Determinants of Clinician and Patient to Prescription of Antimicrobials: Case of Mulanje, Southern Malawi

Background: Antimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. Methods: In-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. Results: Participants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance.Conclusion: Inappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

Occupational Toxicity and Health Hazards of the Healthcare Providers at Healthcare Facilities in Sulaimani City, Iraq

Objective: The present study aimed to evaluate the occupational health hazards that face health care providers in Sulaimani City. Methods: A cross-sectional study conducted utilizing quantitative data collection methods. It involved 159 respondents including Physicians, Pharmacists, Medical assistants, Laboratory Instructors and Nurses who worked in 8 major health facilities in Sulaimani city, Kurdistan region, Iraq. Results: Nurses were the most susceptible group to sharp related injuries 13.84%, cuts and wounds 10.69% than the others and they were more experiencing verbal abuse in the workplace 15%. Laboratory instructors represent the most exposed group to contaminated specimens/biohazards 17.6% and blood borne pathogens 13.84, while the physicians represent the most prone group to acquire infectious diseases 15.1% and both the physicians and the nurses were equally exposed to airborne diseases 11.32%. Furthermore, physicians were the most group that suffered from work related stress 13.8%; and medical assistants were the most susceptible to radiation 3.1%. Meanwhile, Laboratory instructors were the most exposed group to physical distress 15.1%, falls 5%, unsafe staffing 13.8%, chemical spills 8.8% and noise 5.4%. Conclusion: Healthcare providers in these settings experienced various types of occupational hazards in their workplaces, which became a dominant issue among the health care providers. Interventions should be established to alleviate these hazards.

Primary Care Disease Management for Venous Leg Ulceration – Study Protocol for the Ulcus Cruris Care [UCC] Randomized Controlled Trial (DRKS00026126)

Background Venous leg ulcers (VLU) have a prevalence of 1–2% in developed countries and affected patients are severely and long-term impaired in daily activities, work and social participation. Evidence-based outpatient treatment based on compression therapy is frequently not implemented. The “Ulcus Cruris Care” project was established to develop a disease management concept to improve outpatient treatment for patients with VLU in German primary care. For this purpose, a multifaceted intervention was conceived consisting of an online training for general practitioners and medical assistants, standardized treatment recommendations, e-learning and print-based information for patients, and a software support for case-management. Main aims of the Ulcus Cruris Care intervention are to promote standardized treatment according to current scientific knowledge, to facilitate case management for VLU patients exerted by medical assistants and to support patient education and participation in the treatment process. The UCC trial was designed to evaluate the effectiveness of the Ulcus Cruris Care intervention. Methods The UCC trial is a prospective cluster-randomized controlled multicenter trial. Fifty GP practices are intended to be recruited and randomized 1:1 to intervention or control arm. Patients with venous leg ulcers will be recruited by participating GP practices, to include a total of 63 patients in each arm. The primary outcome is time to ulcer healing. Secondary outcomes comprise number and sizes of ulcers, recurrence, pain intensity according to the Visual Analogue Scale, health-related quality of life according to EQ-5D-5L, depressiveness according to Patient Health Questionnaire (PHQ-9), patient satisfaction according to the Patient Assessment of Chronic Illness Care (PACIC-5A) query and adherence to VLU treatment. The outcome analysis of the UCC trial is accompanied by a health economic analysis and a process evaluation. Discussion The UCC trial will evaluate whether the Ulcus Cruris Care intervention may lead to faster wound healing, higher health-related quality of life and lower use of medical resources. If the intervention turns out to have a positive impact on assessed outcomes, comprehensive implementation in primary care may be considered. Trial registration The trial protocol (version 1 as of July 19th, 2021) has been registered in the German Clinical Trials Register on August 30th, 2021 (DRKS000261265).

Implementation of the GSA KAER Toolkit in a Large Clinic System: Workflow Modifications and EMR Tools

We implemented the KAER toolkit in the University of Washington primary care clinics. In this session we share the workflows implemented to promote the KAER model and share the tools we developed within EPIC, the system's electronic medical record (EMR). We collaborated with clinic staff to develop interdisciplinary workflows including: training patient service representatives, social workers, nurses, and medical assistants (MAs) about 'red flags;' training medical assistants to complete the Patient Health Questionnaire (PHQ-9) and Montreal Cognitive Assessment (MoCA); and assuring they are appropriately entered into flowsheets in EPIC. We created a checklist (EPIC 'SmartPhrase') and educated the clinics' interdisciplinary teams to utilize it within their scope of practice. Additionally, we created an order set (EPIC 'SmartSet') of commonly ordered tests and referrals to expedite evaluation of patients with suspected cognitive impairment. Lastly, we created a direct link from our EMR to our website containing community resources.

A pilot study of participatory and rapid implementation approaches to increase depression screening in primary care

Background Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed. Methods This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament—a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs. Results The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care. Conclusions Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.

Determinants of Clinician and Patient to prescription of antimicrobials: case of Mulanje, Southern Malawi

BackgroundAntimicrobial resistance is an emerging problem in low- and middle-income countries. The problem is exacerbated by inappropriate prescription of antimicrobials. Factors leading to overuse or inappropriate prescription of antimicrobials by the cadre of medical assistants, clinical technicians and clinical officers have received limited attention. This study investigated factors that influence prescription behaviours of antimicrobials among clinical officers in various health facilities in Mulanje district, Southern Malawi. MethodsIn-depth interviews (n=18) and focus group discussions (n=2) were conducted with COs from four health facilities in Mulanje district. Purposive sampling was done to arrive at a sample size of 30 health cadres. ResultsParticipants pointed out that patient preferences, belief and clinicians’ inadequate education on this issue were among the factors that contribute to inappropriate antimicrobial prescription. 75-% of clinicians showed lack of knowledge on the definition of antibiotic and antimicrobial resistance. ConclusionInappropriate use of antimicrobials is facilitated by prescribing decisions made by clinicians who are greatly influenced by their patients. Interventions aimed at improving antimicrobial prescription should target both clinicians and patients.

History of non-physician anaesthesia providers in Papua New Guinea: from heil tultuls to Anaesthetic Scientific Officers

The most recent estimates, published in 2016, have indicated that around 70% of anaesthesia providers in Papua New Guinea are non-physician anaesthetic providers and that they administer over 90% of anaesthetics, with a significant number unsupervised by a physician anaesthetist. Papua New Guinea has a physician anaesthetist ratio estimated to be 0.25 per 100,000 population, while Australia and New Zealand have a ratio of 19 physician anaesthetists per 100,000, which is 75 times that of Papua New Guinea. To reach a ratio of seven per 100,000, recommended as the minimum acceptable by the Lancet Commission in 2016, there will need to be over 35 practitioners trained per annum until 2030, at a time when the average annual numbers of recent years are less than three physicians and less than five non-physician anaesthetic providers. We review the development of anaesthesia administered by non-physician indigenous staff and the stages of development from heil tultuls, dokta bois, liklik doktas, native medical assistants, aid post orderlies, and Anaesthetic Technical Officers up to the current Anaesthetic Scientific Officers having attained the Diploma in Anaesthetic Science from the University of Papua New Guinea.

Associations between Psychosocial Working Conditions and Quality of Care (i.e., Slips and Lapses, and Perceived Social Interactions with Patients)—A Cross-Sectional Study among Medical Assistants

Adverse psychosocial working conditions in the health care sector are widespread and have been associated with a reduced quality of patient care. Medical assistants (MA) assume that their unfavorable working conditions predominantly lead to a poorer quality of care in terms of slips and lapses, and poorer social interactions with patients. We examined those associations for the first time among MAs. A total of 944 MAs in Germany participated in a survey (September 2016–April 2017). Psychosocial working conditions were measured by the effort-reward imbalance (ERI) questionnaire and a questionnaire specifically designed for MAs. Slips and lapses (3 items, e.g., measurement or documentation errors) and the quality of interactions (3 items) with patients were measured by a questionnaire developed by the study team based on prior qualitative research. We ran Poisson regression to estimate multivariable prevalence ratios (PRs). The ERI ratio and MA-specific working conditions were significantly associated with frequent self-reported slips and lapses (PR = 2.53 and PR ≥ 1.22, respectively) or poor interactions with patients (PR = 3.62 and PR ≥ 1.38, respectively) due to work stress. Our study suggests that various types of adverse psychosocial working conditions are associated with perceptions of slips and lapses or poorer interaction with patients due to work stress among MAs.