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1.  Task Shifting for Scale-up of HIV Care: Evaluation of Nurse-Centered Antiretroviral Treatment at Rural Health Centers in Rwanda 
PLoS Medicine  2009;6(10):e1000163.
Fabienne Shumbusho and colleagues evaluate a task-shifting model of nurse-centered antiretroviral treatment prescribing in rural primary health centers in Rwanda and find that nurses can effectively and safely prescribe ART when given adequate training, mentoring, and support.
The shortage of human resources for health, and in particular physicians, is one of the major barriers to achieve universal access to HIV care and treatment. In September 2005, a pilot program of nurse-centered antiretroviral treatment (ART) prescription was launched in three rural primary health centers in Rwanda. We retrospectively evaluated the feasibility and effectiveness of this task-shifting model using descriptive data.
Methods and Findings
Medical records of 1,076 patients enrolled in HIV care and treatment services from September 2005 to March 2008 were reviewed to assess: (i) compliance with national guidelines for ART eligibility and prescription, and patient monitoring and (ii) key outcomes, such as retention, body weight, and CD4 cell count change at 6, 12, 18, and 24 mo after ART initiation. Of these, no ineligible patients were started on ART and only one patient received an inappropriate ART prescription. Of the 435 patients who initiated ART, the vast majority had adherence and side effects assessed at each clinic visit (89% and 84%, respectively). By March 2008, 390 (90%) patients were alive on ART, 29 (7%) had died, one (<1%) was lost to follow-up, and none had stopped treatment. Patient retention was about 92% by 12 mo and 91% by 24 mo. Depending on initial stage of disease, mean CD4 cell count increased between 97 and 128 cells/µl in the first 6 mo after treatment initiation and between 79 and 129 cells/µl from 6 to 24 mo of treatment. Mean weight increased significantly in the first 6 mo, between 1.8 and 4.3 kg, with no significant increases from 6 to 24 mo.
Patient outcomes in our pilot program compared favorably with other ART cohorts in sub-Saharan Africa and with those from a recent evaluation of the national ART program in Rwanda. These findings suggest that nurses can effectively and safely prescribe ART when given adequate training, mentoring, and support.
Please see later in the article for the Editors' Summary
Editors' Summary
Infection with the human immunodeficiency virus (HIV) is a serious health problem in sub-Saharan Africa. The virus attacks white blood cells that protect against infection, most commonly a type of white blood cell called CD4. When a person has been infected with HIV for a long time, the number of CD4 cells they have goes down, resulting in acquired immune deficiency syndrome (AIDS), in which the person's immune system no longer functions effectively.
The World Health Organization (WHO) has divided the disease into four stages as it progresses, according to symptoms including weight loss and so-called opportunistic infections. These are known as clinical stage I, II, III, or IV but were revised and renamed 1, 2, 3, and 4 in September 2005. HIV infection and AIDS cannot be cured but they can be managed with antiretroviral treatment (ART). The WHO currently recommends that ART is begun when the CD4 count falls below 350.
Rwanda is a country situated in the central Africa with a population of around 9 million inhabitants; over 3% of the rural population and 7% of the urban population are infected with HIV. In 2007, the WHO estimated that 220,000 Rwandan children had lost one or both parents to AIDS.
Why Was This Study Done?
The WHO estimates that 9.7 million people with HIV in low- to middle-income countries need ART but at the end of 2007, only 30% of these, including in Rwanda, had access to treatment. In many low-income countries a major factor in this is a lack of doctors. Rwanda, for example, has one doctor per 50,000 inhabitants and one nurse per 3,900 inhabitants.
This situation has led the WHO to recommend “task shifting,” i.e., that the task of prescribing ART should be shifted from doctors to nurses so that more patients can be treated. This type of reorganization is well studied in high-income countries, but the researchers wanted to help develop a system for treating AIDS that would be effective and timely in a predominantly rural, low-income setting such as Rwanda.
What Did the Researchers Do and Find?
In conjunction with the Rwandan Ministry of Health, the researchers developed and piloted a task-shifting program, in which one nurse in each of three rural Rwandan primary health centers (PHCs) was trained to examine HIV patients and prescribe ART in simple cases. Nurses had to complete more than 50 consultations observed by the doctor before being permitted to consult patients independently. More complex cases were referred to a doctor. The authors developed standard checklists, instructions, and evaluation forms to guide nurses and the doctors who supervised them once a week.
The authors evaluated the pilot program by reviewing the records of 1,076 patients who enrolled on it between September 2005 and March 2008. They looked to see whether the nurses had followed guidelines and monitored the patients correctly. They also considered health outcomes for the patients, such as their death rate, their body weight, their CD4 cell count, and whether they maintained contact with caregivers.
They found that by March 2008, 451 patients had been eligible for ART. 435 received treatment and none of the patients were prescribed ART when they should not have been. Only one prescription did not follow national guidelines.
At every visit, nurses were supposed to assess whether patients were taking their drugs and to monitor side effects. They did this and maintained records correctly for the vast majority of the 435 patients who were prescribed ART. 390 patients (over 90%) of the 435 prescribed receiving ART continued to take it and maintain contact with the pilot PHC's program. 29 patients died. Only one was lost to follow up and the others transferred to another ART site. The majority gained weight in the first six months and their CD4 cell counts rose. Outcomes, including death rate, were similar to those treated on the (doctor-led) Rwandan national ART program and other sub-Saharan African national (doctor-led) programs.
What Do These Findings Mean?
The study suggests that nurses are able to prescribe ART safely and effectively in a rural sub-Saharan setting, given sufficient training, mentoring, and support. Nurse-led prescribing of ART could mean that timely, appropriate treatment reaches many more HIV patients. It would reduce the burden of HIV care for doctors, freeing their time for other duties, and the study is already being used by the Rwandan Ministry of Health as a basis for plans to adopt a task-shifting strategy for the national ART program.
The study does have some limitations. The pilot program was funded and designed as a health project to deliver ART in rural areas, rather than a research project to compare nurse-led and doctor-led ART programs. There was no group of equivalent patients treated by doctors rather than nurses for direct comparison, although the authors did compare outcomes with those achieved nationally for doctor-led ART. The most promising sites, nurses, and patients were selected for the pilot and careful monitoring may have been an additional motivation for the nurses and doctors taking part. Health professionals in a scaled-up program may not be as committed as those in the pilot, who were carefully monitored. In addition, the nature of the pilot, which lasted for under three years and recruited new patients throughout, meant that patients were followed up for relatively short periods.
The authors also warn that they did not consider in this study the changes task shifting will make to doctors' roles and the skills required of both doctors and nurses. They recommend that task shifting should be implemented as part of a wider investment in health systems, human resources, training, adapted medical records, tools, and protocols.
Additional Information
Please access these Web sites via the online version of this summary at
PLoS Medicine includes a page collecting together its recent articles on HIV infection and AIDS that includes research articles, perspectives, editorials, and policy forums provides news, views, and information about science, technology, and the developing world, including a section specific to HIV/AIDs
The World Health Organization (WHO) has published a downloadable booklet Task Shifting to Tackle Health Worker Shortages
The WHO offers information on HIV and AIDS (in Arabic, Chinese, English, French, Russian, and Spanish) as well as health information and fact sheets on individual countries, including on Rwanda
The UNAIDS/WHO working group on HIV/AIDS and Sexually Transmitted Infections (STI) Surveillance gathers and publishes data on the prevalence of HIV and AIDS in individual countries, including on Rwanda
AIDS.ORG provides information to help prevent HIV infections and to improve the lives of those affected by HIV and AIDS. Factsheets on many aspects of HIV and AIDS are available. It is the official online publisher of AIDS Treatment News
PMCID: PMC2752160  PMID: 19823569
2.  Accuracy of Self-Screening for Contraindications to Combined Oral Contraceptive Use 
Obstetrics and gynecology  2008;112(3):572-578.
To estimate how well a convenience sample of women from the general population could self-screen for contraindications to combined oral contraceptives using a medical checklist.
Women 18-49 years old (N=1,271) were recruited at two shopping malls and a flea market in El Paso, Texas, and asked first whether they thought pills were medically safe for them. They then used a checklist to determine the presence of level 3 or 4 contraindications to combined oral contraceptives according to the World Health Organization Medical Eligibility Criteria. Women were then interviewed by a blinded nurse practitioner who also measured blood pressure.
The sensitivity of the unaided self-screen to detect true contraindications was 56.2% (95% CI: 51.7%-60.6%) and specificity 57.6% (54.0%-61.1%). The sensitivity of the checklist to detect true contraindications was 83.2% (79.5%-86.3%) and specificity 88.8% (86.3%- 90.9%). Using the checklist, 6.6% (5.2%-8.0%) of women incorrectly thought they were eligible for use when, in fact, they were contraindicated, largely due to unrecognized hypertension. Seven percent (5.4%-8.2%) of women incorrectly thought they were contraindicated when they truly were not, primarily due to misclassification of migraine headaches. In regression analysis, younger women, more educated women and Spanish-speakers were significantly more likely to correctly self-screen (p<0.05).
Self-screening for contraindications to oral contraceptives using a medical checklist is relatively accurate. Unaided screening is inaccurate and reflects common misperceptions about the safety of oral contraceptives. Over-the-counter provision of this method would likely be safe, especially for younger women and if independent blood pressure screening were encouraged.
PMCID: PMC2615461  PMID: 18757654
3.  How do caregivers know when to take their child for immunizations? 
BMC Pediatrics  2005;5:44.
Childhood vaccinations help reduce and eliminate many causes of morbidity and mortality among children. The objective of this study was to compare 4:3:1:3:3 (4+ doses of diphtheria and tetanus toxoids and pertussis vaccine, 3+ doses of poliovirus vaccine, 1+ doses of measles-containing vaccine, 3+ doses of Haemophilus influenzae type b vaccine, and 3+ doses of hepatitis B vaccine) coverage among children whose caregivers learned by different methods when their child's most recent immunization was needed.
Between July 2001 and December 2002, a portion of households receiving the National Immunization Survey were asked how they knew when to take the child in for his/her most recent immunization. Responses were post-coded into several categories: 'Doctor/nurse reminder at previous immunization visit', 'Shot card/record', 'Reminder/recall', and 'Other'. Respondents could give more than one answer. Children who did not receive any vaccines, had ≤ 1 visits for vaccinations, or whose caregiver did not provide an answer to the question were excluded from analyses. Chi-square analyses were used to compare 4:3:1:3:3 coverage among 19–35 month old children.
Children whose caregivers indicated that a doctor/nurse told them at a previous immunization visit when to return for the next immunization had significantly greater 4:3:1:3:3 coverage than those who did not choose the response (77.2% vs. 70.1%, p < 0.01). However, no significant difference in coverage was found between households that did/did not indicate that reminder/recalls (71.0% vs. 75.5%, p = 0.24) helped them remember when to take their child for their most recent immunization visit; only borderline significance was found between those that did/did not choose shot cards (70.6% vs. 76.2%, p = 0.07).
A doctor or nurse's reminder during an immunization visit of the next scheduled immunization visit effectively encourages caregivers to bring children in for immunizations, providing an inexpensive and easy way to effectively increase immunization coverage.
PMCID: PMC1314897  PMID: 16316458
4.  Health checks on patients 75 years and over in Nottinghamshire after the new GP contract. 
BMJ : British Medical Journal  1992;305(6854):619-621.
OBJECTIVE--To investigate annual health checks for patients of 75 years and over required by the 1990 contract for general practitioners. DESIGN--Visits to practices to collect information on how assessments were organised and carried out; completion of questionnaires for every patient who had been assessed in a sample month, using information provided by the practice records. SETTING--20 general practices in one family health services authority. SUBJECTS--Patients of 75 years and over in 20 general practices. RESULTS--Three practices (15%) had not performed checks. Thirteen practices sent a letter to invite patients to undergo a check. Of these practices, seven followed up non-responders. Two practices visited patients' homes unannounced, and two did checks on an opportunistic basis only. Sixteen practices used a checklist. Sixteen practices involved their practice nurses; at eight of these, doctors also performed checks; in six practices the nurses undertaking the checks had no training in assessing old people. Ten practices assessed more than 75% of their old people in the first year of the new contract. Practices that did not follow up patients who had not responded to the invitation for assessment completed significantly fewer checks. During the sample month, 331 patients were assessed in the 17 practices. 204 new problems were discovered in 143 patients. Significantly more problems per patient were found in inner city areas. CONCLUSIONS--The way health checks were performed varied greatly, both in their organisation and the practices' attitudes. Many old people did not respond to letters asking if they wanted an assessment but very few refused one if followed up. Forty three per cent of those assessed had some unmet need. The number of new problems found per patient may reduce over the next few years if the assessments are successful. The need for annual assessment should be kept under review and adequate resources made available for the needs uncovered. Improved training for practice nurses in assessment is needed. Effectiveness of the checks must be monitored. If most unmet need falls in particular high risk groups it would seem sensible to modify the annual check to target these groups.
PMCID: PMC1883333  PMID: 1393076
5.  Barriers to Provider-Initiated Testing and Counselling for Children in a High HIV Prevalence Setting: A Mixed Methods Study 
PLoS Medicine  2014;11(5):e1001649.
Rashida Ferrand and colleagues combine quantitative and qualitative methods to investigate HIV prevalence among older children receiving primary care in Harare, Zimbabwe, and reasons why providers did not pursue testing.
Please see later in the article for the Editors' Summary
There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children.
Methods and Findings
Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive.
The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed.
Please see later in the article for the Editors' Summary
Editors' Summary
Over 3 million children globally are estimated to be living with HIV (the virus that causes AIDS). While HIV infection is most commonly spread through unprotected sex with an infected person, most HIV infections among children are the result of mother-to-child HIV transmission during pregnancy, delivery, or breastfeeding. Mother-to-child transmission can be prevented by administering antiretroviral therapy to mothers with HIV during pregnancy, delivery, and breast feeding, and to their newborn babies. According to a report by the Joint United Nations Programme on HIV/AIDS published in 2012, 92% of pregnant women with HIV were living in sub-Saharan Africa and just under 60% were receiving antiretroviral therapy. Consequently, sub-Saharan Africa is the region where most children infected with HIV live.
Why Was This Study Done?
If an opportunity to prevent mother-to-child transmission around the time of birth is missed, diagnosis of HIV infection in a child or adolescent is likely to depend on HIV testing in health care facilities. Health care provider–initiated HIV testing and counselling (PITC) for children is important in areas where HIV infection is common because earlier diagnosis allows children to benefit from care that can prevent the development of advanced HIV disease. Even if a child or adolescent appears to be in good health, access to care and antiretroviral therapy provides a health benefit to the individual over the long term. The administration of HIV testing (and counselling) to children relies not only on health care workers (HCWs) offering HIV testing but also on parents or guardians consenting for a child to be tested. However, more than 30% of children in countries with severe HIV epidemics are AIDS orphans, and economic conditions in these countries cause many adults to migrate for work, leaving children under the care of extended families. This study aimed to investigate the reasons for acceptance and rejection of PITC in primary health care settings in Harare, Zimbabwe. By exploring HCW perspectives on providing HIV testing to children and adolescents, the study also sought to gain insight into factors that could be hindering implementation of testing procedures.
What Did the Researchers Do and Find?
The researchers identified all children aged 6 to 15 years old at six primary care clinics in Harare, who were offered HIV testing as part of routine care between 22 January and 31 May 2013. Study fieldworkers collected data on numbers of child attendances, numbers offered testing, numbers who underwent HIV testing, and reasons why HIV testing did not occur. During the study 2,831 children attending the health clinics were eligible for PITC, and just over half (1,534, 54.2%) underwent HIV testing. Eighty-two children tested HIV-positive, and nearly all of them received counselling, medication, and follow-up care. HCWs offered the test to around 75% of those eligible. The most frequent explanation given by HCWs for a diagnostic test not being offered was that the child was accompanied by a guardian not appropriate for providing consent (401 occasions, 59%); Other reasons given were a lack of available counsellors or test kits and counsellors refusing to conduct the test. The likelihood of being offered the test was lower for children not exhibiting symptoms (such as persistent skin problems), older children, or those attending with a male or a younger guardian. In addition, over 100 guardians or parents provided consent but left before the child could be tested.
The researchers also conducted semi-structured interviews with 12 clinic nurses and counsellors (two from each clinic) to explore challenges to implementation of PITC. The researchers recorded the factors associated with testing not taking place, either when offered to eligible children or when HCWs declined to offer the test. The interviewees identified the frequent absence or unavailability of parents or legal guardians as an obstacle, and showed uncertainty or misconceptions around whether testing of the guardian was mandatory (versus recommended) and whether specifically a parent (if one was living) must provide consent. The interviews also revealed HCW concerns about the availability of adequate counselling and child services, and fears that a child might experience maltreatment if he or she tested positive. HCWs also noted long waiting times and test kits being out of stock as practical hindrances to testing.
What Do These Findings Mean?
Prevalence of HIV was high among the children tested, validating the need for PITC in sub-Saharan health care settings. Although 76% of eligible attendees were offered testing, the authors note that this is likely higher than in routine settings because the researchers were actively recording reasons for not offering testing and counselling, which may have encouraged heath care staff to offer PITC more often than usual. The researchers outline strategies that may improve PITC rates and testing acceptance for Zimbabwe and other sub-Saharan settings. These strategies include developing clear laws and guidance concerning guardianship and proxy consent when testing older children for HIV, training HCWs around these policies, strengthening legislation to address discrimination, and increasing public awareness about HIV infection in older children.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Davies and Kalk
The Joint United Nations Programme on HIV/AIDS publishes an annual report on the global AIDS epidemic, which provides information on progress towards eliminating new HIV infections
The World Health Organization has more information on mother-to-child transmission of HIV
The World Health Organization's website also has information about treatment for children living with HIV
Personal stories about living with HIV/AIDS, including stories from young people infected with HIV, are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline
PMCID: PMC4035250  PMID: 24866209
6.  Child protection procedures in emergency departments 
Emergency Medicine Journal : EMJ  2007;24(12):831-835.
Emergency departments (EDs) may be the first point at which children who have been subject to abuse or neglect come into contact with professionals who are able to act for their protection. In order to ascertain current procedures for identifying and managing child abuse, we conducted a survey of EDs in England and Northern Ireland.
Questionnaires were sent to the lead professionals in a random sample of 81 EDs in England and 20 in Northern Ireland. Departments were asked to provide copies of their procedures for child protection. These were analysed qualitatively using a structured template.
A total of 74 questionnaires were returned. 91.3% of departments had written protocols for child protection. Of these, 27 provided copies of their protocols for analysis. Factors judged to improve the practical usefulness of protocols included: those that were brief; were specific to the department; incorporated both medical and nursing management; included relevant contact details; included a single page flow chart which could be accessed separately. 25/71 (35.2%) departments reported that they used a checklist to highlight concerns. The most common factors on the checklists included an inconsistent history or one which did not match the examination; frequent attendances; delay in presentation; or concerns about the child's appearance or behaviour, or the parent–child interaction.
There is a lack of consistency in the approach to identifying and responding to child abuse in EDs. Drawing on the results of this survey, we are able to suggest good practice guidelines for the management of suspected child abuse in EDs. Minimum standards could improve management and facilitate clinical audit and relevant training.
PMCID: PMC2658353  PMID: 18029514
7.  Contraindications to progestin-only oral contraceptive pills among reproductive aged women 
Contraception  2012;86(3):199-203.
Progestin-only oral contraceptive pills (POPs) have fewer contraindications to use compared to combined pills. However, the overall prevalence of contraindications to POPs among reproductive aged women has not been assessed.
Study Design
We collected information on contraindications to POPs in two studies: 1) the Self-Screening Study, a sample of 1,267 reproductive aged women in the general population in El Paso, Texas, and 2) the Prospective Study of Oral Contraceptive (OC) Users, a sample of current OC users who obtained their pills in El Paso clinics (n=532) or over the counter (OTC) in Mexican pharmacies (n=514). In the Self-Screening Study, we also compared women’s self-assessment of contraindications using a checklist to a clinician’s evaluation.
Only 1.6% of women in the Self-Screening Study were identified as having at least one contraindication to POPs. The sensitivity of the checklist for identifying women with at least one contraindication was 75.0% (95% CI: 50.6–90.4%), and the specificity was 99.4% (95% CI: 98.8–99.7%). In total, 0.6% of women in the Prospective Study of OC Users reported having any contraindication to POPs. There were no significant differences between clinic and OTC users.
The prevalence of contraindications to POPs was very low in these samples. POPs may be the best choice for the first OTC oral contraceptive in the US.
PMCID: PMC3368072  PMID: 22364816
oral contraceptives; contraindications; self-screening; over-the-counter status
8.  Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial 
BMC Family Practice  2006;7:44.
To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting.
A prospective cluster randomized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto. Preventive Care Checklist Forms© were created to be used by family physicians at adult health check-ups over a five-month period. The sex-specific forms incorporate evidence-based recommendations on preventive health services and documentation space for routine procedures such as physical examination. The forms were used in two intervention clinics and two control clinics. Rates and relative risks (RR) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to-date preventive health services delivered per patient were compared between the two groups.
Randomly-selected charts were reviewed at baseline (n = 509) and post-intervention (n = 608). Baseline rates for provision of preventive health services ranged from 3% (fecal occult blood testing) to 93% (blood pressure measurement), similar to other settings. The percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 48.9% in the control group and 71.7% in the intervention group. This is an overall 22.8% absolute increase (p = 0.0001), and 46.6% relative increase in the delivery of preventive health services per patient in the intervention group compared to controls. Eight of thirteen preventive health services showed a statistically significant change (p < 0.05) in favor of the intervention (adjusted RR (95% C.I.)): counseling on brushing/flossing teeth (9.2 (4.3–19.6)), folic acid counseling (7.5 (2.7–20.8)), fecal occult blood testing (6.7 (1.9–24.1)), smoking cessation counseling (3.9 (2.2–7.2)), tetanus immunization (3.0 (1.7–5.2)), history of alcohol intake (1.33 (1.2–1.5)), history of smoking habits (1.28 (1.2–1.4)) and blood pressure measurement (1.05 (1.00–1.10)).
This simple, low cost, clinically relevant intervention improves the delivery of preventive health services by prompting physicians of evidence-based recommendations in a checklist format that incorporates existing practice patterns. Periodic updates of the Preventive Care Checklist Forms© will allow a feasible and easy-to-use tool for primary care physicians to provide evidence-based preventive health services to adults at routine health check-ups. The forms can also be incorporated into an electronic health record. The Preventive Care Checklist Forms© are accessible in English and French at the College of Family Physicians of Canada web site.
PMCID: PMC1543627  PMID: 16836761
9.  Surgical checklists: the human factor 
Surgical checklists has been shown to improve patient safety and teamwork in the operating theatre. However, despite the known benefits of the use of checklists in surgery, in some cases the practical implementation has been found to be less than universal. A questionnaire methodology was used to quantitatively evaluate the attitudes of theatre staff towards a modified version of the World Health Organisation (WHO) surgical checklist with relation to: beliefs about levels of compliance and support, impact on patient safety and teamwork, and barriers to the use of the checklist.
Using the theory of planned behaviour as a framework, 14 semi-structured interviews were conducted with theatre personnel regarding their attitudes towards, and levels of compliance with, a checklist. Based upon the interviews, a 27-item questionnaire was developed and distribute to all theatre personnel in an Irish hospital.
Responses were obtained from 107 theatre staff (42.6% response rate). Particularly for nurses, the overall attitudes towards the effect of the checklist on safety and teamworking were positive. However, there was a lack of rigour with which the checklist was being applied. Nurses were significantly more sensitive to the barriers to the use of the checklist than anaesthetists or surgeons. Moreover, anaesthetists were not as positively disposed to the surgical checklist as surgeons and nurse. This finding was attributed to the tendency for the checklist to be completed during a period of high workload for the anaesthetists, resulting in a lack of engagement with the process.
In order to improve the rigour with which the surgical checklist is applied, there is a need for: the involvement of all members of the theatre team in the checklist process, demonstrated support for the checklist from senior personnel, on-going education and training, and barriers to the implementation of the checklist to be addressed.
PMCID: PMC3669630  PMID: 23672665
Surgical checklist; Surgery; Patient safety
10.  Tonsillitis and sore throat in children 
Surgery of the tonsils is still one of the most frequent procedures during childhood. Due to a series of fatal outcomes after hemorrhage in children in Austria in 2006, the standards and indications for tonsillectomy have slowly changed in Germany. However, no national guidelines exist and the frequency of tonsil surgery varies across the country. In some districts eight times more children were tonsillectomized than in others.
A tonsillectomy in children under six years should only be done if the child suffers from recurrent acute bacterially tonsillitis. In all other cases (i.e. hyperplasia of the tonsils) the low risk partial tonsillectomy should be the first line therapy. Postoperative pain and the risk of hemorrhage are much lower in partial tonsillectomy (=tonsillotomy). No matter whether the tonsillotomy is done by laser, radiofrequency, shaver, coblation, bipolar scissor or Colorado needle, as long as the crypts are kept open and some tonsil tissue is left behind. Total extracapsular tonsillectomy is still indicated in severely affected children with recurrent infections of the tonsils, allergy to antibiotics, PFAPA syndrome (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) and peritonsillar abscess. With regard to the frequency and seriousness of the recurrent tonsillitis the indication for tonsillectomy in children is justified if 7 or more well-documented, clinically important, adequately treated episodes of throat infection occur in the preceding year, or 5 or more of such episodes occur in each of the 2 preceding years (according to the paradise criteria). Diagnosis of acute tonsillitis is clinical, but sometimes it is hard to distinguish viral from bacterial infections. Rapid antigen testing has a very low sensitivity in the diagnosis of bacterial tonsillitis and swabs are highly sensitive but take a long time. In all microbiological tests the treating physician has to keep in mind, that most of the bacterials, viruses and fungi belong to the healthy flora and do no harm. Ten percent of healthy children even bear strepptococcus pyogenes all the time in the tonsils with no clinical signs. In these children decolonization is not necessary. Therefore, microbiological screening tests in children without symptoms are senseless and do not justify an antibiotic treatment (which is sometimes postulated by the kindergartens).
The acute tonsillitis should be treated with steroids (e.g. dexamethasone), NSAIDs (e.g. ibuprofene) and betalactam antibiotics (e.g. penicillin or cefuroxime). With respect to the symptom reduction and primary healing the short-term late-generation antibiotic therapy (azithromycin, clarithromycin or cephalosporine for three to five days) is comparable to the long-term penicilline therapy. There is no difference in the course of healing, recurrence or microbiological resistance between the short-term penicilline therapy and the standard ten days therapy.
On the other hand, only the ten days antibiotic therapy has proven to be effective in the prevention of rheumatic fever and glomerulonephritic diseases. The incidence of rheumatic heart disease is currently 0.5 per 100,000 children of school age.
The main morbidity after tonsillectomy is pain and the late haemorrhage. Posttonsillectomy bleeding can occur till the whole wound is completely healed, which is normally after three weeks. Life-threatening haemorrhages occur often after smaller bleedings, which can spontaneously cease. That is why every haemorrhage, even the smallest, has to be treated properly and in ward. Patients and parents have to be informed about the correct behaviour in case of haemorrhage with a written consent before the surgery.
The handout should contain important addresses, phone numbers and contact persons. Almost all cases of fatal outcome after tonsillectomy were due to false management of haemorrhage. Haemorrhage in small children can be especially life-threatening because of the lower blood volume and the danger of aspiration with asphyxia. A massive haemorrhage is an extreme challenge for every paramedic or emergency doctor because of the difficult airway management. Intubation is only possible with appropriate inflexible suction tubes.
All different surgical techniques have the risk of haemorrhage and even the best surgeon will experience a postoperative haemorrhage. The lowest risk of haemorrhage is after cold dissection with ligature or suturing. All “hot” techniques with laser, radiofrequency, coblation, mono- or bipolar forceps have a higher risk of late haemorrhage.
Children with a hereditary coagulopathy have a higher risk of haemorrhage. It is possible, that these children were not identified before surgery. Therefore it is recommended by the Society of paediatrics, anaesthesia and ENT, that a standardised questionnaire should be answered by the parents before tonsillectomy and adenoidectomy. This 17-point-checklist questionnaire is more sensitive and easier to perform than a screening with blood tests (e.g. INR and PTT). Unfortunately, a lot of surgeons still screen the children preoperatively by coagulative blood tests, although these tests are inappropriate and incapable of detecting the von Willebrand disease, which is the most frequent coagulopathy in Europe.
The preoperative information about the surgery should be done with the child and the parents in a calm and objective atmosphere with a written consent. A copy of the consent with the signature of the surgeon and both custodial parents has to be handed out to the parents.
PMCID: PMC4273168  PMID: 25587367
tonsillitis; tonsillectomy; intracapsular; extracapsular; antibiotics
11.  Improving Child Protection in the Emergency Department: A Systematic Review of Professional Interventions for Health Care Providers 
This systematic review evaluated the effectiveness of professional and organizational interventions aimed at improving medical processes, such as documentation or clinical assessments by health care providers, in the care of pediatric emergency department (ED) patients where abuse was suspected.
A search of electronic databases, references, key journals/conference proceedings was conducted and primary authors contacted. Studies whose purpose was to evaluate a strategy aimed at improving ED clinical care of suspected abuse were included. Study methodological quality was assessed by two independent reviewers. One reviewer extracted the data and a second checked for completeness and accuracy.
Six studies met the inclusion criteria: one randomized (RCT) and one quasi-randomized trial (qRCT), and four observational studies. Study quality ranged from modest (observational studies) to good (trials). Variation in study interventions and outcomes limited between study comparisons. One qRCT supported self-instructional education kits as a means to improve physician knowledge for both physical abuse (mean pre-test score: 13.12, SD 2.36; mean post-test score: 18.16, SD 1.64) and sexual abuse (mean pre-test score: 10.81, SD 3.20; mean post-test score: 18.45, SD 1.79). Modest quality observational studies evaluated reminder systems for physician documentation with similar results across studies. Compared to standard practice, chart checklists paired with an educational program increased physician consideration of non-accidental burns in burn cases (59% increase), documentation of time of injury (36% increase), as well as documentation of consistency (53% increase) and compatibility (55% increase) of reported histories. Decisional flowcharts for suspected physical abuse also increased documentation of non-accidental physical injury (69.5% increase; p<0.0001) and had a similar significant impact as checklists on increasing documentation of history consistency and compatibility (69.5% and 70.0% increases, respectively; p<0.0001) when compared to standard practice. No improvements were noted in these studies for documentation of consultations or current status with child protective services. The introduction of a specialized team and crisis center to standardize practice had little effect on physician documentation, but did increase documentation of child protective services involvement (22.7% increase; p<0.005) and discharge status (23.7% increase; p<0.02). Referral to social services increased in one study following the introduction of a chart checklist (8.6% increase; p=0.018). A recently conducted multi-site RCT did not support observational findings, reporting no significant effect of educational sessions and/or a chart checklist on ED practices.
The small number of studies identified in this review highlights the need for future studies that address care of a vulnerable clinical population. While moderate quality observational studies suggested education and reminder systems increased clinical knowledge and documentation, these findings were not supported by a single randomized trial. The limited theoretical base for conceptualizing change in health care providers and the influence of the ED environment on clinical practice are limitations to this current evidence base.
PMCID: PMC3023813  PMID: 20370740 CAMSID: cams1630
12.  Adjusting team involvement: a grounded theory study of challenges in utilizing a surgical safety checklist as experienced by nurses in the operating room 
BMC Nursing  2012;11:16.
Even though the use of perioperative checklists have resulted in significant reduction in postoperative mortality and morbidity, as well as improvements of important information communication, the utilization of checklists seems to vary, and perceived barriers are likely to influence compliance. In this grounded theory study we aimed to explore the challenges and strategies of performing the WHO’s Safe Surgical Checklist as experienced by the nurses appointed as checklist coordinators.
Grounded theory was used in gathering and analyzing data from observations of the checklist used in the operating room, in conjunction with single and focus group interviews. A purposeful sample of 14 nurse-anesthetists and operating room nurses as surgical team members in a tertiary teaching hospital participated in the study.
The nurses’ main concern regarding checklist utilization was identified as “how to obtain professional and social acceptance within the team”. The emergent grounded theory of “adjusting team involvement” consisted of three strategies; distancing, moderating and engaging team involvement. The use of these strategies explains how they resolved their challenges. Each strategy had corresponding conditions and consequences, determining checklist compliance, and how the checklist was used.
Even though nurses seem to have a loyal attitude towards the WHO’s checklist regarding their task work, they adjusted their surgical team involvement according to practical, social and professional conditions in their work environment. This might have resulted in the incomplete use of the checklist and therefore a low compliance rate. Findings also emphasized the importance of: a) management support when implementing WHO’s Safe Surgical Checklist, and b) interprofessional education approach to local adaptation of the checklists use.
PMCID: PMC3499446  PMID: 22958326
13.  Identification and characteristics of vaccine refusers 
BMC Pediatrics  2009;9:18.
This study evaluated the utility of immunization registries in identifying vaccine refusals among children. Among refusers, we studied their socioeconomic characteristics and health care utilization patterns.
Medical records were reviewed to validate refusal status in the immunization registries of two health plans. Racial, education, and income characteristics of children claiming refusal were collected based on the census tract of each child. Health care utilization was identified using both electronic medical record and insurance claims. Within the immunization registries of two HMOs in the study, some providers use refusal and medical contraindication interchangeably, and some providers tend to always use "ever refusal." Therefore, we combined medical contraindication and refusal together and treated them all as "refusal" in this study.
The immunization registry, compared to chart review, had negative predictive values of 85–92% and 90–97% for 2- and 6-year olds, and positive predictive values of only 52–74% and 59–62% to identify vaccine refusals. Refusers were more likely to reside in well-educated, higher income areas than non-refusers. Refusers had not opted out of health care system and continued, although less frequently for the age 2 and under group, to use services.
Without enhancements to immunization registries, identifying children with immunization refusal would be time consuming. Since communities where refusers live are well educated, interventions should target these communities to communicate vaccine adverse events and consequences of vaccine preventable diseases.
PMCID: PMC2667392  PMID: 19261196
14.  Implementation of the WHO safe childbirth checklist program at a tertiary care setting in Sri Lanka: a developing country experience 
To study institutionalization of the World Health Organization’s Safe Childbirth Checklist (SCC) in a tertiary care center in Sri Lanka.
A hospital-based, prospective observational study was conducted in the De Soysa Hospital for Women, Colombo, Sri Lanka. Healthcare workers were educated regarding the SCC, which was to be used for each woman admitted to the labor room during the study period. A qualitatively pretested, self-administered questionnaire was given to all nursing and midwifery staff to assess knowledge and attitudes towards the checklist. Each item of the SCC was reviewed for adherence.
A total of 824 births in which the checklist used were studied. There were a total of births 1800 during the period, giving an adoption rate of 45.8%. Out of the 170 health workers in the hospital (nurses, midwives and nurse midwives) 98 answered the questionnaire (response rate = 57.6%). The average number of childbirth practices checked in the checklist was 21 out of 29 (95% CI 20.2, 21.3). Educating the mother to seek help during labor, after delivery and after discharge from hospital, seeking an assistant during labor, early breast-feeding, maternal HIV infection and discussing contraceptive options were checked least often. The mean level of knowledge on the checklist among health workers was 60.1% (95% CI 57.2, 63.1). Attitudes for acceptance of using the checklist were satisfactory. Average adherence to checklist practices was 71.3%. Sixty eight (69.4%) agreed that the Checklist stimulates inter-personal communication and teamwork. Increased workload, poor enthusiasm of health workers towards new additions to their routine schedule and level of user-friendliness of Checklist were limitations to its greater use.
Amongst users, the attitude towards the checklist was satisfactory. Adoption rate amongst all workers was 45.8% and knowledge regarding the checklist was 60.1%. These two factors are probably linked. Therefore prior to introducing it to a facility awareness about the value and correct use of the SCC needs to be increased, while giving attention to satisfactory staffing levels.
PMCID: PMC4324022  PMID: 25648543
Safe childbirth; Checklist; World health organization; Sri Lanka
15.  Excluding pregnancy among women initiating antiretroviral therapy: efficacy of a family planning job aid 
BMC Public Health  2010;10:249.
Guidelines for initiating ART recommend pregnancy testing, typically a urine test, as part of the basic laboratory package. The principal reason for this recommendation is that Efavirenz, a first-line antiretroviral medication, has the potential of causing birth defects when used in the first trimester of pregnancy and is therefore contraindicated for use by pregnant women. Unfortunately, in many African countries pregnancy tests are not routinely provided or available in ART clinics, and, when available outside clinics, are often not affordable for clients.
Recently, the World Health Organization added a family planning job aid called the 'pregnancy checklist,' developed by researchers at Family Health International, as a recommended tool for screening new ART clients to exclude pregnancy. Although the checklist has been validated for excluding pregnancy among family planning clients, there are no data on its efficacy among ART clients.
This study was conducted to assess the clinical performance of a job aid to exclude pregnancy among HIV positive women initiating ART.
Non-menstruating women eligible for ART were enrolled from 20 sites in four provinces in Zambia. The pregnancy checklist was administered followed by a urine pregnancy test as a reference standard. Sensitivity, specificity, and positive and negative predictive values were estimated.
Of the 200 women for whom the checklist ruled out pregnancy, 198 were not pregnant, for an estimated negative predictive value of 99%. The sensitivity of the checklist was 90.0%, and specificity was 38.7%. Among the women, 416 out of 534 (77.9%) did not abstain from sex since their last menses. Only 72 out of the 534 women (13.4%) reported using reliable contraception. Among the 416 women who did not abstain, 376 (90.4%) did not use reliable contraception.
The pregnancy checklist is effective for excluding pregnancy in many women initiating ART, but its moderate sensitivity and specificity precludes its use to completely replace pregnancy testing. Its use should be encouraged in low resource settings where pregnancy tests are unavailable or must be rationed. Family planning methods should be available and integrated into ART clinics.
PMCID: PMC2876108  PMID: 20470367
16.  The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda 
PLoS Medicine  2008;5(6):e116.
The objective of the study was to compare rates of adverse events (AEs) related to male circumcision (MC) in HIV-positive and HIV-negative men in order to provide guidance for MC programs that may provide services to HIV-infected and uninfected men.
Methods and Findings
A total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization [WHO] stage I or II and CD4 counts > 350 cells/mm3) were circumcised in two separate but procedurally identical trials of MC for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1–2 d and 5–9 d, and at 4–6 wk, to assess surgery-related AEs, wound healing, and resumption of intercourse. AE risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios (AdjORs) were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrollment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe AEs were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (AdjOR 0.91, 95% confidence interval [CI] 0.47–1.74). Infections were the most common AEs (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 wk postsurgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). AEs were more common in men who resumed intercourse before wound healing compared to those who waited (AdjOR 1.56, 95% CI 1.05–2.33).
Overall, the safety of MC was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counseled to refrain from intercourse until full wound healing is achieved.
Trial registration:; for HIV-negative men, #NCT00047073 and for HIV-positive men, #NCT00047073.
Ron Gray and colleagues report on complications of circumcision in HIV-infected and HIV-uninfected men from two related trials in Uganda, finding increased risk with intercourse before wound healing.
Editors' Summary
Worldwide over 33 million people are thought to be living with HIV, and in the absence of a vaccine, preventing its spread is a major health issue. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate that 68% of 2.5 million new infections worldwide in 2007 took place in sub-Saharan Africa, where 76% of 2.1 million AIDS-related deaths also took place.
One of the principal means of person-to-person transmission of HIV is through sex without the protection of a condom. In parts of Africa, male circumcision is performed in infancy or childhood for religious or cultural reasons or is a traditional rite of passage that marks the transition from child to man. Three trials, in South Africa, Kenya, and Uganda, each found that circumcised men were around half as likely as uncircumcised men to contract HIV from HIV-positive female partners. After reviewing the results, WHO and UNAIDS issued joint advice that male circumcision should be promoted for preventing HIV infection in heterosexual men. As male circumcision does not provide complete protection against HIV infection, they advised that it should be promoted in addition to existing strategies of promoting condom use, abstinence, and a reduction in the number of sexual partners.
Why Was This Study Done?
Although earlier studies had shown that adult male circumcision, when performed in Africa under optimal conditions, is a safe procedure for HIV-negative men, it was not known whether it would also be a safe procedure for HIV-positive men. WHO guidelines recommend that HIV-positive men who request the procedure or have a medical need and no contraindications for it should be circumcised. Also, exclusion of HIV-positive men from circumcision programs may result in stigmatization of these men, and discourage participation by men who do not wish to be tested for HIV. Therefore, it is important to know whether the procedure is safe for HIV-positive men.
What Did the Researchers Do and Find?
The authors compared results from two separate clinical trials carried out with identical procedures in rural Rakai, Uganda. The first, which compared the effect of circumcision with no circumcision in HIV-negative men, was one of the three trials that persuaded the WHO and UNAIDS to promote male circumcision as an HIV prevention strategy. The second Rakai trial did the same comparison but in men who were HIV positive and without symptoms. In this present study, the authors used data from both trials to compare the likelihood of surgery-related complications following circumcision for HIV-negative and HIV-positive men.
The trials recruited men aged 15–49, who were randomly assigned to be circumcised either on enrollment or two years later and were followed up to monitor complications related to the procedure, such as infections, as well as wound healing and when the participant first had sex after the operation. Condom use was recorded at enrollment and six months after enrollment.
The researchers found that most complications were infrequent, mild, and comparable in both groups, with moderate-to-severe complications occurring in only 3%–4% of men in each group. However, delayed wound healing was more frequent in HIV-positive men. Complications were more likely among men who had sex before healing was complete; such men were more likely to be HIV-positive and/or married. Similarly, moderate or severe complications were more likely where men had symptoms of sexually transmitted disease at enrollment, although these were treated before surgery, and these men were more likely to be HIV-positive. Six months after enrollment, similar proportions of HIV-positive and HIV-negative men used condoms consistently, but HIV-positive men were more likely to report using condoms inconsistently than HIV-negative men. However, consistent use of a condom increased among the HIV-positive men compared to when they enrolled.
What Do these Findings Mean?
Circumcision in HIV-positive men without symptoms of AIDS has a low rate of complications, although healing is slower than in HIV-negative men. Because of the greater risk of complications if sex is resumed before full healing, both men and their women partners should be advised to have no sex for at least six weeks after the operation. A separately reported analysis from one of these studies found that women partners are more likely to become HIV infected by HIV-positive men who resume sex prior to complete wound healing. Therefore, for protection of both men and their female partners, it is essential to refrain from intercourse after circumcision until the wound has completely healed.
Because the study found no increased risk of surgical complications in HIV-positive men who undergo circumcision, it should not be necessary to screen men with no symptoms of HIV in future circumcision programs. This should reduce the complexity of implementing such programs and reduce any stigma resulting from exclusion, making it likely that more men will be willing to be circumcised. The rise in consistent condom use among HIV-positive men suggests that messages of safe sex are reaching an important target group and changing their behavior, and that circumcision does not make men less likely to use a condom.
The authors also noted that the rates of complications they observed were low compared with those following traditional circumcision procedures. Others have found that circumcision carried out under unsafe conditions has a high rate of complications. The authors of this study comment that the resources and standards of surgery during the trial represented best practice and that to attain similarly low rates of complications—and the confidence of men in the safety of the procedure—there is a need to ensure sufficient resources and high standards of training.
Additional Information.
Please access these Web sites via the online version of this summary at
WHO and the UNAIDS issued a joint report recommending male circumcision for HIV prevention and another on the HIV epidemic worldwide in December 2007
An information pack here on male circumcision and HIV prevention has also been developed jointly by WHO/UNAIDS, the United Nations International Children's Emergency Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Bank
The University of California San Francisco's HIV InSite provides information on HIV prevention, treatment, and policy
AEGIS is the world's largest searchable database on HIV and AIDS
The National AIDS Trust provides information on HIV prevention
PMCID: PMC2408615  PMID: 18532873
17.  A pragmatic randomised controlled trial of a prompt and reminder card in the care of people with epilepsy. 
BACKGROUND: The quality of epilepsy care has often been noted to be poor and fragmentary. Most people with epilepsy are solely under the care of their general practitioner (GP). Many patients report medication side-effects and poor seizure control. Most GPs accept responsibility for epilepsy care; however, many report problems with knowledge of epilepsy and nearly all support guidance on epilepsy management. AIM: To determine whether a GP-completed prompt and reminder card is effective in improving the quality of epilepsy care when used opportunistically. DESIGN OF STUDY: Primary care-based pragmatic cluster-randomised controlled trial. SETTING: People with active epilepsy (n = 1275) from 82 practices. METHOD: Practices were randomly categorised as 'control', 'doctor-held card' (card in patient records), or 'patient-held card' practices. RESULTS: Compared with control practices, recording of seizure frequency was significantly increased in doctor-held card practices (57.4% versus 42.8%, P = 0.003) but not in patient-held card practices (44.6% versus 42.8%). No differences were found in the proportion of seizure-free patients (doctor-held card [56.0%] versus control [51.5%]; patient-held card [58.1%] versus control [51.5%]) or in the proportion on monotherapy. Patients in both intervention groups reported more medication-related side-effects and patients in doctor-held card practices were less satisfied with information provision about epilepsy. Participating GPs found the card useful. The doctor-held card was retrieved and completed more often than the patient-held card. CONCLUSIONS: A doctor-held prompt and reminder card is effective in improving the recording of key clinical information for people with epilepsy, is felt to be useful by GPs, and is completed more often than a patient-held card. However it does not improve outcomes and may result in less patient-centred care.
PMCID: PMC1314230  PMID: 11885833
18.  Are physicians performing neonatal circumcisions well-trained? 
Notwithstanding the recommendations from the Canadian Pediatric Association and the American Academy of Pediatrics on the indications for neonatal circumcision, this procedure is still common in North America and throughout the world. Our purpose is not to argue whether this procedure should be done, but rather to examine who is doing it, their training, how it is performed and how can we prevent unsatisfactory results and complications. The objective is to identify what fields of knowledge require improvement and then design a teaching module to improve the outcomes of neonatal circumcision.
A 19-question cross-sectional survey, including a visual identification item, was submitted to 87 physicians who perform neonatal circumcisions in Southwestern Ontario, Canada. To improve our response rate, study subjects were contacted in a variety of ways, including mail and fax and telephone. Once the survey was completed, we produced a surgical technique training video on using the Gomco clamp and the Plastibell techiques. A knowledge dissemination workshop was held with survey participants to discuss contraindications and the use of anesthesia and management of complications of neonatal circumcision and to evaluate the surgical technique training video. A 6-month follow-up questionnaire was completed to determine the impact of the teaching course on participants’ daily practice.
In total, we received 54 responses (62% response rate). From these, 46 (85%) were family doctors and pediatricians, while the remaining 8 (15%) were pediatric general surgeons and urologists. The circumcisions were carried out with the Gomco clamp 35 (63%) and the Plastibell 21 (37%). No respondent admitted to learning the procedure through a structured training course. Of the non-surgeons, 19 (43%) learned to perform a circumcision from a non-surgeon colleague. A little over a third of the participants (17, 31%) were happy to perform a circumcision in a child born with a concealed penis, where circumcision is contraindicated. With respect to the early complications post-circumcision, 8 (100%) surgeons versus 29 (63%) non-surgeons felt comfortable dealing with bleeding (p = 0.046). In total, 7 (88%) surgeons versus 16 (35%) non-surgeons were comfortable dealing with urinary retention (p = 0.01). Also, 8 (100%) surgeons versus 24 (52%) non-surgeons were comfortable dealing with a wound dehiscence (p = 0.02). Moreover, 6 (75%) surgeons and 5 (10%) non-surgeons were comfortable managing meatal stenosis (p < 0.01). Five (63%) surgeons versus 15 (33%) non-surgeons were confident in dealing with a trapped penis post-circumcision (p = 0.24).
Our survey findings indicate that most physicians performing neonatal circumcisions in our community have received informal and unstructured training. This lack of formal instruction may explain the complications and unsatisfactory results witnessed in our pediatric urology practice. Many practitioners are not aware of the contraindications to neonatal circumcision and most non-surgeons perform the procedure without being able to handle common post-surgical complications. Based on our survey findings, we planned and carried out a formal training course to address these issues.
PMCID: PMC3758943  PMID: 24032062
19.  Validating child vaccination status in a demographic surveillance system using data from a clinical cohort study: evidence from rural South Africa 
BMC Public Health  2011;11:372.
Childhood vaccination coverage can be estimated from a range of sources. This study aims to validate vaccination data from a longitudinal population-based demographic surveillance system (DSS) against data from a clinical cohort study.
The sample includes 821 children in the Vertical Transmission cohort Study (VTS), who were born between December 2001 and April 2005, and were matched to the Africa Centre DSS, in northern KwaZulu-Natal. Vaccination information in the surveillance was collected retrospectively, using standardized questionnaires during bi-annual household visits, when the child was 12 to 23 months of age. DSS vaccination information was based on extraction from a vaccination card or, if the card was not available, on maternal recall. In the VTS, vaccination data was collected at scheduled maternal and child clinic visits when a study nurse administered child vaccinations. We estimated the sensitivity of the surveillance in detecting vaccinations conducted as part of the VTS during these clinic visits.
Vaccination data in matched children in the DSS was based on the vaccination card in about two-thirds of the cases and on maternal recall in about one-third. The sensitivity of the vaccination variables in the surveillance was high for all vaccines based on either information from a South African Road-to-Health (RTH) card (0.94-0.97) or maternal recall (0.94-0.98). Addition of maternal recall to the RTH card information had little effect on the sensitivity of the surveillance variable (0.95-0.97). The estimates of sensitivity did not vary significantly, when we stratified the analyses by maternal antenatal HIV status. Addition of maternal recall of vaccination status of the child to the RTH card information significantly increased the proportion of children known to be vaccinated across all vaccines in the DSS.
Maternal recall performs well in identifying vaccinated children aged 12-23 months (both in HIV-infected and HIV-uninfected mothers), with sensitivity similar to information extracted from vaccination cards. Information based on both maternal recall and vaccination cards should be used if the aim is to use surveillance data to identify children who received a vaccination.
PMCID: PMC3118246  PMID: 21605408
20.  Mobile and Fixed Computer Use by Doctors and Nurses on Hospital Wards: Multi-method Study on the Relationships Between Clinician Role, Clinical Task, and Device Choice 
Selecting the right mix of stationary and mobile computing devices is a significant challenge for system planners and implementers. There is very limited research evidence upon which to base such decisions.
We aimed to investigate the relationships between clinician role, clinical task, and selection of a computer hardware device in hospital wards.
Twenty-seven nurses and eight doctors were observed for a total of 80 hours as they used a range of computing devices to access a computerized provider order entry system on two wards at a major Sydney teaching hospital. Observers used a checklist to record the clinical tasks completed, devices used, and location of the activities. Field notes were also documented during observations. Semi-structured interviews were conducted after observation sessions. Assessment of the physical attributes of three devices—stationary PCs, computers on wheels (COWs) and tablet PCs—was made. Two types of COWs were available on the wards: generic COWs (laptops mounted on trolleys) and ergonomic COWs (an integrated computer and cart device). Heuristic evaluation of the user interfaces was also carried out.
The majority (93.1%) of observed nursing tasks were conducted using generic COWs. Most nursing tasks were performed in patients’ rooms (57%) or in the corridors (36%), with a small percentage at a patient’s bedside (5%). Most nursing tasks related to the preparation and administration of drugs. Doctors on ward rounds conducted 57.3% of observed clinical tasks on generic COWs and 35.9% on tablet PCs. On rounds, 56% of doctors’ tasks were performed in the corridors, 29% in patients’ rooms, and 3% at the bedside. Doctors not on a ward round conducted 93.6% of tasks using stationary PCs, most often within the doctors’ office. Nurses and doctors were observed performing workarounds, such as transcribing medication orders from the computer to paper.
The choice of device was related to clinical role, nature of the clinical task, degree of mobility required, including where task completion occurs, and device design. Nurses’ work, and clinical tasks performed by doctors during ward rounds, require highly mobile computer devices. Nurses and doctors on ward rounds showed a strong preference for generic COWs over all other devices. Tablet PCs were selected by doctors for only a small proportion of clinical tasks. Even when using mobile devices clinicians completed a very low proportion of observed tasks at the bedside. The design of the devices and ward space configurations place limitations on how and where devices are used and on the mobility of clinical work. In such circumstances, clinicians will initiate workarounds to compensate. In selecting hardware devices, consideration should be given to who will be using the devices, the nature of their work, and the physical layout of the ward.
PMCID: PMC2762853  PMID: 19674959
Study; multi-method study; observational study; mobility; mobile computers; computers; computer hardware; medical order entry systems; computerized physician order entry system; computerized provider order entry (CPOE)
21.  An audit of blood bank services 
An audit is a written series of simple, direct questions, which when answered and reviewed, tell whether the laboratory is performing its procedures, activities, and policies correctly and on time.
The aim of this study is to briefly highlight the importance of audit in blood bank services.
Materials and Methods:
An Audit of Blood Bank Services was carried out in a Blood bank of the tertiary care hospital, Central India by using the tool kit, (comprised of checklists) developed by Directorate General of Health Services, Dhaka WHO, July 2008.
After going through these checklists, we observed that there is no system for assessing the training needs of staff in the blood bank. There was no provision for duty doctor's room, expert room, medical technologist room and duty care service. There was no checklist for routine check for observation of hemolysis and deterioration of blood and plasma. There was no facility for separate private interview to exclude sexual disease in the donor. Requisition forms were not properly filled for blood transfusion indications. There was no facility for notification of donors who are permanently deferred. There were no records documented for donors who are either temporarily or permanently deferred on the basis of either clinical examination, history, or serological examination. It was found that wearing of apron, cap, and mask was not done properly except in serology laboratory. When the requisition forms for blood transfusions were audited, it was found that many requisition forms were without indications.
Regular audit of blood bank services needs to be initiated in all blood banks and the results needs to be discussed among the managements, colleagues, and staffs of blood bank. These results will provide a good opportunity for finding strategies in improving the blood bank services with appropriate and safe use of blood.
PMCID: PMC3977393  PMID: 24741651
Audit; blood bank; checklists; quality control
22.  Checking it twice: an evaluation of checklists for detecting medication errors at the bedside using a chemotherapy model 
Quality & Safety in Health Care  2010;19(6):562-567.
To determine what components of a checklist contribute to effective detection of medication errors at the bedside.
High-fidelity simulation study of outpatient chemotherapy administration.
Usability laboratory.
Nurses from an outpatient chemotherapy unit, who used two different checklists to identify four categories of medication administration errors.
Main outcome measures
Rates of specified types of errors related to medication administration.
As few as 0% and as many as 90% of each type of error were detected. Error detection varied as a function of error type and checklist used. Specific step-by-step instructions were more effective than abstract general reminders in helping nurses to detect errors. Adding a specific instruction to check the patient's identification improved error detection in this category by 65 percentage points. Matching the sequence of items on the checklist with nurses' workflow had a positive impact on the ease of use and efficiency of the checklist.
Checklists designed with explicit step-by-step instructions are useful for detecting specific errors when a care provider is required to perform a long series of mechanistic tasks under a high cognitive load. Further research is needed to determine how best to assist clinicians in switching between mechanistic tasks and abstract clinical problem solving.
PMCID: PMC3002832  PMID: 20724398
Medication error; medication safety; checklist; double check; error detection
23.  Frequency of use and knowledge of the WHO-surgical checklist in Swiss hospitals: a cross-sectional online survey 
The WHO-surgical checklist is strongly recommended as a highly effective yet economically simple intervention to improve patient safety. Its use and potentially influential factors were investigated as little data exist on the current situation in Switzerland.
A cross-sectional online survey with members (N = 1378) of three Swiss professional associations of invasive health care professionals was conducted in German, French, and Italian. The survey assessed use of, knowledge of and satisfaction with the WHO-surgical checklist. T-Tests and ANOVA were conducted to test for differences between professional groups. Bivariate correlations were computed to test for associations between measures of knowledge and satisfaction.
1090 (79.1%) reported the use of a surgical checklist. 346 (25.1%) use the WHO-checklist, 532 (38.6%) use the Swiss Patient Safety Foundation recommendations to avoid Wrong Site Surgery, and 212 (15.7%) reported the use of other checklists. Satisfaction with checklist use was generally high (doctors: 71.9% satisfied, nurses: 60.8% satisfied) and knowledge was moderate depending on the use of the WHO-checklist. No association between measures of subjective and objective knowledge was found.
Implementation of a surgical checklist remains an important task for health care institutions in Switzerland. Although checklist use is present in Switzerland on a regular basis, a substantial group of health care personnel still do not use a checklist as a routine. Influential factors and the associations among themselves need to be addressed in future studies in more detail.
PMCID: PMC4176192  PMID: 24304634
Dissemination of surgical checklist; Self-rated knowledge; Objective knowledge; Satisfaction; Patient safety; Survey data
24.  Mutans Streptococci Colonization in Relation to Feeding Practices, Age and the Number of Teeth in 6 to 30-Month-Old Children: An in vivo Study 
Background: Early childhood caries has been characterized as first affecting the primary maxillary anterior teeth, followed by the involvement of the primary molars. Other terms for dental caries in preschool children, which inappropriately may imply cause for the disease, includes baby bottle tooth decay, nursing caries, milk bottle syndrome, baby bottle caries, nursing bottle mouth and nursing mouth.
Aim: To explore the relationships of feeding practices, age and number of teeth present with mutans streptococci colonization in infants.
Design and setting: A comparative clinical study conducted on 160 children aged from 6 to 30 months in the Department of Pedodontics and Preventive Dentistry, Bapuji Dental College and Hospital in collaboration with Child Health Institute and Research Center and Department of Oral Pathology and Microbiology, Bapuji Dental College and Hospital, Davangere.
Materials and methods: Baseline data collection included: (i) Parents of the infants were asked open ended questions about the baby feeding practices, (ii) The age of the subjects were obtained from the immunization register maintained at Child Health Institute and Research Center and were grouped into group I (6-11 months), group II (12-17 months), group III (18-23 months) and group IV (24-30 months), (iii) Clinical examination of children was done by using mouth mirror and explorer in flash light.6 For each child number and location of erupted teeth was recorded, (iv) Microbial screening for mutans streptococci involved sampling of saliva from each child was performed by placing a sterile wooden tongue blade on the dorsum of the tongue and the number of colony forming units (CFU) were recorded.
Results: According to feeding practices, 34 children were in breastfed category, 39 were in baby bottle category and 87 children reported no bottle usage. Out of 160 children examined, a total 142 children were colonized with mutans streptococci. 18 children were found to be colonized with low colony forming units, 78 children were found to be colonized with moderate colony forming units and 64 children were colonized with high colony forming units. In baby bottle group, all of 39 subjects were reported to have sweetened milk, sugar in the bottle.
Conclusion: Among different feeding practices, all the three subgroups viz breastfed children, children with nursing bottle usage and children with no bottle usage, all have shown mutans streptococci acquisition. But breastfed children have shown least number of high colony forming units, which is increased in the case of children using nursing bottle and is maximum in the children who were neither breastfed nor fed with nursing bottle. Percentage of children colonized with mutans streptococci increases with age and as the number of teeth increase, number of colony forming units were also found to be increasing.
How to cite this article: Sharma R, Prabhakar AR, Gaur A. Mutans Streptococci Colonization in Relation to Feeding Practices, Age and the Number of Teeth in 6 to 30-Month-Old Children: An in vivo Study. Int J Clin Pediatr Dent 2012;5(2): 124-131.
PMCID: PMC4148738  PMID: 25206151
Mutans streptococci; Feeding practices; Early childhood caries (ECC); Colony forming units (CFU); Saliva
25.  WHO Surgical Checklist and Its Practical Application in Plastic Surgery 
Plastic Surgery International  2011;2011:579579.
The WHO surgical checklist was introduced to most UK surgical units following the WHO “Safe Surgery Saves Lives” initiative. The aim of this audit was to review patient's safety in the delivery of surgical care and to evaluate the practical application of the new WHO surgical checklist. We conducted a retrospective audit of patients who received operative treatment under general anaesthesia at our Plastic Surgery Department, involving a total number of 90 patients. The WHO form was compared to its former equivalents. Complications or incidents occurring during or after surgery were recorded. Using the department's previous surgical checklist, “Time out” was only performed in only 30% of cases. One patient arrived at theatre reception without a completed consent form, and two clinical incidents were reported without patients suffering harm. Following introduction of current WHO surgical checklist, “Time out” was recorded in 80% of cases. In all cases, the new WHO surgical checklist was used and no incidents were reported. The WHO surgical checklist provides a structured frame work that standardizes the delivery of care across hospitals and specialized units; however, it will take some time and practice for teams to learn to use the checklist effectively and reliably.
PMCID: PMC3335640  PMID: 22567243

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