In what is becoming something of a regular occurrence for Gauteng hospitals, another fire has broken at beleaguered Charlotte Maxeke Academic Hospital on Tuesday night. Fortunately, the fire was contained to a currently unused parking area in a damaged section of the hospital. The situation was deemed not to be serious enough to warrant a patient evacuation.
A fire in April 2021 caused the closure of seven wards, with some 200 beds. Reopening had long been delayed, and there have been complaints of thefts of equipment and construction material. Alleged corruption has continued to dog the full reopening of the 1088-bed academic hospital, overloading other hospitals and also impacting the training of student doctors.
An investigation by Spotlight revealed a number of factors for the 2021 fire including ageing infrastructure, essential equipment such as fire doors not working, low water pressure and incompatible fire hydrants (due to theft), a lack of evacuation plans and a fire service that was woefully underequipped.
Gauteng department of health spokesperson Motalatale Modiba gave a report on the latest fire: “Late on Tuesday night, security personnel reported that there was smoke that seemed to be coming from one of the structures. Firefighters for the City of Joburg immediately responded to the situation and managed to contain the fire which was confined to a small section of the level two parking.”
“The level two parking is one of the areas that was affected by the April 2021 fire and is currently under props and not accessible to the public or staff except for construction people,” Modiba said.
“Upon assessment of the situation clinicians on site together with the facility’s head of disaster made a call that the situation did not warrant for patients to be evacuated as the smoke from the fire was not too thick or high risk for inhalation.”
This comes after two fires broke out within weeks of one another at Steve Biko Academic Hospital.
A new US study has found that Ringer’s lactate may be a better and safer treatment option for emergency department and hospital patients than saline solution, especially in sepsis.
According to the study of nearly 150 000 hospital patients, which was published in JAMA Network Open, Intermountain Healthcare researchers found that patients who received Ringer’s lactate solution instead of normal saline for IV fluids had a lower risk of kidney injury and death than when they were given saline.
Saline solution has long been the standard for IV solution with more than 200 million litres administered to hospital patients annually in the US.
Intermountain researchers found that patients who were given Ringer’s lactate as an alternative to saline solution had a 2.2% reduced risk of kidney injury and death.
Joseph Bledsoe MD, principal investigator of the study, said: “That might not sound like a big difference but considering how many patients receive IV fluids every day, it could lead to a major improvement in health outcomes. For our health system alone, that’s 3000 people every year who may avoid complications from normal saline, at no additional cost.”
For this large-scale, study researchers encouraged clinicians, through education and electronic order entry alerts, to use Ringer’s lactate solution rather than saline solution for IV fluid treatment.
Saline solution is a combination of sodium chloride and water at a concentration of 9g of salt per litre (0.9%) which are levels higher than blood, commonly called normal saline.
Mounting evidence points to intravenous normal saline solution increasing the risk of metabolic acidosis, acute kidney injury, and death. This could be due to normal saline having higher levels of chloride and being slightly more acidic than fluids in the human body.
Though they have different ingredients, both Ringer’s lactate and normal saline are used for replacing fluids and electrolytes in hospital patients who have low blood volume or low blood pressure.
Ringer’s lactate contains electrolytes more similar to blood plasma than saline solution. Ringer’s lactate, which is a type of balanced crystalloid, is also much closer to human fluid pH and did not show the same related risk of kidney injury, in line with previous smaller studies.
The study included 148 423 adult patients admitted to the emergency department or inpatient units at 22 Intermountain Healthcare hospitals in Utah and Idaho between November 1, 2018, and February 29, 2020.
At 30 days post treatment, researchers found a 2.2% reduction in major adverse kidney events, including persistent kidney dysfunction, new initiation of dialysis, and death in patients who were given Ringer’s lactate rather than normal saline solution during their emergency department or hospital treatment course.
The impact was even greater on patients with sepsis and on patients who received more fluids as part of their treatment. Not all patients benefit from Ringer’s lactate – patients with brain injury may still benefit from normal saline, but further studies are needed.
Researchers determined that before the study, approximately 25% of patients received Ringer’s lactate, and 75% received normal saline solution. Afterward, the percentages flipped to 25% receiving normal saline and 75% Ringer’s lactate.
Researchers found that nudges in the Intermountain electronic order system were more effective in changing clinician habits than relying on education.
“Given the success of nudges in making this change, our success could be replicated in other health systems and allows for sustained improvement,” said Dr. Bledsoe. “Given the scope of this study, and its success in addition to previous studies, hospitals around the country should consider what they use for IV fluids, too.”
In an editorial about these findings published in the same issue of JAMA Network Open, Matthew W. Semler, MD, MSc, assistant professor of medicine at Vanderbilt University Medical Center, wrote that the study “raises important questions about the choice between Ringer’s lactate solution and saline and, more broadly, how we should make evidence-based choices between widely available, commonly used treatment alternatives in acute care.”
Compared to non-users, cannabis users have 22% higher rates in emergency department (ED) visits and hospitalisations, according to new research findings. The study, published in BMJ Open Respiratory Research revealed that serious physical injury and respiratory-reasons were the two leading causes of ED visits and hospitalisations among cannabis users.
The findings suggest an association between cannabis use and negative health events, which the researchers say should underline the need to educate and remind the public of the harmful impacts of cannabis on health.
“Our research demonstrates that cannabis use in the general population is associated with heightened risk of clinically serious negative outcomes, specifically, needing to present to the ED or be admitted to hospital,” said Dr Nicholas Vozoris, lead author, a respirologist at St. Michael’s and an associate scientist at the hospital’s Li Ka Shing Knowledge Institute.
“Unlike tobacco, there is some uncertainty or controversy regarding the adverse health impacts of cannabis. Some individuals may perceive that cannabis has some health benefits and is otherwise benign. Our research highlights to those using – or considering to use – cannabis, that this behaviour is associated with important negative health events.”
To compare health outcomes among cannabis users and individuals who don’t use cannabis, researchers used data collected in a survey of individuals who self-reported cannabis use and linked it with health administrative data for Ontario residents.
Using propensity score matching, researchers compared the health outcomes of nearly 4800 individuals who reported any cannabis use in the preceding 12 months with the health outcomes of over 10 000 individuals never-users, or having used cannabis only once and more than 12 months ago. Researchers incorporated 31 different variables while matching study participants to minimise an unfair comparison, including demographics, multiple physical and mental health diseases, and tobacco, alcohol and illicit drug use.
The study’s main aim was to see if there was a link between cannabis use and respiratory-related hospitalisation or ED visits. No significant associations were found between cannabis use and respiratory-related ED visits, hospitalisations, or death from any cause. However, they did find that overall visits to the ED or hospitalisations for any reason was significantly higher among cannabis users.
In addition to having greater odds of ED visits or hospitalisation, the findings show that one of every 25 cannabis users will go to the emergency department (ED) or be admitted to hospital within a year of using cannabis.
Among the reasons for ED visits or hospitalisations of cannabis users, acute trauma was the most common, with 15% of cannabis users who got medical attention receiving it for this reason, and 14% receiving care for respiratory reasons.
“The results of our research support that health care professionals and government should discourage recreational cannabis consumption in the general population,” noted Dr Vozoris.
Lessening sepsis’s deadly effects means quickly recognising its signs and symptoms, and initiating antibiotic treatments, but some experts have wondered whether this may contribute to antibiotic overuse, especially with time-to-treatment performance measures. A new study published in JAMA Internal Medicine showed that it was possible to effectively treat sepsis while engaging in antibiotic stewardship.
The study led by Hallie Prescott, MD, of the University of Michigan Health Division of Pulmonary and Critical Care and Vincent Liu, MD, of Kaiser Permanente Division of Research, looked at data from more than 1.5 million patients from 2013–2018. Patients included came to the emergency department with signs of systemic inflammatory response syndrome (SIRS), which includes increased heart rate, abnormal body temperature, among other signs.
The research team analysed antibiotics use in these patients, including number receiving antibiotics, when treatment started, treatment duration medications and the broadness of spectrum of the antibiotics.
“We showed in the overall cohort, that antibiotic use decreased. There was a slight decrease in the proportion treated within 48 hours, a more impressive decrease in the average number of days of antibiotic treatment, and also a decrease in the use of broad-spectrum antibiotics,” said Dr Prescott.
About half of the people who met the criteria for SIRS received antibiotics within 12 to 48 hours after admission, a practice that decreased slightly over time. At the same time, 30-day mortality, length of hospitalisation, and the development of multi-drug resistant bacteria also decreased.
“This study adds to our national conversation about how to combat sepsis most effectively. It also confirms that we now need to look for new opportunities to mitigate sepsis by finding patients at high risk before they arrive at the hospital, identifying hospitalised patients most likely to benefit from specific treatments, and enhancing their recovery after they survive sepsis,” said Dr Liu.
Dr Prescott agrees: “The pushback has been [time-to-treatment for sepsis] should not be a performance measure because it’s going to cause more harm than good, and I think our data shows it probably does more good than harm. We have shown that 152 hospitals have been able to make improvements in stewardship and sepsis treatment at the same time, contrary to popular belief.”
Physicians prescribe less analgesic medication during nightshifts than during the day, according to a new study published in PNAS.
In the first part of the study, 67 doctors were given empathy assessment tasks in the morning and asked to respond to simulated patient scenarios. These doctors were either at the end of a 26-hour shift or just beginning their workday. The study found that doctors who recently completed night shift showed less empathy for patient’s pain. For example, these physicians’ exhibited decreased emotional responses to pictures of people in pain and consistently scored their patients low on pain assessment charts.
In the second part of the study, the researchers looked at actual medical decisions made by emergency room doctors in the United States and Israel. Analysed 13 482 discharge letters for patients who came to the hospital in 2013–2020 with a chief complaint of pain, they found that physicians were 20–30% less likely to prescribe an analgesic during nightshifts (compared to daytime shifts) and in amounts less than generally recommended by the World Health Organization. “They’re tired and therefore they’re less empathic to patients’ pain. When we looked at ER doctors’ discharge papers, we found that they prescribed fewer painkillers,” explained Professor Shoham Choshen-Hillel from the Hebrew University of Jerusalem (HU)’s School of Business Administration and Federmann Center for the Study of Rationality, who led the study.
The bias persisted after adjusting for patients’ reported level of pain, patient and physician’s demographics, type of complaint, and emergency department characteristics. “Our takeaway is that nightshift work is an important and previously unrecognised source of bias in pain management, likely stemming from impaired perception of pain. The researchers explain that even medical experts, who strive to provide the best care for their patients, are susceptible to the effects of a nightshift,” noted co-lead author HU Psychology Department’s Dr Anat Perry.
Looking ahead, the researchers suggest implementing more structured pain management guidelines in hospitals. Another important implication relates to physician work structure, and the need to improve physicians’ working schedules. “Our findings may have implications for other workplaces that involve shiftwork and empathic decision-making, including crisis centres, first responders, and the military. In fact, these results should probably matter to all people who are sleep-deprived,” added co-lead author Dr Alex Gileles-Hillel from Hadassah Medical Center and HU.
On Sunday evening, another fire broke out at Steve Biko Academic Hospital – the second in two weeks. The fire damaged linen and prompted an evacuation but fortunately, there were no injuries resulting from the incident, Times Live reported.
Gauteng health department spokesperson Kwara Kekana said the cause of the latest fire was due to till-burning cigarette butts discarded by patients which “touched the ward linen room lights, burning the steel shelves and linen.”
Kekana said the damage was limited to a few items of linin. The fire started at around 6.15pm in a linen closet in a medical ward.
“The fire was quickly extinguished by staff. Patients were temporarily evacuated as a safety precaution because of smoke. By 8.15pm, patients were returned to the ward after the City of Tshwane declared the site safe,” Kekana said.
The previous fire at the hospital broke out at around 1:20am in a temporary storage area for COVID medical waste and as an in-transit corpse area. That fire affected temporary structures outside the hospital casualty area, and forced the evacuation of 18 patients.
This is the latest in a string of fires in Gauteng hospitals, such as the devastating fire at Charlotte Maxeke hospital – something which has caused concern for Gauteng Health MEC Nomathemba Mokgethi.
Speaking about the previous fire, she said that, “It looks like every year in the Department of Health we have to deal with fires. I will be getting a report the afternoon from the law enforcement agency, especially on the Charlotte issue.”
The problem of hospital fires is not confined to Gauteng: exactly a week earlier, a blaze broke out at Chatsmed Hospital in Durban.
Amid an ongoing worldwide shortage of contrast agent for medical imaging, a new UC San Francisco research letter in JAMA described strategies that can be used to safely reduce contrast agent use in computed tomography (CT) by up to 83%.
The three conservation strategies are weight-based (rather than fixed) dosing, reducing contrast dose while reducing tube voltage on scanners, and replacing contrast-enhanced CT with nonenhanced CT when it will minimally affect diagnostic accuracy.
That third strategy – not using the contrast agent in certain CT scans where there is only a small improvement in accuracy – yielded the most dramatic reduction of contrast agent use: 78%.
“Contrast is essential in any situation where we need to assess the blood vessels – for example, for some trauma patients or those with a suspected acute gastrointestinal bleed – and it is also needed for evaluation of certain cancers, such as in the liver or pancreas,” said senior study author Rebecca Smith-Bindman, MD, professor at UCSF.
“However, most CT scans are done for less specific indications such as abdominal pain in a patient with suspected appendicitis,” Prof Smith-Bindman added. “These can and should be done without contrast during the shortage, because the loss of information in these patients will be acceptable for most patients.”
The global shortage of contrast agent started in April with a COVID-related supply chain disruption of GE Healthcare in Shanghai and is expected to last at least several more weeks. More than 54 million diagnostic imaging exams using contrast agents are done every year in the US, a majority being CT scans, and these conservation methods could continue past the current shortage to reduce the use of contrast agent in general, the authors noted.
Referring clinicians are key to conservation Researchers modelled the three strategies individually and in combination using a sample of 1.04 million CT exams in the UCSF International CT Dose Registry from January 2015 to March 2021.
On its own, weight-based dosing for abdomen, chest, cardiac, spine and extremity imaging reduced contrast agent use by 10%; reducing the tube voltage in appropriate patients allowed a contrast agent reduction of 25%. These two measures combined with using non-contrast CT when possible led to a total reduction of 83%.
Following all three strategies at once may not be possible for some facilities, but each can help conserve supply, Prof Smith-Bindman said. And it is not just radiologists who need to know about them.
“Given the acute shortage, it’s important that clinicians who order imaging exams coordinate with radiology to cancel scans that aren’t absolutely necessary, postpone exams that can be safely delayed, replace CT with MRI and ultrasound where possible, and order an unenhanced scan where possible. Further, clinicians should communicate with their patients about why this is necessary. It is crucial that contrast be conserved for clinical situations where its use is essential for accurate diagnosis,” said Prof Smith-Bindman.
After the shortage ends, medical facilities should consider continuing some of these practices that conserve contrast agent, she added. For example, reducing the tube voltage not only reduces the contrast agent used but also lowers the radiation dose. Tailoring doses weight allows lower dosing volumes for many patients.
In addition, Prof Smith-Bindman noted that this analysis highlights the large amount of contrast agent that is wasted when single-dose vials are used Hospitals and imaging centres that routinely use single-dose contrast agent vials should consider using larger multi-dose vials, which allows for exact dosing and obviates the need to discard unused portions, she said.
“By carrying some of these practices forward, we can mitigate future supply-chain risk and reduce overall waste,” said Smith-Bindman.
Music session interventions were found to reduce anxiety among patients admitted to the intensive care unit (ICU), according to a systematic review and meta-analysis in the Journal of Clinical Nursing.
Reviewing 25 studies, music was found to significantly reduce anxiety scores overall, regardless of the system of measurement, reported Öznur Erbay Dalli, RN, MSc, PhD, of Bursa Uludag University in Turkey, and colleagues.
Music also significantly reduced anxiety scores versus standard care, including prescribed drugs or care protocol as part of usual treatment. This was comparable to noise-reducing methods. In the ICU, noise is an important driver of stress, the authors explained.
Throughout history, music has been used as one of the “proven non-pharmacological tools” to reduce anxiety, depression, and pain and to increase patient comfort, they added.
Dr Dalli told MedPage Todaythat ICU nurses and other healthcare workers may complement their daily routine care with music to reduce the anxiety of ICU patients and to avoid the side effects of medications, which are commonly used for treating anxiety.
No effect on diastolic blood pressure, respiration rate, or heart rate due to the music was seen. Subgroup analysis showed that multiple sessions produced better outcomes.
The researchers searched for studies published up to January 2022. All of the 25 included studies were randomised controlled trials or controlled clinical trials in 9 different countries with 1751 participants in total. Average age was 59 and 57% were male.
Of the anxiety assessment tools, the State-Trait Anxiety Inventory was the most commonly used tool (9 studies), followed by the Fear, Anxiety, and Stress Scale (4 studies) and the Visual Analogue Scale for Anxiety (2 studies).
Music interventions were mostly recorded music, although one study included a harp being played live. Music was used during rest times in most studies, though in four studies, music was used during specific procedures, like catheterisation or endotracheal suctioning.
No side effects were reported in the studies examined, but some patients objected to the choice of music, something which could be addressed by consultation with family members.
Limitations to the study included the fact that it was “difficult or impossible” to blind participants and other healthcare personnel involved in the study due to the nature of the intervention, which could lead to a “high risk of performance bias,” the authors noted. Additionally, the range of protocols and evaluation techniques used among the studies resulted in high heterogeneity.
Publication bias was possible due certain studies having small sample sizes, and a lack of available data.
The whistle-blowing paediatrician Dr Tim de Maayer who spoke out about appalling conditions at Rahima Moosa Mother and Child Hospital (RMMCH) was suspended yesterday, apparently in a retaliatory move.
In the widely-read open letter appearing on the Daily Maverick, he spoke of the preventable tragedy of babies dying due to lack of resources. This came shortly after a viral video showed pregnant mothers sleeping on the floor.
Presciently, the Daily Maverick, which broke the story, stated that there were two options: act to change the situation for the better, or “shoot the messenger”. As the newspaper wryly noted as it broke the news on Friday, 10 June, the option of shooting the messenger has been taken.
Although there appeared to be an initial positive response, Dr Maayer gave notice on Thursday evening that he was not able to come into work on Friday as he was being placed on suspension. RMMCH doctors then contacted the Daily Maverick.
His suspension leaves the hospital without its only paediatric gastroenterologist, according to an anxious doctor who got in touch with the Daily Maverick late Thursday night. The news has spread like wildfire across social media, with other doctors quick to come to Dr de Maayer’s defence.
A petition on Change.org to reinstate the paediatrician is being circulated by ordinary citizens and clinicians including Professor Shabir Madhi, who has been vocal in his support of Dr de Maayer.
The Progressive Health Forum (PHF) called for the suspension of Dr de Maayer to be overturned.
“Dr de Maayer has been suspended on the grounds that he has a voice, a conscience and a professional ethic and being a committed public health clinician. This pattern of victimisation has been repeatedly applied to clinicians who dare call out inadequacies of the administration and negative impact on clinicians and on the lives of patients,” the PHF said in a statement.
The delivery of the primary healthcare approach and the achievement of any semblance of universal health coverage are moot if South Africa does not rapidly address the critical skills shortages and working conditions of nurses, especially those with specialised skills, including midwives.
“The pandemic very clearly highlighted the crucial role that nurses play in the frontline of healthcare, and how important they are in ensuring that patients have access to quality health services and disease prevention, management and education. However, a combination of factors is stymieing attempts to grow our nursing capabilities and skills – from changes in the nurse training curriculum, limitations of and delays in the accreditation of training facilities, poor working conditions and workplace safety, lack of equipment and resources, low remuneration by global standards, the regulatory uncertainty around NHI, changing social dynamics which has seen declining nursing recruits, as well as the significant mental health deterioration that nurses have battled for two years of being on the frontline of the pandemic. Add to this the fact that we have a significant number of experienced nurses heading for retirement age without the commensurate follow through of new nursing talent coming through, and we have the makings of a serious crisis,” warns Paul Cox, Managing Director at the Essential Group of Companies including health insurance provider, EssentialMED.
“Making matters worse, South Africa’s nurses are in huge demand in many first world countries that suffer the same skills shortages. These countries offer significantly higher pay and better working and living conditions to attract talent to their shores. This is a significant risk as South Africa is losing some of its most experienced nurses and healthcare workers to emigration, and with it we lose vast amounts of institutional knowledge, specialisation, experience, training investment and mentoring and training skills,” he adds.
Data published by the South African Nursing Council (SANC) in 2021 shows that the country has a nursing staff contingent of one nurse to 213 patients – the World Health Organisation recommends a ratio of 1 nurse to 5 patients in a general hospital. While there are currently around 280,000 nurses in active employment and a further 21 000 nurses in training, the 2030 Human Resources for Health Strategy projects a shortage of 34 000 nurses in primary healthcare by 2025 if nothing is done to attract new talent to the nursing sector. According to SANC’s 2020 statistics, the ageing population of South Africa’s nursing population is another looming crisis. Its statistics show that less than a third of the registered nurses and midwives are under the age of 40, while 47% of registered nurses will have retired within the next 15 years. Primary healthcare will take a big hit given the important role of nurses in primary healthcare delivery, and TB, HIV and diabetes management programmes are likely to falter, with patients in remote and rural areas impacted the most.
Perplexingly, despite these serious skills shortages and looming crisis, nurses never made it onto the Critical Skills List released by the Department of Home Affairs at the end of February 2022, despite the huge demands that Government’s drive to NHI will make on already stretched and overburdened healthcare human resources.
“The implications of the current skills shortages and deteriorating working and safety conditions, notably in the public sector which takes care of more than 80% of the population, are plain to see. We already have a situation where healthcare facilities are struggling to fill posts – there are some 21,000 specialist medical personnel posts vacant across all provinces and which the Department of Health has thus far been unable to fill. What more then will the implications be for healthcare delivery under the proposed universal healthcare system of NHI? The Department of Health has acknowledged that the NHI will need skilled personnel to function not only across healthcare professionals, but general skilled human resources to underpin the health system. Right now, even the most fundamental of primary care delivery is in crisis due to skills shortages, exacerbated by the deleterious state of many public healthcare facilities and regular medicine stock-outs. More skilled and experienced nursing professionals are heading offshore, and at the same time, the sector is struggling to attract and train new nursing recruits to a profession and working environment that are increasingly unattractive to young South Africans. The planned introduction of the National Health Insurance scheme adds further grist to the wheel, with industry experts warning of a mass exodus of healthcare skills due to the valid concerns around the lack of financial and operational clarity of the plan,” adds Cox.
The current and future dwindling nurse staffing levels are a serious threat to patient health, safety and quality of care. Equally so to the health and safety of nurses due to increasing pressure on the remaining workforce to meet ever growing healthcare needs, fatigue and burnout, mental health issues and deteriorating work conditions. Poor resource allocation and poor maintenance of healthcare facilities need to be urgently addressed, and there needs to be the political will to dramatically improve the working conditions of the nurses who form the backbone of healthcare delivery. It is crucial that both public and private sector stakeholders collaborate to help bridge the skills challenges. A major acceleration of training is needed, and to do this it’s essential to fast-track the new education requirements and processes and accredit more nurse training colleges, allowing the private sector to contribute to closing the skills gap.
“Nurses are the single largest group of healthcare providers in our country representing 56% of all healthcare providers. The performance of our healthcare system – both public and private – is dependent on the quality of care provided by these professionals. Nurses are central to addressing the complex burden of disease, achieving the primary healthcare (PHC) approach as purported under universal health coverage, as well as improving health system performance across both the public and private healthcare sectors. The pandemic has shown unequivocally the need to value our nurses, to invest in nursing, resolve the nursing education challenges as a matter of priority, as well as address their working conditions, remuneration, practice environment, resources, management and leadership. Without a strong, skilled and growing nursing profession, any semblance of NHI and universal health coverage success in South Africa is questionable,” concludes Cox.
