The contribution of non-physician clinicians to the provision of surgery in rural Zambia-a randomised controlled trial

BACKGROUND

The global shortage of surgeons disproportionately impacts low- and middle-income countries. To mitigate this, Zambia introduced a 'task-shifting' solution and started to train non-physician clinicians (NPCs) called medical licentiates (ML) to perform surgery. The aim of this randomised controlled trial was to assess their contribution to the delivery of surgical care in rural hospitals in Zambia.

METHODS

Sixteen hospitals were randomly assigned to intervention and control arms of the study. Nine MLs were deployed to eight intervention sites. Crude numbers of selected major surgical procedures between intervention and control sites were compared before and after the intervention. Volume and outcomes of surgery were compared within intervention hospitals, between NPCs and surgically active medical doctors (MDs).

RESULTS

There was a significant increase in the numbers of caesarean sections (CS) in the intervention hospitals (+ 15.2%) and a drop by almost half in the control group (- 47%) (P = 0.015), between the two time periods. There were marginal shifts in the numbers of index procedures: a small drop in the intervention group (- 4.9%) and slight increase in the control arm (+ 4.8%) (P = 0.505). In all pairs, MLs had higher mean number of CS and other major surgical cases done in the intervention period compared with MDs. There was no significant difference in postoperative wound infection rates for CS (P = 0.884) and other major surgical cases (P = 0.33) at intervention hospitals between MLs and MDs.

CONCLUSION

This study provided evidence that the ML training programme in Zambia is an effective and safe way to bridge the gap in rural hospitals between the demand and the limited availability of surgically trained workforce in the country. Such evidence is greatly needed as more developing countries are developing national surgical plans.

TRIAL REGISTRATION

ISRCTN66099597 Registered: 07/01/2014.

An Audit of Medication Administration: A Glimpse Into School Health Offices

Many students require prescription and nonprescription medication to be administered during the school day for chronic and acute illnesses. School office staff members are typically delegated this task, yet these individuals are unlicensed assistive personnel without medical training. Five school nurses developed and participated in a medication audit providing a glimpse into the administration and management of medications in school health offices. The audit included 154 medications. Results of the audit showed a wide range of errors and discrepancies, including problems with transcription, physician orders or lack thereof, timing, documentation, and storage. Audit results highlight the importance of training in medication administration and management at schools. It also directs attention to view training not as a once-a-year event, but as a process. A process is needed to ensure and sustain the safe and accurate administration of medication. Towards this end, school nurses need to periodically evaluate school office staff, audit school medication records and documents, and conduct refresher classes throughout the school year.

Trends in task shifting in HIV treatment in Africa: Effectiveness, challenges and acceptability to the health professions

BACKGROUND

Task shifting has been suggested to meet the demand for initiating and managing more patients on antiretroviral therapy. Although the idea of task shifting is not new, it acquires new relevance in the context of current healthcare delivery.

AIM

To appraise current trends in task shifting related to HIV treatment programmes in order to evaluate evidence related to the effectiveness of this strategy in addressing human resource constraints and improving patient outcomes, challenges identified in practice and the acceptability of this strategy to the health professions.

METHOD

Electronic databases were searched for studies published in English between January 2009 and December 2014. Keywords such as 'task shifting', 'HIV treatment', 'human resources' and 'health professions' were used.

RESULTS

Evidence suggests that task shifting is an effective strategy for addressing human resource constraints in healthcare systems in many countries and provides a cost-effective approach without compromising patient outcomes. Challenges include inadequate supervision support and mentoring, absent regulatory frameworks, a lack of general health system strengthening and the need for monitoring and evaluation. The strategy generally seems to be accepted by the health professions although several arguments against task shifting as a long-term approach have been raised.

CONCLUSION

Task shifting occurs in many settings other than HIV treatment programmes and is viewed as a key strategy for governing human resources for healthcare. It may be an opportune time to review current task shifting recommendations to include a wider range of programmes and incorporate initiatives to address current challenges.

Task delegation and computerized decision support reduce coronary heart disease risk factors in type 2 diabetes patients in primary care

BACKGROUND

Reducing cardiovascular risk in patients with diabetes mellitus type 2 (DM2) is important in diabetes care. However, treating patients according to clinical guidelines appears to be difficult. Delegating routine tasks to a practice nurse combined with computerized decision support systems (CDSS) may be helpful. The objective was to study the effectiveness of practice nurse-managed CDSS for diabetes care on improving cardiovascular risk factors in DM2 patients.

METHODS

In 113 primary care practices (n = 7,893 DM2 patients) across the Netherlands, the diabetes care protocol (DCP) was assessed in a before-after study, lasting 1 year. All practices implemented DCP, which is characterized by delegation of routine tasks in diabetes care to a practice nurse, software that supports diabetes management, medical decisions, and benchmarking (CDSS). All DM2 patients treated by their primary care physician were asked to attend the program. Primary outcome was the percentage of patients achieving treatment targets: hemoglobin A1c (HbA1c) <or=7%, blood pressure <or= 150/85 mm Hg, and total cholesterol <or= 5 mmol/L.

RESULTS

The percentage of DM2 patients who achieved targets increased significantly, from 60.6% to 66.5% for HbA1c, from 48.7% to 61.9% for blood pressure, and from 47.4 % to 60.6% for total cholesterol. The percentage of patients achieving all three targets increased from 15.3% to 26.9% (all P < 0.01).

CONCLUSION

Delegating routine tasks in diabetes care to a practice nurse combined with CDSS and benchmarking helps achieve treatment goals for HbA1c, blood pressure, and cholesterol and reduce cardiovascular risk of DM2 patients in primary care.

The increasing demand and necessity for a team approach

The role of professionals complementary to dentistry (PCDs) has changed radically in recent times and further changes are likely in the foreseeable future. The modernisation of dentistry throughout the UK dictates that the existing workforce takes into account the substantial contribution which can be made by PCDs in addressing the unacceptable levels of disease which exist in many parts of the country.