Clinical Care Quality Improvement in a Mozambique Hospital
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Transcript of Clinical Care Quality Improvement in a Mozambique Hospital
M. Preziosi MD, K.Lee MD, M. Tomas MD, T. Paunde MD, C. PaivaMD, S. Kinlin MD, R. Bene MD, H.Lopes MD, R. Ryder MD, E.VNoormahomed MD, PhD, E.A Spencer MD PhD, T. Zimba MD
Top 10” HIV prevalence Zimbabwe 25.84% Botswana 25.10%Namibia 19.94%Zambia 19.10%Swaziland 18.50%South Africa 16.70%Malawi 14.92%Moçambique 11.5%Tanzania 9.42%Lesotho 8.35%
Top Causes of Mortality
Malaria ( 29%) AIDS( 27%) Perinatal causes ( 7%) Diarrhea ( 4%) Pneumonia ( 4%) Trauma( 4%) Tb( 3%) CVA ( 3%) Neoplasias(1%) Sepsis(1%)
Mozambique- INE 2009
Bacteremia Study Design
Enrollment
Admitted to Internal Medicine Ward?
Axillary temp ≥ 38C?
HIV status known?
No antibiotics started?
Consent?
Inter
Medicine Wards
Identify problems in workflow
Quality improvement
Clinical Labs
Medical Records Paper charts Illegible Incomplete Hard to find or lost Retrospective
studies not possible
Hematology Lab
Chemistry Lab
Microbiology Lab
TB Reference Lab
Immunology Lab
Pathology
Patient ChartServentes
How do you do a prospective observational study in this environment and have reliable data?
1. Create a Team
Residents Nurse Lab tech ID attending American
collaborators
2. Use touch screen devices and webpage to collect and organize data
3. Repeated QI Cycles
Identify areas for quality improvement Propose solutions Implement and Measure Review Data and Repeat
Initial QI Projects
Increase enrollment Reduce contamination rate Improve documentation of CD4 counts
in charts Improve clinical follow-up in hospital
Preliminary Results- Bacteremia
Patient enrolled: 435
75 % HIV (Avg CD4=120, 44% on ARVs)
42 bloodstream infections (Staph aureus and Non- Typhoidal Salmonella most common.)
BSI 20 % in hospital-mortality
Blood culture contamination rate in study vs. hospital
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Study
Hospital
P < .001
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Sept Oct Nov Dec Jan Feb March April May June July August
Percentage of Enrolled Patients with documented CD4 count
P < .001
Percentage of patients with documented outcome
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October November December January February March April May June
Infectious Diagnoses other than HIV
N= 320
Microbiologic Confirmation?
Use of Empiric Antibiotics is Common, and Antibiotics are Rarely Changed
Antibiotic Use in Known Bacteremia Cases
Outcomes
Lessons learned
Think more about sepsis/bacteremia in differential diagnosis
Empiric antibiotic choices are often wrong
Blood culture is a useful test QI is possible at MCH Requires multidisciplinary organization,
great communication