Summary of the International Patient Safety Conference, June 28—29, 2019, Kathmandu, Nepal
Globally, medical errors are associated with an estimated $42 billion in costs to healthcare systems. A variety of errors in the delivery of healthcare have been identified by the World Health Organization and it is believed that about 50% of all errors are preventable. Initiatives to improve patient safety are now garnering increased attention across a range of countries in all regions of the world. From June 28--29, 2019, the first International Patient Safety Conference (IPSC) was held in Kathmandu, Nepal and attended by over 200 healthcare professionals as well as hospital, government, and non-governmental organization leaders. During the conference, presentations describing the experience with errors in healthcare and solutions to minimize future occurrence of adverse events were presented. Examples of systems implemented to prevent future errors in patient care were also described. A key outcome of this conference was the initiation of conversations and communication among important stakeholders for patient safety. In addition, attendees and dignitaries in attendance all reaffirmed their commitment to furthering actions in hospitals and other healthcare facilities that focus on reducing the risk of harm to patients who receive care in the Nepali healthcare system. This conference provides an important springboard for the development of patient-centered strategies to improve patient safety across a range of patient care environments in public and private sector healthcare institutions.
Antibiotic Stewardship in Burn and Chronic Wound Centers in Nepal
Data surrounding antibiotic stewardship (AMS) in burn and chronic wound centers in low- and middle-income countries (LMIC) are limited. Given the long-term nature of the wounds, increased risk of infection and the potential for further infections being treated with antibiotics, burn and chronic wound centers represent a unique opportunity for antimicrobial stewardship.
Three hospitals that maintain long-term burn or chronic wound wards were selected in two regions in Nepal. A post-prescription review and feedback program (PPRF) was instituted in these departments, and locally salient antibiotic practice guidelines were developed based on international and local standards by the research team and local experts. Chosen physicians at each facility were trained as master physician champions. Champions subsequently trained physicians in their wards and ensured that guidelines were followed by prescribing physicians. Baseline and post-intervention phases covered 5 months each during 2018–2019. During the post-intervention phase, physician champions reviewed antimicrobial use at 72 hours and made one of the three recommendations if the antibiotic course was deemed unjustified: changing the antibiotic, stopping the antibiotic course, or de-escalation of the antibiotic.
482 patients were enrolled throughout the duration of the study, with 241 patients in each of the baseline and post-intervention periods. The average length of stay was 8.0 days in baseline (range 3–48 days) vs. 6.4 days (range 3–70 days) during post-intervention. Between baseline and post-intervention, IV antibiotics decreased from 1,161 antibiotic-days per 1,000 patient-days (PD/1,000) to 1,137 PD/1,000. Oral antibiotics decreased from 101 PD/1,000 to 77 PD/1,000. In addition, cephalosporins decreased from 526 PD/1,000 to 474 PD/1,000, and aminoglycosides decreased from 264 PD/1,000 to 117 PD/1,000.
Appropriate antimicrobial use is vital in patients with a long length of stays in the hospital to reduce the development of multi-drug-resistant organisms. This intervention showed that a post-prescription review and feedback model can have impact in chronic wound and burn centers in Nepal and be further adapted for use in other LMIC.
Evaluation of a Hospital-Based Post-Prescription Review and Feedback Pilot in Kathmandu, Nepal
Capacity building is needed in low- and middle-income countries (LMICs) to combat antimicrobial resistance (AMR). Stewardship programs such as post-prescription review and feedback (PPRF) are important components in addressing AMR. Little data are available regarding effectiveness of PPRF programs in LMIC settings. An adapted PPRF program was implemented in the medicine, surgery, and obstetrics/gynecology wards in a 125-bed hospital in Kathmandu. Seven "physician champions" were trained. Baseline and post-intervention patient chart data were analyzed for changes in days of therapy (DOT) and mean number of course days for intravenous and oral antibiotics, and for specific study antibiotics. Charts were independently reviewed to determine justification for prescribed antibiotics. Physician champions documented recommendations. Days of therapy per 1,000 patient-days for courses of aminoglycoside (P < 0.001) and cephalosporin (P < 0.001) decreased. In the medicine ward, data indicate increased justified use of antibiotics (P = 0.02), de-escalation (P < 0.001), rational use of antibiotics (P < 0.01), and conforming to guidelines in the first 72 hours (P = 0.02), and for definitive therapy (P < 0.001). Physician champions documented 437 patient chart reviews and made 138 recommendations; 78.3% of recommendations were followed by the attending physician. Post-prescription review and feedback can be successfully implemented in LMIC hospitals, which often lack infectious disease specialists. Future program adaptation and training will focus on identifying additional stewardship programming and support mechanisms to optimize antibiotic use in LMICs.
Feasibility of a Comprehensive Targeted Cholera Intervention in The Kathmandu Valley, Nepal
A comprehensive targeted intervention (CTI) was designed and deployed in the neighborhoods of cholera cases in the Kathmandu Valley with the intent of reducing rates among the neighbors of the case. This was a feasibility study to determine whether clinical centers, laboratories, and field teams were able to mount a rapid, community-based response to a case within 2 days of hospital admission. Daily line listings were requested from 15 participating hospitals during the monsoon season, and a single case initiated the CTI. A standard case definition was used: acute watery diarrhea, with or without vomiting, in a patient aged 1 year or older. Rapid diagnostic tests and bacterial culture were used for confirmation. The strategy included household investigation of cases; water testing; water, sanitation, and hygiene (WASH) intervention; and health education. A CTI coverage survey was conducted 8 months postintervention. From June to December of 2016, 169 cases of Vibrio cholerae O1 were confirmed by bacterial culture. Average time to culture result was 3 days. On average, the CTI Rapid Response Team (RRT) was able to visit households 1.7 days after the culture result was received from the hospital (3.9 days from hospital admission). Coverage of WASH and health behavior messaging campaigns were 30.2% in the target areas. Recipients of the intervention were more likely to have knowledge of cholera symptoms, treatment, and prevention than non-recipients. Although the RRT were able to investigate cases at the household within 2 days of a positive culture result, the study identified several constraints that limited a truly rapid response.
Epidemiology of multi drug resistant gram negative bacteria in Kathmandu, Nepal
Purpose: Multi drug resistant (MDR) bacterial infections are considered to be hospital-acquired in high income countries. Little data are available regarding the epidemiology of MDR bacteria in low and middle-income countries. Our study looked at the epidemiology of gram negative bacterial infections in Kathmandu, Nepal.
Social and Economic Burden Associated With Typhoid Fever in Kathmandu and Surrounding Areas: A Qualitative Study
Typhoid fever is a significant contributor to infectious disease mortality and morbidity in low- and middle-income countries, particularly in South Asia. With increasing antimicrobial resistance, commonly used treatments are less effective and risks increase for complications and hospitalizations. During an episode of typhoid fever, households experience multiple social and economic costs that are often undocumented. In the current study, qualitative interview data from Kathmandu and surrounding areas provide important insights into the challenges that affect those who contract typhoid fever and their caregivers, families, and communities, as well as insight into prevention and treatment options for health providers and outreach workers. When considering typhoid fever cases confirmed by blood culture, our data reveal delays in healthcare access, financial and time costs burden on households, and the need to increase health literacy. These data also illustrate the impact of limited laboratory diagnostic equipment and tools on healthcare providers’ abilities to distinguish typhoid fever from other febrile conditions and treatment challenges associated with antimicrobial resistance. In light of these findings, there is an urgent need to identify and implement effective preventive measures including vaccination policies and programs focused on at-risk populations and endemic regions such as Nepal.
Factors Determining Availability, Utilization and Retention of Child Health Card in Western Nepal
Background: The immunization card is revised with addition of general information about child health and is later called as child health card. This card is a tool used by Health Management Information System in Nepal. It is important for tracking the records of immunization. Aim is to identify the factors determining the availability, utilization and retention of the child health card in Western Nepal.
Methods: A cross sectional study was conducted among mothers having children < 24 months old from Gorkha (Western Hill) and Nawalparasi (Western Terai) districts. The sample size for the study was 600 and systematic random sampling was used to select the mothers having less than 24 months old children. Data entry and analysis was done by using SPSS. Qualitative data was analyzed by making matrix.
Results: The average age of respondents was 24 years. The majority of respondents have gained higher level education. Retention of the card was found to be 82.2%. 90.3% retention was seen among 0-12 months children age group whereas it was 74 % among12 to 24 months age group. The reasons for less retention were torn by the child/played by child (54.6%) followed by lack of proper place,unaware about importance and poor quality of card.The new child health cards were insufficient, compelling use of both new and old cards which created problem in consistency. Regarding utilization of child health card, it was found to be used for birth registration and for further studies in abroad.
Conclusions: The areas of utilization of child health card should be broadened so that the retention of card can be increased. The main reasons for less retention of the card are torn by children and lack of the proper place.
Typhoid Vaccine Introduction: An Evidence-Based Pilot Implementation Project in Nepal and Pakistan
The World Health Organization (WHO) in 2008 recommended the use of currently licensed typhoid vaccines using a high risk or targeted approach. The epidemiology of disease and the vaccine characteristics make school-based vaccination most feasible in reducing typhoid disease burden in many settings. To assess feasibility of school-based typhoid vaccination, two districts in Kathmandu, Nepal and two towns in Karachi, Pakistan were selected for pilot program. Vaccination campaigns were conducted through the departments of health and in partnerships with not-for-profit organizations. In total 257,015 doses of Vi polysaccharide vaccine were given to students in grades 1-10 of participating schools. The vaccination coverage ranged from 39 percent (38,389/99,503) in Gulshan town in Karachi, to 81 percent (62,615/77,341) in Bhaktapur in Kathmandu valley. No serious adverse event was reported post vaccination. The coverage increased for vaccination of the second district in Pakistan as well as in Nepal. There was an initial concern of vaccine safety. However, as the campaign progressed, parents were more comfortable with vaccinating their children in schools. Supported and conducted by departments of health in Pakistan and Nepal, a school-based typhoid vaccination was found to be safe and feasible.
25 Years after Vi Typhoid Vaccine Efficacy Study, Typhoid Affects Significant Number of Population in Nepal
Salmonella Typhi, first isolated in 1884, results in infection of the intestines and can end in death and disability. Due to serious adverse events post vaccination, whole cell killed vaccines have been replaced with new generation vaccines. The efficacy of Vi polysaccharide (ViPS) vaccine, a new generation, single-dose intramuscular typhoid vaccine was assessed in Nepal in 1987. However, despite the availability of ViPS vaccine for more than 25 years, Nepal has one of the highest incidence of typhoid fever. Therefore we collected information from hospitals in the Kathmandu Valley from over the past five years. There were 9901 enteric fever cases between January 2008 and July 2012. 1,881 of these were confirmed typhoid cases from five hospitals in the Kathmandu district. Approximately 70% of the cases involved children under 15 years old. 1281 cases were confirmed as S. Paratyphi. Vaccines should be prioritized for control of typhoid in conjunction with improved water and sanitation conditions in Nepal and in endemic countries of Asia and Africa.
Factors Associated Participation in a School Based Typhoid Vaccination Campaign in Nepal
The study aimed to determine the factors associated with parents’ decision of their child participation in a school-based typhoid vaccination program in Lalitpur District, Nepal.
Following a typhoid vaccination campaign in 2012, a household cross-sectional survey, following a two stage stratified, cluster-sampling strategy. The strata were based on type of school (public/private) and geographic location (urban/rural). Data were collected through a structured questionnaire ensuring standard quality practices. Logistic regression analysis was used to assess the effect of socio-economic and behavioral characteristics with participation in the school-based vaccination campaign. The study was approved by Institutional Review Board of International Vaccine Institute and Nepal Health Research Council.
A total of 1,248 interviews were conducted with parents of children from 42 schools with a response rate of 85 percent. The participation in the vaccination campaign was statistically significantly associated with confidence on the organization conducting the vaccination campaign (OR=0.2; 95% CI: 0.1 - 0.7) knowledge of typhoid vaccine preventing the disease (OR=9; 95% CI: 4.2 - 19.7), concern of vaccine related adverse events following vaccination (OR=0.3; 95% CI: 0.2 - 0.6), information on typhoid vaccination campaign (OR=3; 95% CI: 1.9 - 5.0), and receipt of a permission slip for the child to receive the vaccine from school (OR=2; 95% CI: 1.3 - 3.2).
Our results suggest that participation in a school-based vaccination program is associated with knowledge of disease specific vaccine on safety and effectiveness, if the parent was reached effectively by the vaccination teams through information material, and if the population have confidence in the organization that is conducting the vaccination campaign. Our results are consistent with the findings from vaccination programs on typhoid and other vaccines, globally and in Asia on a perceived risk of the disease, knowledge and confidence over vaccines and a set of communication channels by which parents are informed about the vaccine benefits to the target population.