload Indicators of Staffing Need (WISN) developed by the World Health Organization (WHO), a facility-based workforce planning method that assists managers in defining the responsibilities of different workforce categories and improving the appropriateness and efficiency of a staff mix.
Methods: This study applied the WISN approach and was employed in 22 clinical departments at four hospitals in Vietnam between 2015 and 2018. 22 targeted group discussions involving nurses were conducted. Hospital personnel records have been retrieved. The data were analyzed according to WISN instructions.
Results: Of the 22 departments, there was a shortage of 1 to 2 nurses in 10 departments, with WISN ratios ranging between 0.88 and 0.95. Only 01 clinical colleges at Can Tho Hospital lacked 05 nurses, facing a high workload with a WISN ratio of 0.78. Administrative time represented 20-40% of the total work time of a nurse. In comparison, nurses at Can Tho Hospital spent time on administration from 24 onwards. 5% to 41.7% of their working time while nurses at Thanh Hoa Hospital spent 21% to 33%.
Conclusion: The application of the WISN enabled health managers to analyze the workload of nurses, calculate staffing needs, and thus effectively contribute to the workforce planning process. It is expected that the results of this research will encourage the use of the WISN tool in other hospitals and health facilities across the health system. At provincial and national levels, this study provides important evidence to help policy makers develop guidelines for personnel norms for health facilities in the context of limited resources, while the existing regulation is no longer appropriat
Research on the needs of family caregivers of people living with cancer remains disproportionately focused in high income contexts. This research gap adds to the critical challenge on global equitable delivery of cancer care. This study describes the roles of family caregivers of people living with cancer in Vietnam and possible implications for intervention development.
Semi-structured interviews and focus groups with family caregivers (n = 20) and health care providers (n = 22) were conducted in two national oncology hospitals. Findings were verified via workshops with carers (n = 11) and health care professionals (n = 28) in five oncology hospitals representing different regions of Vietnam. Data was analyzed collaboratively by an international team of researchers according to thematic analysis.
Family caregivers in Vietnam provide an integral role in the delivery of inpatient cancer care. In the hospital environment families are responsible for multiple roles including feeding, hydration, changing, washing, moving, wound care and security of personal belongings. Central to this role is primary decision making in terms of treatment and end-of-life care; relaying information, providing nutritional, emotional and financial support. Families are forced to manage severe complications and health care needs with minimal health literacy and limited health care professional input.
Understanding context and the unique roles of family caregivers of people living with cancer is critical in the development of supportive services. As psycho-oncology develops in low and middle income contexts, it is essential that family caregiver roles are of significant importance.
This study examined the financial toxicity faced by breast cancer (BC) patients in Vietnam and the factors associated with the risk and degree of that toxicity.
A total of 309 BC patients/survivors completed an online survey (n=209) or a face-to-face interview (n=100) at two tertiary hospitals. Descriptive statistics and χ2 tests were used to identify and analyse the forms and degree of financial toxicity faced by BC patients/survivors. A Cragg hurdle model assessed variation in risk and the degree of financial toxicity due to treatment.
41% of respondents faced financial toxicity due to BC treatment costs. The mean amount of money that exceeded BC patients/survivors’ ability to pay was 153 million Vietnamese Dong (VND) ($6602) and ranged from 2.42 million VND to 1358 million VND ($104–58,413). A diagnosis at stage II or III of BC was associated with 16.0 and 18.0 million VND (~$690–777) more in the degree of financial toxicity compared with patients who were diagnosed at stage 0/I, respectively. Being retired or married or having full (100%) health insurance was associated with a decrease in the degree of financial toxicity.
A significant proportion of Vietnamese BC patients/survivors face serious financial toxicity due to BC treatment costs. There is a need to consider the introduction of measures that would attenuate this hardship and promote uptake of screening for the reduction in financial toxicity as well as the health gains it may achieve through earlier detection of cancer.
Estimating the cost of postoperative respiratory complications is crucial in developing appropriate strategies to mitigate the global and national economic burden. However, systematic analysis of the economic burden in low- and middle-income countries is lacking.
We used the nationwide database of the Vietnam Social Insurance agency and extracted data from January 2017 to September 2018. The data contain 1 241 893 surgical patients undergoing one of seven types of surgery. Propensity score matching method was used to match cases with and without complications. We used generalized gamma regressions to estimate the direct medical costs; logistic regressions to evaluate the impact of postoperative respiratory complications on re-hospitalization and outpatient visits.
Postoperative respiratory complications increased the odds of re-hospitalization and outpatient visits by 3·49 times (95% CI: 3·35–3·64) and 1·39 times (95% CI: 1·34–1·45) among surgical patients, respectively. The mean incremental cost associated with postoperative respiratory complications occurring within 30 days of the index admission was 1053·3 USD (95% CI: 940·7–1165·8) per procedure, which was equivalent to 41% of the GDP per capita of Vietnam in 2018. We estimated the national annual incremental cost due to respiratory complications occurring within 30 days after surgery was 13·87 million USD. Pneumonia contributed the greatest part of the annual cost burden of postoperative respiratory complications.
The economic burden of postoperative respiratory complications is substantial at both individual and national levels. Postoperative respiratory complications also increase the odds of re-hospitalization and outpatient visits and increase the length of hospital stay among surgical patients.
Traffic injuries place a significant burden on mortality, morbidity and health services worldwide. Qualitative factors are important determinants of health but they are often ignored in the study of injury and corresponding development of prehospital Emergency Medical Services (EMS), especially in developing country settings. Here we report our research on sociocultural factors shaping pathways to hospital care for those injured on the roads and streets of Vietnam.
Qualitative fieldwork on pathways to emergency care of traffic injury was carried out from March to August 2016 in four hospitals in Vietnam, two in Ho Chi Minh City and two in Hanoi. Forty-eight traffic injured patients and their families were interviewed at length using a semi-structured topic guide regarding their journey to the hospital, help received, personal beliefs and other matters that they thought important. Transcribed interviews were analysed thematically guided by the three-delay model of emergency care.
Seeking care was the first delay and reflected concerns over money and possessions. The family was central for transporting and caring for the patient but their late arrival prolonged time spent at the scene. Reaching care was the second delay and detours to inappropriate primary care services had postponed the eventual trip to the hospital. Ambulance services were misunderstood and believed to be suboptimal, making taxis the preferred form of transport. Receiving care at the hospital was the third delay and both patients and families distrusted service quality. Request to transfer to other hospitals often created more conflict. Overall, sociocultural beliefs of groups of people were very influential.
Analysis using the three-delay model for road traffic injury in Vietnam has revealed important barriers to emergency care. Hospital care needs to improve to enhance patient experiences and trust. Socioculture affects each of the three delays and needs to inform thinking of future developments of the EMS system, especially for countries with limited resources.
Hospital acquired infections (HAIs), especially ventilator associated respiratory infection (VARI) cause significant morbidity and mortality, and disproportionally so in low and middle-income countries (LMICs), including Vietnam, where infection control in hospitals is often neglected. The management of HAIs in these settings is challenging because of the high proportions of antimicrobial drug resistance and limitations of laboratory diagnostics, financial and human resources in terms of knowledge and skills for antimicrobial stewardship and infection prevention and control.
Because resistance is driven by use of antimicrobials, my thesis started with a question on use and cost of antimicrobials in public hospitals in the country followed by a detailed
assessment of use and cost of antimicrobials in the management of ventilator associated respiratory infections (VARI). I obtained detailed bids from hospitals and provincial departments of health representing 28.7% (1.68 / 5.85 billion US$) of the total hospital medication budget in Vietnam. Antimicrobials represented 28.6% of these costs.
Antimicrobials were stratified using the Access, Watch, Reserve (AWaRe) groups proposed by WHO in 2017. I showed that the most commonly used antimicrobials across sites were second generation cephalosporins (20.3% of total procured defined daily dose, DDD) followed by combinations of penicillins and beta-lactamase inhibitors (18.4% of total procured DDD). The most expensive antimicrobials are the last resort antimicrobials, which can considerably increase the cost of treatment for patients with HAIs caused by multidrug resistant pathogens in critical care units in Vietnam. In recognition of this problem, I estimated the excess cost of management of VARI using a costing model study. At the current incidence rate of 21.7 episodes per 1000 ventilation-days, I estimated there were 34,428 episodes of VARI nationally, associated with a direct cost of more than US$ 40 million per year. Our studies showed the need for an affordable and scalable intervention in critical care units to reduce the burden of VARI and provide cost savings for national health expenditure.
My studies also showed that antimicrobial costs are a major component of the excess cost of VARI management in Vietnam (51.1%) and that a one day reduction in the duration of antimicrobial therapy can save US$ 1.72 million. Therefore, my thesis has focused on interventions to prevent VARI and to shorten antimicrobial therapy. In recognition of human resources constraints in Vietnam, including for microbiology diagnostics and critical care nursing, I have studied automatic technology and equipment, including matrix assisted
laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) for rapid identification of pathogens and continuous automatic cuff pressure control device to prevent VARI. To examine effectiveness of these intervention, I conducted 2 randomised controlled trials to evaluate the clinical effectiveness of matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDITOF-MS) in optimizing antimicrobial therapy and to evaluate the effectiveness of continuous cuff pressure control in preventing VARI. For the latter, pending unblinding and final results I describe the implementation of the trial and report the incidence of hospital acquired bloodstream infection during this trial.
A diagnostic randomised controlled trial (RCT) was conducted to evaluate the impact of MALDITOF-MS versus conventional diagnostics in improving antimicrobial use in patients with confirmed infection. Although MALDITOF-MS provided more rapid identification of invasive bacterial and fungal pathogens than conventional microbiology, the proportion of patients on optimal therapy at 24 or 48 hours after growth of specimen did not increase. These findings showed that without human resources and an effective antimicrobial stewardship programme, technology alone cannot provide a solution for antimicrobial overuse in hospitals in LMICs.
A randomized controlled clinical trial was conducted to evaluate the effectiveness of
continuous cuff pressure control versus daily manual cuff measurement (VARI-prevent). In this study I recruited and followed-up 597 adult patients who were admitted to ICUs and
were intubated within 48 hours of admission. The patients were randomised to receive either continuous or manual cuff pressure measurement and control and were followed for occurrence of VARI during ICU stay and up to 90 days after randomisation. The study has completed recruitment and follow-up and final analysis is ongoing. The overall rate of VARI and VAP in eligible patients was 23.7% (140/591) and 17.3% (102/591) respectively. The data from this trial (VARI-prevent) was analysed to estimate the incidence density rate of hospital acquired bloodstream infection (HABSI) in 3 ICUs in Vietnam for the first time. The most common pathogens causing HABSI were Klebsiella pneumoniae followed by Pseudomonas aeruginosa, Acinetobacter baumannii and Coagulase-Negative staphylococci. Polymicrobial culture results were reported in 6.8% (3/44) patients with culture confirmed HABSI. The rate of HABSI and central line associated BSI (CLABSI) were 7.4% (44/591) and 9.3% (31/333), respectively. The incidence density rate of HABSI and CLABSI were 3.76 per 1000 patients-days and 8.43 per 1000 catheter-days, respectively. This suggests that the implementation of infection prevention and control bundle including catheter care is important to reduce the high incidence of HABSI in Vietnam. The findings in my thesis are relevant to healthcare professionals and policy stakeholders. It demonstrates the magnitude of HAI burden and creates awareness of potential beneficial interventions. Results of my trials will be helpful to inform decisions to establish the antimicrobial stewardship programmes and infection prevention and control bundles to improve patients’ outcomes.