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Outcomes of diaphyseal femur fractures managed in children 10 years and younger at Charlotte Maxeke Johannesburg Academic Hospital
(University of the Witwatersrand, Johannesburg, 2023-10) Hitge, Curran; Robertson, Anthony; Simmons, Dina
Introduction: Paediatric femur fractures have a bimodal age presentation. Children under the age of six are generally treated with non-operative management, while those older than ten have been shown to do better with surgical fixation. The management of the intermediate age group of six to ten years remains controversial, with recent opinions tending to favour surgical fixation. At Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) a clearly defined stepwise protocol has been established, in which patients that do not meet defined indications for surgery are managed in skin traction until clinical and radiological signs of union are present, at which point, patients are discharged to weight-bear as tolerated. Methods: This study was a retrospective review with a prospective recall of paediatric orthopaedic patients aged 10 years and younger treated in skin traction for femur fractures at CMJAH from January 2016 to December 2018. X-ray parameters were assessed on the Picture Archiving and Communication System for patients who met the inclusion criteria. Patients were then followed up at a minimum of 24 months to assess outcomes according to Flynn’s criteria. Other variables assessed included length of hospital stay and rotational profiles. Results: One hundred and seventy-nine patients were admitted to the paediatric orthopaedic ward at CMJAH with femur fractures over this period. Sixty-nine patients met the inclusion criteria set out in the study, of which 31 were available for follow-up. Seventy-seven percent of patients were aged 5 years and younger and 52% of injuries occurred due to low velocity falls. In terms of complications, 3 patients were found to have a limb length discrepancy, none of which exceeded 1cm. Three patients were found to have radiological malunion of >5 degrees. One patient sustained a pressure sore which healed uneventfully, and no patients had any joint stiffness, pain or refracture. Twenty-four of the patients achieved excellent outcomes, with 6 satisfactory and 1 poor outcome. No patients reported any subjective concerns or complaints with the outcome. Time in traction showed a median of 25 days per patient, with increased length of traction having a significant correlation to advancing age. There was a median time to full weight-bearing of 6 weeks and a median of 8 weeks of school missed per child. Conclusion: The majority of patients with femur fractures treated non-operatively at CMJAH went on to excellent outcomes with no patient subjective complaints. These findings were comparable to similar studies reviewing surgical management. The findings in this study suggest that there is a role for promoting our protocol of treatment to surrounding regional and peripheral hospitals that do not have access to orthopaedic expertise to offload specialist hospitals.
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A Cost Comparison study of the electronic tick register with a paper based tick register in clinics within the Ekurhuleni District
(University of the Witwatersrand, Johannesburg, 2023-08) Khoza, Courage Macduff; Thomas, Leena Susan
Introduction & Background: A paper-based register is used to capture routine health information from Primary Health Care (PHC) clinics into the District Health Information System (DHIS) in South Africa. However, DHIS data was reportedly unreliable and inaccurate, as the paper-based system was error-prone. To address this, the Ekurhuleni Health District in the Gauteng Department of Health (GDOH) developed and piloted an electronic (E-tick) PHC register in three of its facilities. Upon completing the pilot in 2019, the implementation of this system was halted as it was not incorporated into the GDOH budget, partly due to inadequate information on its costs compared to the paper-based system. Aim: This study aims to cost and compare the expenditure of the electronic tick register and the paper-based tick register systems and determine provider views on their use in the Ekurhuleni Health District. Methods: Two methods were used: a) a descriptive cost-comparison study of the paper-based tick and the E-tick registers from November 2017 to December 2019 and b) a descriptive cross-sectional study using interviewer-administered questionnaires about health worker experiences using both registers during the stated period. Results: The study found that the E-tick register was less costly than the paper-based register. The year 2018/19, which was the only complete financial year in the study period is used for comparison. The paper-based register cost the district R42.4 per patient, while the E-tick cost R29.9 (29.5% cheaper). Of ten study theme areas explored in the interviews, the E-tick was advantageous in eight, these were: Convenience, easy accesses, quick recording time, safe information storage, immediate data capturing, ability to add more elements, fewer errors and good font size and legibility. The paper-based register was found to be advantageous in just four study themes which were: Convenience, easy accesses, independence from electricity supply and sufficient writing space. Conclusions: The E-tick register was found to be preferred over the paper-based register as it was quicker, cheaper, and acceptable to most of the health workers who used it. These are important findings for the health district as the study generates local evidence that the Ekurhuleni Health District and the Gauteng Department of Health can use to justify investments in scaling up and sustaining locally developed innovative digital solutions such as the E-tick register. This further enables the health district to improve recording times and compliance with record management legislation.
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Critical incidents in gynaecology: audit at Charlotte Maxeke, Johannesburg Academic Hospital
(University of the Witwatersrand, Johannesburg, 2023-07) Chikwiri, Christopher; Chauke, Lawrence
Background: Critical incidents are among the ten leading causes of death and disability worldwide. Improving patient safety has become a global priority and one way to reach this goal is to report and analyse critical incidents. Objectives: To describe the epidemiology, patient outcomes and avoidable factors associated with critical incidents in gynaecology department at Charlotte Maxeke Johannesburg Academic Hospital (CJMAH). Methods: This research was a retrospective descriptive analysis of critical incidents in patients admitted to gynaecology wards at CMJAH from 1st January 2019 to 31st December 2019. All medical records of patients identified to have experienced critical incidents were reviewed and demographic information, timing of admission, critical incident markers and avoidable factors were extracted for analysis. Results: In total there were 257 critical incidents (CI) in 2082 gynaecology admissions during the one-year study period, which gives a critical incidence of 12.3%. A total of 158 patients experienced at least one or more critical incidents. The mean age (SD) of patients was 41.1 (14.8) years. The median (IQR) duration of admission was 6 days (3-10). Reasons for admission were emergencies 60 (38.0%), elective 54 (34.2%), oncology 44 (27.8%). Majority of the critical incident events were omission of procedures (n=45, 17.5%), deaths (n=34, 13.2%), massive transfusion (n=30, 11.7%), repeat laparotomies (n=29,11.3%) and fistula/organ damage (n=19, 7.4%). Avoidable critical incidents were (n=87, 55.1%). Most critical incidents were associated with no harmful outcomes to the patients (50, 31.5%), death (34, 22.8%) (mainly as a result on oncology admissions), moderate disability (29,17.9%), minimal disability (26, 16,1%), permanent/severe disability (14, 8.6%) and in (5,3.1%) harm could not be specified. Critical incidents forms were only filled out in 39 patients, that is a reporting rate of 24.7%. Conclusions: Critical incidents are a major cause of unnecessary harm in gynaecology at CMJAH. Half of these critical incidents are avoidable and therefore corrective measures can be undertaken to eliminate them in order to improve patient safety. Underreporting of critical incidents is still a major problem. There is need for precise definitions of critical incidents terms and modification of critical incident reporting system (including electronic) to promote patient safety culture in gynaecology.
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Prevalence and correlates of alcohol use, mental disorders, and awareness and utilization of support services among healthcare professionals in West Rand District, Gauteng, South Africa
(University of the Witwatersrand, Johannesburg, 2022-06) Mc Magh, Charlotte Stephanie; Francis, Joel
Background: Healthcare professionals (workers) are at an increased risk for developing mental and alcohol use disorders due to increased psychological distress, long working hours, medical litigation, role conflict and verbal/physical abuse from colleagues and patients. Psychological well-being in Healthcare workers is crucial to provide the best quality of care to patients. There is limited data on mental and alcohol use disorders among healthcare professionals in South Africa. Objectives: To determine the prevalence and correlates of alcohol use disorder, depression, anxiety, suicidality and covid anxiety during the covid pandemic among healthcare professionals in West Rand district, Johannesburg, South Africa. Methods: We conducted a cross-sectional study conducted on a sample of healthcare professionals including doctors, nurses, clinical associates and dentists working in the West Rand District of Gauteng, South Africa, during Covid-19 pandemic. Participants were invited to complete a paper-based questionnaire addressing socio-demographic questions, a set of measures for alcohol use disorder (AUDIT-C), depression (PHQ-2), anxiety (GAD-7), suicidality (PSS-3), covid anxiety (CAS) and awareness and utilization of support services. Results: A total of 330 Healthcare professionals (60.9% nurses, 33% doctors, 5.5% other) participated. Majority of the participants were females 78.8%, and 48.2% of the participants were in the age band 35-64 years. Overall, 20.9% of the healthcare professionals reported risky alcohol use. Females were 73% less likely to report risky alcohol use (AOR=0.27;95% CI 0.13-0.54). Prevalence of probable depression was 13.6% and female professionals were 5 times more likely to be classified as having probable depression (AOR=4.86;95% CI=1.08-21.90). The grouped prevalence of anxiety ranging from mild to severe was reported at 47.3%, female professionals were 3 times more likely to be classified as having anxiety symptoms (AOR=2.78;95%CI 1.39-5.57). Furthermore, races other than black were found to have higher rates of anxiety (AOR=2.54; 95%CI 1.00-6.42). The prevalence of suicide symptoms was 7.9% and that of covid dysfunctional anxiety 4.8%. Only 5% of participants were involved in an employee wellness program, with 60% expressing interest in joining one. Conclusion: Alcohol use and mental disorders were common among healthcare professionals in West Rand district, Johannesburg, South Africa. There is overall poor awareness and use of support structures highlighting the need to design and pilot targeted interventions to increase awareness and utilization of the existing services and delivery of alcohol use and mental disorder screening and referral to treatment.
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Incidence of incomplete excision of basal cell carcinoma and associated factors at two tertiary hospitals
(University of the Witwatersrand, Johannesburg, 2023-10) Hoogendyk, Charles August; Sofianos, Chrysis; Kruger, Deirdré
Introduction: Basal Cell Carcinomas (BCC) account for the majority of skin cancers in South Africa. They have low mortality but can cause significant morbidity primarily through local destruction, therefore recurrence should be mitigated. Surgery is the preferred treatment for BCC. The excision margin is determined firstly by oncological safety and then preservation of normal tissues. Therefore, a wider or narrower margin increase the risk for aesthetic complications and recurrence, respectively. However, the optimal surgical excision margin size remains unclear and guidelines established based on lesion size and histological aggression are inconsistent. This may be because incomplete excision has a more complex relation with other associated factors. Aim: The aim of this study was to examine the rate of incomplete excision (involved margin) of BCC at tertiary Hospitals in South Africa, and to assess the influence from associated factors, such as age, sex, histological type, size, site, and lesion occurrence (primary; re-excision; recurrence). Method: This was a retrospective quantitative observational study with chart reviews, performed at the Plastic Surgery Department at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) and Chris Hani Baragwanath Academic Hospital (CHBAH). Patients who underwent BCC excision from January 2016 to December 2020 were screened and biopsies were collected. The normality of continuous data (age and biopsy size) was tested with Shapiro-Wilks test. The standard descriptive statistics and interquartile ranges (IQR) were reported. Involved excisional margins associations with continuous and categorical variables were tested using the Mann-Whitney U test, and Chi-squared test, respectively. Results: he cohort consisted of 226 patients who underwent a total of 461 biopsies. The median age was 65.3 years, there were predominantly male (56.0%) patients, from CHBAH (81.0%). Baseline associated factors of largest biopsies (n=226) and smallest (n=91) biopsies of the cohort were examined overall. Margin was involved at excision on 16.8% (38/226) of largest samples and 23.1% (21/91) of smallest biopsies. The commonest site was the Head and Neck region, with 146 (64.6%) in the largest biopsies and 61 (67.0%) amongst smallest biopsies. The commonest subtype was nodular which was 38.9% (88/262) and 40.6% (37/91) amongst the largest and smallest, respectively. On assessment of the diameter and the involved excisional margin, there was a significant association for smallest biopsy (p<0.001). On cross-tabulation, involved excisional margin for larger biopsies was significantly associated with head and neck biopsies (p<0.001) and aggressive lesions (p=0.004). In smallest biopsies lesions, involved excisional margin was also associated with head and neck sites (p=0.009) and primary occurrence (p<0.001), and smallest biopsies in the head and neck region was associated with aggressive type lesions (p=0.003). In the latter group, indolent type lesions were associated with primary biopsies (p=0.001). Conclusion: In this population the associated factors for margin involvement on excision are head and neck site, aggressive type, and non-primary lesions. For best patient outcomes, and the prevention of BCC recurrence, we recommend that these factors are considered when deciding on excision margin size.