Training of public health workforce at the National School of Public Health: Meeting Africa's needs

2008 Volume 44 Number 2

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World Hospitals and Health ServicesThe Official Journal of the International Hospital Federation

Editorial

IHF NewsletterInternational Hospital Federation newsInternational newsConference and event calendar

Country profileThe Peruvian health system: Challenges for hospital management in the new millennium

PolicyPutting medical nutrition on to the international agenda: Actions by the European Nutrition for Health Alliance

ManagementWe shape our buildings, then they kill us: Why health-care buildings contribute to the error pandemic

Knowledge and anticipated behaviour of health-care workers in response to an outbreak of pandemic influenza in Georgia

Training the public health workforce at the National School of Public Health: Meeting Africa’s needs

Clinical careSurgical site infections in an abdominal surgical ward at Kosovo Teaching Hospital

eHealthIncreased patient safety with an Internet-based reporting system

Opinion mattersClimate change, migration and health

International Hospital Federation | Fédération Internationale des Hôpitaux | Federación Internacional de Hospitales

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CONTENTS

Contents

World Hospitals and Health Services 2008 Volume 44 Number 2

The Official Journal of the International Hospital Federation

Editorial Eric de Roodenbeke

International Hospital Federation news

Conference and event calendar

International news roundup

The Peruvian health system: Challenges for hospital managementin the new millenniumDra Luz Loo de Li, Dr Víctor Yamamoto Miyakawa, DrDarwin Hidalgo Salas and Eco Juan Carlos Chávez

PolicyPutting medical nutrition on to the international agenda: Actionsby the European Nutrition for Health Alliance Pascal Garel

ManagementWe shape our buildings, then they kill us: Why health-carebuildings contribute to the error pandemic Ken N Dickerman,Paul Barach and Ray Pentecost III

Knowledge and anticipated behaviour of health-care workers inresponse to an outbreak of pandemic influenza in GeorgiaMaia Butsashvili, Wayne Triner, George Kamkamidze, MaiaKajaia and Louise-Anne McNutt

Training the public health workforce at the National School ofPublic Health: Meeting Africa’s needsKebogile Mokwena, Mathilda Mokgatle-Nthabu, SphiweMadiba, Helen Lewis and Busi Ntuli-Ngcobo

Clinical careSurgical site infections in an abdominal surgical ward at KosovoTeaching Hospital Lul Raka, Avdyl Krasniqi, Faton Hoxha,Ruustem Musa, Selvete Krasniqi, Arsim Kurti, AntigonaDervishaj, Beqir Nuhiu, Baton Kelmendi, Dalip Limani andIlir Tolaj

Increased patient safety with an Internet-based reporting systemTimo Keistinen and Marina Kinnunen

Abstract translations in French and Spanish

Directory of IHF professional and industry members

Climate change, migration and health Dr Manuel Carballo

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IHF NEWSLETTER

ARTICLES

REFERENCE

E-HEALTH SUPPLEMENT

OPINION MATTERS

COUNTRY PROFILE

EDITORIAL STAFFExecutive Editor: Eric de Roodenbeke, PhDDesk Editor: Sheila Anazonwu, BA(Hons), MSc

EDITORIAL BOARDDr René PetersDutch Hospital Association Norberto LarrocaCamara Argentina de Empresas de SaludDr Harry McConnellISHEDDr Persephone DoupiSTAKES

EDITORIAL OFFICEImmeuble JB SAY,13 Chemin du Levant, 01210 Ferney Voltaire, FranceEmail: [email protected] Internet: www.ihf-fih.org

SUBSCRIPTION OFFICEInternational Hospital Federation c/o MB Associates52 Bow Lane, London EC4M 9ET, UKTelephone: +44 (0) 20 7236 0845 Fax: +44 (0) 20 7236 0848

ISSN: 0512-3135

Published by Pro-Brook Publishing Limited for the International Hospital Federation

13 Church Street,Woodbridge,Suffolk IP12 1DS, UKTelephone: +44 (0) 1394 446006Fax: +44 5601 525315Internet: www.pro-brook.com

For advertising enquiries contact Pro-Brook Publishing Limitedon +44 (0) 1394 446006

World Hospitals and Health Services is publishedquarterly. All subscribers automatically receive acopy of the IHF reference books. The annualsubscription to non-members for 2008 costs £175 or US$250.

World Hospitals and Health Services is listed in Hospital LiteratureIndex, the single most comprehensive index to English languagearticles on healthcare policy, planning and administration. The index is produced by the American Hospital Association in co-operation with the National Library of Medicine. Articlespublished in World Hospitals and Health Services are selectivelyindexed in Health Care Literature Information Network.

The International Hospital Federation (IHF) is an independentnon-political body whose aims are to improve patient safety andpromote health in underserved communities. The opinionsexpressed in this journal are not necessarily those of theInternational Hospital Federation or Pro-Brook PublishingLimited.

Vol. 44 No. 2 | World Hospitals and Health Services | 01

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IHF NEWSLETTER

International Hospital Federation news

Governing council meeting and leadership dinner heralds the transition of the IHF Director General

Farewell lunch for Per-Gunnar Svensson

ON 16 MAY 2008, THE OFFICIAL GOVERNING COUNCIL MEETING marked the transition from Per-Gunnar Svensson to Eric de Roodenbeke as Director General of the IHF. This meeting was the best attendedin the history of the IHF with only two absences.

Governing Council Members in deliberation IHF Governing Council Members 2007 – 2009

Farewell lunch Per-Gunnar and the secretariat staff featur-ing national dishes prepared by the staff and a parting giftfor Per-Gunnar from the staff who had had the pleasure ofworking with Per-Gunnar.

Marylene Ballestero - Membership Services Coordinator (left);Dwight Moe Events and Project Manager (right) having lunchPer-Gunnar

Sheila Anazonwu, Communications & DevelopmentProgrammes Officer with Per-Gunnar

Per Gunnar Svensson with one of hisleaving gifts

Gayle Crozier,Deputy Presidentof the InternationalAssociation of InfantFood Manufacturers

Per Gunnar Svensson(left) EricdeRoodenbeke,Incoming IHF DirectorGeneral (right)

ON THURSDAY, MAY 15 2008 the IHF hosted thethird Governing Council Leadership Dinner which wassponsored by the International Association of InfantFood Manufacturers, a new corporate member of IHF.The dinner was held at the Intercontinental Hotel inGeneva and was a pleasant occasion to wish a finalfond farewell to Per-Gunnar Svensson who would beretiring at the end of the month. As always there wereinvited guests from other Geneva area based ONGs thatjoined us. The birthday of the IHF President DesignateDr Jose Carlos Abrahão was also celebrated.

IHF Governing Council members and guests

06 | World Hospitals and Health Services | Vol. 44 No. 2

IHF NEWSLETTER

Human & Health: publication of a new journal from the SyndicatDes Hopitaux Du Liban (Lebanon)

THE INTERNATIONAL HOSPITALFEDERATION (IHF) is pleased toannounce, on behalf of its national memberassociation in Lebanon, Syndicat DesHopitaux Du Liban, the publication of theirnew quarterly journal, entitled Human &Health. The journal is published in English,French and Arabic and is available free ofcharge to subscribers.The IHF congratulates the Syndicat on

this initiative and wishes it much success.

In addition, the IHF seizes this opportunity to assure ourLebanese colleagues of its continued support .

Further information regarding the journal andsubscriptions may be obtained from:

Mr Sleiman Haroun, SYNDICAT DES HOPITAUX DULIBAN, Ghazal Bldg - 7th Floor, P O Box 662-165 Adlieh,662 Beirut, LEBANON

Tel: +961 1 611011 / 6154;Fax: +961 1 616772/3/4Email: [email protected]: www.hospitals-synd.org.lb

2007 Tom Hurst International Award winners for the best smoke-free hospitalALTHOUGH AN AWARD was not made this year,two hospitals received commendations – theSeinajoki Central Hospital, Finland and theGeneva University Hospitals, Switzerland. Thepresentation of the plaque for the former was madeby Professor Svensson at the Future HospitalSeminar in Helsinki, Finland. The closing date forthe 2008 Tom Hurst Award is 30 September 2008.The Tom Hurst Award is offered annually by the

International Network Towards Smoke-FreeHospitals, a branch of the IHF. It commemoratesthe Network’s founder, a senior British hospitaladministrator, who was a loyal attender at IHFconferences.

Details are available at: http://www.ihf-fih.org/jsp/index.jsp?lnk=180

For more information please contact:Mr. John BickerstaffGeneral SecretaryInternational Network Towards Smoke-FreeHospitals (INTSH)Tel: +44 (0) 20 8651 5436Email: [email protected] Legerer, Press and Public Relations,Geneva University Hospitals (HUG)Tel. +41 (0) 22 372 60 06

Professor Per Gunnar Svensson, Director General of the InternationalHospital Federation (1998 – May 2008) presenting Mr. Yves Grandjean,Secretary General of the Geneva University Hospitals (HUG) and his colleagues from the « Smoking or Health Working Group» of the University,with the 2007 Tom Hurst

Professor Per-Gunnar Svensson, Director General of the InternationalHospital Federation (1998 –May 2008), presents the Tom HurstInternational Award for the best smoke-free hospital policiescommendation for Seinajoki Central Hospital, Finland, to Ms RaijaJarvela.


IHF NEWSLETTER

Governing Council member profileMr Dipl.-Volkswirt Georg Baum

MR GEORG BAUM (53) is theChief Executive Officer of theGerman Hospital Federation,representing all Germany’s2,100 hospitals with about 1.1million employees, providingservices for approximately 17million patients, generating agross income of more than 61billion Euros. He was electedMember of the Governing

Council of the International Hospital Federation during thelast assembly in Seoul in November 2007.Mr Baum is a graduated economist with a long career in

health policies. Starting his occupational live as an economicand health policy officer at the Friedrich-Naumann-Foundation and in the German Bundestag (German Federal

Parliament) he then led the office of the Federal Associationof the company’s health insurance funds. Afterwards he gotappointed director in the Federal Ministry for Health,heading the directorate for heath care and for the healthsystem since he became Chief Executive Officer of theGerman Hospital Federation in early 2006.Mr Baum has a strong focus on European and

international hospital affairs. As the European Union isproviding many actions on cross-bordering health careservices concerning German hospitals, he installed apermanent representative office in Brussels and widened thescope of his national work on the European level.Additionally, and representing the European Hospital scene,he was elected Vice-president of HOPE - European Hospitaland Healthcare Federation (since May 2008) after beingmember of the Board of Governors and of the President’sCommittee for years.

First IHF Benchmarking installation in Dubai

THE AL WASL HOSPITAL IN DUBAI has become the firsthospital to access IHF’s new online benchmarking service,known as IHF Benchmarking. The Department of Healthand Medical Services pioneering medical facility will adoptstandardized IHF measures which may be used by anyhealth-care facility anywhere in the world.Developed in partnership with a leading Finnish

healthcare IT company, Mawell Oy, its rationale is to collectand share hospital performance data with others of differentsizes and types, via the Internet, facilitating a rise ininformation transparency, quality and relative standards ofpatient care. The service will capture demographics and datapertinent to patient centredness, efficiency and quality butthe functionality is there for separate measures tailored tousers’ internal requirements. IHF Benchmarking will alsointegrate users’ computer systems to allow automated data

collection, eliminating the need for staff to input datamanually. A planned service update for September 2008 willsee additional data captured, in the areas of HP andPersonnel Development.Al Wasl was the first health-care facility in Dubai to achieve

JCI accreditation and is equipped to serve as a teaching andreferral hospital, offering state-of-the-art medical care at itsSpecial Baby Care Unit, Thalassaemia centre, and thePediatric Surgery Unit. Its mission is to offer qualitydiagnostic, curative and preventative health-care services.Accessing the IHF Benchmarking service will allow Al Wasl’smanagement to monitor their daily performance in key areasrelative to similar institutions.

For more information about IHF Benchmarking pleasecontact Trevor Brooker on Tel: +44 (0)1394 446006

World Hospital & Health Services is always interested in considering articles submitted by readers.Any potential author should submit an abstract to Sheila Anazonwu at [email protected]


IHF NEWSLETTER

IHF EVENTS

Conference andevent calendar

20088-10 September MCC Hospital WorldBerlin, Germany [email protected] http://www.ihf-fih.org / www.hospitalworld.info

OctoberMasters of Science in Public Health: Excellence in Health Care Management& Senior Hospital and Health Services Manager ProgramE-mail: [email protected]; [email protected]://wwwihf-fih.org; http://www.hm.ae Registration for Academic Year 2008-2009 is Open to All IHF MembersFor registration: visit: www.etqm.ae

2009 201110-12 November 5-7 April36th IHF World Hospital Congress* 37th IHF World Hospital Congress*Rio de Janeiro, Brazil Dubai, Unites Arab [email protected] [email protected]://www.ihf-fih.org / http://ihfrio2009.com/ http://www.ihf-fih.org

200825 & 26 September 17-21 NovemberHospital Management Asia Management Training Workshop [email protected] / [email protected] TB Hospital Managershttp://www.hospitalmanagementasia.com/index.htm Beijing, China

[email protected]

COLLABORATIVE EVENTS

Events marked * are interpreted into English, French and Spanish. All other events will bein English/host country language only. IHF members will automatically receive brochuresand registration forms on all the above events approximately 6 months before the startdate. IHF members will be entitled to a discount on IHF Congresses, pan-regionalconferences and field study courses.

For further details contact the: IHF Project & Event Manager, International HospitalFederation, Immeuble JB Say, 13 Chemin du Levant, 01210 Ferney Voltaire, France; E-Mail: [email protected] Or visit the IHF website: http://www.ihf-fih.org

08 Diary Dates:Diary dates 8/7/08 11:19 Page 8

IHF NEWSLETTER

International newsround up


EASTERN MEDITERRANEAN REGION ACHIEVESMEASLES GOAL THREE YEARS EARLY 4 DECEMBER 2008.Atlanta/Geneva/New York/Washington – Measles deathsworldwide fell by 74% between 2000 and 2007, from anestimated 750 000 to 197 000. In addition, the EasternMediterranean region*, which includes countries such asAfghanistan, Pakistan, Somalia, and Sudan, has cut measlesdeaths by a remarkable 90% during the same period. Byreducing measles deaths from 96 000 to 10 000, the regionhas achieved the United Nations goal to reduce measlesdeaths by 90% by 2010, three years early.

The progress was announced today by the foundingpartners of the Measles Initiative: the American Red Cross, theUnited States Centers for Disease Control and Prevention(CDC), the United Nations Foundation (UN Foundation),UNICEF and WHO. The data will be published in the 5December edition of WHO’s Weekly epidemiological recordand CDC’s Morbidity and mortality weekly report.

"This achievement is a tribute to the hard work andcommitment of countries in the Eastern Mediterranean regionto combat measles" said Dr Margaret Chan, WHO Director-General. "With only two years until the 2010 target date, Iurge all countries affected by measles to intensify their effortsto immunize all children against the disease."

The significant decline in measles deaths in the EasternMediterranean region was the result of intensified vaccinationcampaigns including several countries with hard-to-reachareas. In 2007, more than twice the number of children wereimmunized in the region through such campaigns ascompared to 2006.

Role of health workers and volunteers"There are thousands of health workers and volunteers fromour Red Cross and Red Crescent family who deserve much ofthe credit for this success. They give their time to literally godoor-to-door informing, educating and motivating mothersand caregivers about the critical need to vaccinate theirchildren," said Bonnie McElveen-Hunter, Chairman of theBoard of the American Red Cross. "This mobilization helps usto consistently reach more than 90% of the vulnerablepopulation and save countless lives."

The African region was the largest contributor to the globaldecline in measles deaths, accounting for about 63% of thereduction in deaths worldwide over the eight-year period. In2007, measles outbreaks occurred in a number of Africancountries due to gaps in immunization coverage, reinforcing

the need to continue immunization support."It’s absolutely wonderful that so many children are off to a

healthy start in life thanks to the progress we’ve made incombating measles through immunization," said Dr JulieGerberding, CDC Director. "Other children’s lives are still atrisk, however, so it’s time we refocus our attention onsustaining our immunization efforts in countries where ratesare low."

The progress in South-East Asia has been limited — withjust a 42% decline in measles deaths. This is due to thedelayed implementation of large-scale vaccination campaignsin India, which currently accounts for two thirds of globalmeasles deaths. Political commitment in India is essential ifthe 2010 global goal is to be achieved.

"The progress that has been made shows what can beachieved through measles vaccination campaigns, but muchmore needs to be done," said Ann M. Veneman, ExecutiveDirector of UNICEF. "It is a tragedy that measles still kills morethan 500 children a day when there is a safe, effective andinexpensive vaccine to prevent the disease."

The world's success in reaching the 2010 measles goaldepends on ensuring that all children receive two doses ofmeasles vaccine including one dose by their first birthday,strengthening disease surveillance systems, and providingeffective treatment for measles.

"Progress also depends on addressing the considerablefunding gap," said Kathy Calvin, Executive Vice President andChief Operating Officer for the UN Foundation. "The shortfallstands at US$ 176 million for 2009-2010, of which US$ 35million is urgently needed for 2009. With continued fundingand increasing ownership and commitment of countries, wecan sustain our progress and achieve our goal by 2010. We askour supporters to stay with us and strongly encourage newsupporters to join us in our effort to save lives."

The Measles InitiativeThe Measles Initiative is a partnership committed toreducing measles deaths globally. Launched in 2001, theinitiative — led by the American Red Cross, the UnitedNations Foundation, the US Centers for Disease Control andPrevention, UNICEF and WHO —provides technical andfinancial support to governments and communities onvaccination campaigns and disease surveillance worldwide.The initiative has supported the vaccination of 600 millionchildren in more than 60 countries helping reduce measlesdeaths by 74% globally and 89% in Africa (compared to

WORLD

Global measles deaths drop by 74%


IHF NEWSLETTER

SOUTH EAST ASIA

2000).Other key partners in the fight against measles include

Becton, Dickinson and Company, the Bill & Melinda GatesFoundation, the Canadian International Development Agency,The Church of Jesus Christ of Latter-day Saints, the GAVIAlliance, the International Federation of Red Cross and RedCrescent Societies, the Izumi Foundation, the Kessler FamilyFoundation, Merck Co., the Vodafone Foundation, andcountries and governments affected by measles.

* The countries in the WHO Eastern Mediterranean regionare: Afghanistan, Bahrain, Djibouti, Egypt, Iran (IslamicRepublic of), Iraq, Jordan, Kuwait, Lebanon, the Libyan ArabJamahiriya, Morocco, Oman, Pakistan, Qatar, Saudi Arabia,Somalia, the Sudan, the Syrian Arab Republic, Tunisia, theUnited Arab Emirates and Yemen.

For more information please contact:Hayatee Hasan, WHO, GenevaTelephone: +41 79 351 6330E-mail: [email protected] Moen, UNICEF, New YorkTelephone: +1 212 326 7516E-mail: [email protected] Feig, American Red Cross, Washington, DCTelephone: +1 202 303 5074E-mail: [email protected] Stewart, CDC, AtlantaTelephone: +1 404 639 8327E-mail: [email protected] DiElsi, UN Foundation, Washington, DCTelephone: +1 202 419 3230

“National programmes will need to pay significant attention tomen who have sex with men (MSMs) and injecting drug users(IDUs)”. Dr Samlee Plianbangchang, Regional Director, WHOSouth-East Asia Region

NEW DELHI, DECEMBER 1, 2008 – Injecting drug users(IDUs) and men who have sex with men (MSM) requireparticular attention in today’s global fight against HIV/AIDS.Twenty years since the birth of World AIDS Day and itsintent to draw attention to this disease, the epidemiccontinues its devastating impact on families, societies andnations, especially these vulnerable groups.

“HIV continues to be a major public health problem in theRegion, with the highest incidence among sex workers andtheir clients, men who have sex with men and injecting drugusers” said Dr Samlee Plianbangchang, WHO RegionalDirector for South-East Asia. India, Thailand, Myanmar,Indonesia and Nepal – account for majority of the Regionalburden.

Significant improvements in coverage of harm reductioninterventions have been seen in the Region. Yet coverage ofharm reduction interventions such as needle syringeprogrammes or opioid substitution therapy remains between20 and 25%. The World Health Organization urges MemberStates to urgently scale up these interventions in order tohave an impact on the epidemic.

National programmes will need to pay significantattention to MSMs as this group engages in a wide variety ofsexual behaviours. But in order to design effectiveinterventions for this group, a better understanding ofdifferent MSM sub-groups, including their behaviours andbeliefs, is fundamental.

This can be done through targeted MSM programmes with

tailored 100% condom use and other preventionprogrammes. Interventions, wherever they have beenappropriate and targeted, have demonstrated favourableresults. Hence the health sector and governments inparticular need to take appropriate action if the MillenniumDevelopment Goal of halting and reversing the spread ofHIV and AIDS are to be achieved by 2015.

“Lead-Empower-Deliver” is this year's World AIDS Dayslogan. “WHO is taking the lead in strengthening all aspectsof the health sector in order to deliver these much-neededHIV services through its collaboration with various UNagencies, ministries of health and other developmentagencies.” said Dr Samlee.

World leaders have promised to provide universal accessto HIV prevention, care and anti-retroviral drug treatment inall resource-poor countries. WHO urges all our partners tokeep that promise and lead those efforts to move towardsthat goal of universal access by urgently scaling up HIVprevention, care and treatment services to the populations inneed. WHO reiterates its support to countries and partnersto halt the epidemic and mitigate its impact.

For any clarification or additional information, pleasecontact:

Ms Vismita Gupta Smith, Public Information AdvocacyOfficer at

telephone: 011 2330 9401;e-mail [email protected];or Ms Shima Roy Communication Officer (CSR Unit)

attelephone: 011 2330 9591;e-mail [email protected]

Who calls for greater attention to vulnerable groups to curb HIV/AIDS


COUNTRY PROFILE: PERU

The Peruvian health system:Challenges for hospital managementin the new millenniumDRA LUZ LOO DE LIPRESIDENT, OF THE PERUVIAN FEDERATION OF HEALTH ADMINISTRATORS (FEPAS)

DR VÍCTOR YAMAMOTO MIYAKAWA FORMER MINISTRY OF HEALTH

DR MAXIMILIANO CÁRDENAS DÍAZ FORMER DEAN, OF THE PERUVIAN COLLEGE OF PHYSICIANS

DR DARWIN HIDALGO SALASLAWYER, FEPAS

ECO JUAN CARLOS CHÁVEZECONOMIST, FEPAS

Peruvian health-care services are divided in two areas:public, which accounts for 77%; and non-public,accounting for the remaining 23%, roughly speaking.

There are 8,000 primary, secondary, and tertiary health-carecentres, with progressive complexity. They have differencesin financing their activities, the services provided, as well asin their efficiency and performance indicators.

Public health-care services are financed by the state(government); nevertheless, people have to pay subsidizedfares for health-care services. Use of private health-careservices in most cases pay through private insurancecompanies, but some pay with their own money, and thissystem is growing with Peruvian economic growth.

Peru also has a social security system (EsSalud), in whichhealth-care services are financed by contributions fromemployers and employees, but only those citizens withformal employment have access to its health-care services.

Peru has a wide range of epidemiological anddemographical profiles. We have plenty of emergent, re-emergent, and infectious diseases; and there is a trend for anincrease in chronic diseases because of the growing elderlypopulation. This implies the need for changes in the health-care system, using proper planning, strengthening certainmedical specialties, and changing paradigms for health care.

The most important challenge for health care in Peru is tostrengthen the competence of national, regional, and localsanitary authorities, particularly with respect to conducting,regulating, and surveying the essential public healthfunctions.

There are different ministries interacting with the Ministryof Health:� Ministry of Labour (Social Security [EsSalud]);� Ministry of Transportation (Mandatory Insurance for

Traffic Accidents);

� Ministry of Defence (Armed Forces Hospitals: Military,Air Force, and Navy Hospitals);

� Ministry of Internal Affairs (Police Hospitals).

Also, within the decentralization and regionalizationprocesses, two new actors are being incorporated: regionaland local government (authorities).

It is a priority to harmonize shared responsibilities withrespect to health-care service assurance, financing, anddelivery, additionally to have appropriate plans for the short,mid- and long-term, understanding that this is the basis forthe development of this country.

In spite of the fragmentation and diversity of health-careservices in Peru, Law #27813 was issued, creating “TheNational Coordinated and Decentralized HealthcareSystem”, based on three levels for coordination according tothe government instances (national, regional, and local),aiming at putting into practice the national health policy,promoting its agreed and decentralized implementation, aswell as coordinating plans and programmes of everyinstance involved, in order to achieve integrated health careand universal health care access for every Peruvian citizen.

Consequently, The “National Coordinated andDecentralized Healthcare System” has been conceived withrespect to its conformation, gathering together every actor inhealth-care services, under the direction of HealthAuthorities. Consequently, not only municipalities, theprivate sector, armed forces and police sanitary servicesparticipate in health care for Peruvian population, but otherindirect actors are incorporated, such as universities andpeople’s organizations, i.e., the Peruvian College ofPhysicians, community associations, and the like.

Hospital management: Where are we now? What is theadvance with respect to hospital management, and what are

PERU

Lima

Peru

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COUNTRY PROFILE: PERU

the immediate, mid-term, and long-term challenges?Currently there is the incorporation of new models for

financing and process improvement in the following areas:welfare, administrative, economical and financing,implementation of modern hotel and catering tradeconcepts, changing the hospital environment for patientsfrom grey and cold to a friendly one, permanently lookingfor patient comfort as if it were a hotel, humanization ofhealth care, efficiency in the delivery of services, decisionmaking and negotiation on the basis of most updatedinformation, and optimal quality of care in its threedimensions: human, technical, and environmental, withevery piece functioning like a clockwork.

Within the current decentralization process, wherecompetences and functions are being transferred from acentral level to regional levels, with respect to health care inPeru there is a rearrangement of adequate resources forexecuting activities in the regions, and new roles are nowbeing played; but we are still in the learning phase and weare strengthening health care integration in the SocialDevelopment Management areas within the RegionalGovernments, so there are now Regional Health Authoritieswhere priority is given to health and educational issues, andwhere appropriate planning is a necessity for the mid-termand long term at national, regional, and local levels.

Nowadays there are funds available in regions forfinancing health-care activities, and the first thing thatcomes to local authorities’ minds is building a new hospital,which does not necessarily reflect the real health-caredemand in that particular area, with sophisticatedequipment but lacking adequate and necessary humanresources, and not corresponding to a properly planneddevelopment at a national level. This leads us to think thatHealth Authorities now have more and greater challenges inorder to satisfy demands of newer developments, includingupdates professional profiles, personnel training, availablepositions for health-care workers in remote places, andadequate working conditions for them.

There is also the need for a nationally oriented hospitalpolicy allowing orderly growth and development of publicand private hospitals, understanding that the health-carecentres network must assure people’s health according toincreasing complexity levels.

Considering that universal access to health care is a goalfor the near future, Peruvian hospitals are now getting ready,in different manners, approaches, and intensity. Many ofthem with a clear vision of the future are strengthening theircompetences. The Peruvian Ministry of Health has takenfirm steps in the past few years with respect to hospitalaffairs, issuing updated regulations, instruments, andmanaging tools, and many of these are being implemented,which is quite complicated, since it implies firminvolvement and motivation from health-care workers inorder to achieve success.

Advances madeCategorization of every health-care centres left newchallenges for infrastructure and equipment management, as

well as for new procedures and their implementation, inorder to face the accreditation process to be carried out inthe near future throughout the country.

Considering the surrounding environment, there is a needto strengthen networks, using standardized instrumentsindependent of that sub-sector the health-care centrebelongs to (private, public, armed forces, etc), being ruledby national, regional, and local health authorities, accordingto their competence levels.

This standardization aims for having efficient, efficacious,good-quality and timely healthcare for every user, not onlypatients but also every external user.

One of the challenges for hospitals with respect touniversal health care access, delivering services in public andprivate modalities, with massive healthcare service purchaseand sale, and looking for hospitals self-sustainability is theinvoicing and charging process, where there is evidence thatthe rules are not the same for the healthcare sector.

Peru has undergone many projects for the development ofinformation systems, economic and financial management,hospital costs, procedures flowcharts, quality managementsystems, clinical practice guidelines, diagnostic-relatedgroups in hospitals and the common denominator has beenlack of continuity in these experiences and theirinappropriate implementation.

Another challenge in hospitals is to have adequateselection processes for hospital directors. Their professionalsmust have appropriate competences, as well as managementabilities and leadership in order to guide their institutions inthis process of change.

Universal health insurancePeru has a proposal in which a universal health-careinsurance plan is being analyzed. This proposal has beendesigned by a group of Peruvian professionals from theMinistry of Health, with the advice and support from Pan-American Health Organization. Public health provisions andindividual health services including medical and surgicalcare have been considered in this model. The plan has itscosts established; as well as detailed benefit plans.

Professional training of Health-care administrators During the past few years the trend is to train healthcareadministrators and managers mainly as postgraduateprogrammes, but there is a university that offers pre-graduate training in health-care administration.

Two medical schools offer specialization in health-careadministration and management. Training is three yearslong, and there are also other postgraduate modalities(diploma and mastership) in many universities in Peru.Training for these professionals involves leadership, humanresource management, ethics, process management, datamanagement, economic, financial, and cost management.

Finally, we must recognize the need for involvement,motivation, leadership, and values in order to contributewith better management and development of health-careinstitutions in Perú and all over the world, in order toachieve universal good health. �

10-11 Peru:ihf18 8/7/08 11:16


POLICY: MEDICAL NUTRITION

Putting medical nutrition on tothe international agenda: Actions by the EuropeanNutrition for Health Alliance

PASCAL GARELCHIEF EXECUTIVE, HOPE (EUROPEAN HOSPITAL AND HEALTHCARE FEDERATION)

Abstract

In the European Union, most attention from the public, policymakers and health promotion campaigns in relation tonutrition is aimed at obesity. Until recently, this has overshadowed another facet of poor nutrition, whereby inadequatenutritional intake – often associated with disease – leads to weight loss, impaired body function and a poor clinicaloutcome. Malnutrition not only compromises health outcomes by impairing response to medical treatment, delayingrecovery and increasing mortality, but also severely impacts on the economic and social burden to carers and health-care systems. A group of stakeholders from across the European health arena recently formed the European Nutritionfor Health Alliance (ENHA) in a united effort to raise awareness of the importance and the urgency of the issue ofmalnutrition and to build an agenda for action, both at European level and in individual countries.

There is growing understanding in the European Unionof the role that nutrition plays in the onset andprogression of many diseases. As a consequence,

political involvement has increased significantly. MostEuropean governments have “health promotion campaigns”aimed primarily at addressing obesity and its associateddiseases, especially diabetes and cardiovascular disease. Thehealth promotion efforts generally aim to reduce thesignificant impact these conditions have on the individual,society and health care resources. Attention to nutrition andin particular healthy eating is a core principle. Theseconditions are recognised as major public health issues and,particularly in the case of obesity, are clearly visible tosociety.

At the other end of the spectrum of poor nutritional statusare the individuals suffering from malnutrition. Mostmalnourished people are either in their own homes, in someform of residential care home or in hospital. Malnutrition isthus much less visible to society than obesity, and does notattract the same level of political or media attention. Evenattention from clinicians managing the care of malnourishedindividuals is often deficient1. Many patients will not havetheir nutritional status assessed at any time during theircare. Despite the availability of simple screening tools fornutritional status that have been validated across health-caresettings (e.g. the “MUST” tool2), a recent survey of generalpractitioners in the UK found that 88% were not aware of

any screening tools and 40% did not give any dietary adviceto patients at risk of malnutrition3. Only 13% of familydoctors surveyed always referred a patient with or at risk ofmalnutrition to a dietician.

What do we know about malnutrition?Malnutrition has a high prevalence across all ages as well asclinical and social settings1. It is the older person, among themost vulnerable in society, who is most at risk ofmalnutrition and its consequences4 As many as 50% of allpatients admitted to hospital either have or are at risk ofmalnutrition5-7 and depending on the survey and the caresetting this figure could be as high as 85% or more1. Thenumber of people suffering from malnutrition rises fromaround 50% in persons over 60 to 77% in persons over 807.The common risk factors for malnutrition in the elderly canbe clinical (poor appetite, poor dentition, loss of taste andsmell, disability and limited mobility, drug interactions, otherdisease states like cancer or diabetes), linked to lifestyle andsocial factors (lack of knowledge about food, cooking andnutrition, isolation and loneliness, poverty, inability to shopor prepare food) or even to psychological factors (confusion,depression, anxiety, bereavement, dementia).8

The economic and personal costs associated withuntreated malnutrition are substantial. A study in the UK9,10

showed that the overall cost of managing patient withmedium and high risk of disease-related malnutrition could

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be higher than £7 billion. The annual additional health-carecosts of managing these patients compared with anequivalent number of patients at low risk of malnutritionwas estimated to be over £5.3 billion. Most of thisincremental cost was due to more frequent and moreexpensive hospital inpatient spells and greater need for long-term care. The figure of £7 billion represents nearly 10% ofthe UK total expenditure on health. A reduction of just 1%in the number of patients suffering from malnutrition couldsave the NHS in the UK up to £70 million. The costs ofmanaging patients with malnutrition may be substantiallymore than that spent today on managing obesity and its co-morbidities, which has been estimated by the House ofCommons Health Committee to be £3.7 billion in the UK11.

Addressing the problem: effectiveness ofinterventionsThe causes and consequences of malnutrition are multi-sectoral and thus interventions must be targeted at all caresettings. There is a large body of evidence whichdemonstrates the clinical value of nutritional intervention indifferent social care and health-care settings1. Pragmaticstudies have shown that when appropriate treatmentinterventions are put in place the results can be dramatic.For example, the Belgian Geriatric study group12

demonstrated a significant reduction in length of hospitalstay in geriatric patients. Similarly, in the community,Arnaud-Battandier showed that use of oral nutritionalsupplements in older people resulted in lower medical costsdue to less hospital admissions, and less nursing and othermedical time13.

Multi-stakeholder approachOver the years, there have been many publications on theproblem of malnutrition but to date these have had limitedimpact in improving either the clinical practice of health-care professionals, or changing health policy or society’sperceptions. A multi-stakeholder approach has a greaterchance of success as each partner contributes a differentperspective and this helps to highlight how the issue affectsall sectors, not just the patient and the health-careprofessional. Malnutrition is a societal issue, affecting manyindividuals in some way either directly, e.g. via amalnourished older family member, or indirectly, e.g. viaconsumption of health-care resources in managing thecomplications caused by malnutrition which in turn maylimit the resources available to adequately treat otherconditions.

The formation of the European Nutrition for HealthAllianceIn response to the raising of the malnutrition issue at theDutch EU presidency conference in The Hague inSeptember 2004, a group of interested stakeholders fromacross the European healthcare arena recognised that allstakeholders must take ownership and action to addressmalnutrition across all care settings and sectoral divides.This led to the formation of the European Nutrition for

Health Alliance which consists of representatives of severalkey European stakeholder bodies in the fields of nutrition,health and social care and policy, together with otherstakeholders from the political arena; among them theEuropean Hospital and Healthcare Federation (HOPE), theInternational Association of Gerontology (EUGMS),European Society for Clinical Nutrition and Metabolism(ESPEN), Association Internationale de la Mutalité (AIM),International Longevity Centre and European NurseDirectors Association.

The European Nutrition for Health Alliance visionand goalsFor truly effective action to be taken on malnutrition, it hasto be seen as a public health issue of equal magnitude andimportance as obesity. With this in mind the first goal forthe European Nutrition for Health Alliance is to getmalnutrition seen and treated as a disease in its own right.Recognising the problem is just the first step; implementingactions and nutritional care plans are essential if realimprovements are to be made in patient care and clinicaloutcomes in this vulnerable group of people. The Alliancewill seek to facilitate the sharing of best practices, theintroduction of patient orientated nutrition care plans,lobbying for medical nutrition to be considered as part offuture health policies and targets at EU and national level,and to improve nutritional education in all sectors of society.To achieve this the Alliance will attempt to:� Raise awareness of the urgent need to prevent

malnutrition in the European Union and ensure thateffective nutritional support is available to all thoseaffected in the community and across all clinical settings.

� Ensure that all stakeholders take responsibility andaccountability for the issue.

� Seek new and innovative finance and delivery models toaddress the problem.

� Build a public media campaign on malnutrition, Involvepatients and consumers to raise awareness and politicalrelevance.

� Obtain recognition of malnutrition as a huge societalissue with significant economic consequences.

� Obtain recognition that malnutrition is preventable,treatable and curable.

� Convince policymakers and stakeholders that solutionsare available, successful and affordable and that theymust implement them.

The European Nutrition for Health Allianceachievements and activitiesThe ENHA has formed partnerships and works alongsidemany key non-governmental organisation (NGO) groupsand patient organisations as well as representatives from thepolitical arena at both EU and national level. On 14September 2005, stakeholders from across Europe gatheredin London for the inaugural conference of the ENHA.Delegates were invited from across a broad spectrum ofhealth, residential and community care. The result of thisconference was a call for action14 which included three key

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elements to advance progress against malnutrition in olderpeople.

Through this multi-stakeholder approach, together withthe British Association of Parenteral and Enteral Nutrition(BAPEN), the International Longevity Centre UK and theParliamentary Food and Health Forum in the UK, the ENHAheld a workshop at the House of Lords in London on 21March 2006. This discussion and follow-up consultation ledto the production of a policy brief15 published on 17 May 2006 that has been forwarded to the UK Departmentof Health. This document included seven keyrecommendations for policymakers:� Malnutrition must be incorporated into the public

health agenda.� Addressing malnutrition in older people in the

community requires an inter-sectoral approach.� Raise awareness of malnutrition amongst older people,

their families and the public at large.� Ensure that access to good nutrition is incorporated

into local and community planning.� Develop adapted and accredited training in nutrition for

all health, social care professionals and associatedpersonnel.

� Embed the practice of screening for malnutrition in thecommunity by health, social care and communityservice providers and professionals.

� Define standards and pathways of care for preventingand treating malnutrition in the community.

Further widening and strengthening of partnershipsfollowed from the second EU Conference held in Brusselson 22 November 2007. In 2008 most of the attention of theAlliance has been concentrated in successfully lobbyingMembers of the European Parliament to includemalnutrition in the European parliament White Paper

Together For Health Strategy 2008–2013.

ConclusionsMalnutrition, like obesity, is a major public health issue,which has a high personal, economic and social cost. Thecosts of malnutrition have repercussions for all care settingsincluding social services. Funding of appropriateinterventions from better nutrition in the home to clinicalnutrition in both the community and the hospital isinconsistent. If we are to prevent both the effects ofmalnutrition and the burden of payment fallingindiscriminately on the most vulnerable in society,policymakers and payers must fund solutions, from theirhealth and social budgets, to defeat malnutrition.

The causes of malnutrition are multi-faceted and whilstimplementing effective solutions may be complex, they willbe successfully accomplished through political engagementat a European, national and community level and throughraising public awareness about the risks of malnutrition.Governments would be seen as negligent if they did notattempt to tackle the growing threat of obesity in our society.Why does malnutrition, which disproportionately affects theolder person, not receive the same attention? Across Europe,society is ageing so the numbers at risk of malnutrition willcontinue to rise placing an ever-increasing strain on scarcehealth-care resources if actions are not taken now. By actingtogether to raise awareness, to assist in the implementationof screening tools and ensuring that those patients whorequire it can receive appropriate and fully reimbursednutritional support, this issue can be resolved. The solutionsare available and achievable and a multidisciplinaryapproach, with dietitians at the core, is needed ifmalnutrition is to be eliminated from within ourcommunities. �

References

1. Stratton RJ, Green CJ, Elia M. Disease-related malnutrition: An evidence basedapproach to treatment. Wallingford: CABI Publishing, 2003.

2. Elia M (Editor). The MUST Report. A Report by the Malnutrition Advisory Groupof the British Association of Parenteral and Enteral Nutrition (BAPEN): Redditch:BAPEN, 2003.

3. Bacon N. “Malnutrition in an ageing society”. Presentation to the EuropeanNutrition for Health Alliance Conference, 2005. www.european-nutrition.org

4. Furman EF. Undernutrition in older adults across the continuum of care. JGerontol Nurs 2006: 32:22-27.

5. Edington J, Boorman J, Durrant ER, et al. Prevalence of malnutrition onadmission to four hospitals in England. The malnutrition prevalence group. ClinNutr 2000; 19: 191–195.

6. McWhirter JP, Pennington CR. Incidence and recognition of malnutrition inhospital. Br Med J 1994; 308:945–948.

7. Kyle U, Unger P, Mensi N, Genton L, Pichard C. Nutrition status in patientsyounger and older than 60y at hospital admission: a controlled population studyin 995 subjects. Nutrition 2002; 18: 463-469.

8. Hickson M. Malnutrition and ageing. Post Grad Med J 2006; 82:2-8.9. Elia M, Stratton R, Russell C, Green C, Pang, F. The cost of disease-related

malnutrition in the UK and economic considerations for the use of oralnutritional supplements (ONS) in adults. Report by the Health Economic Groupof the British Association of Parenteral and Enteral Nutrition (BAPEN). Redditch:BAPEN, 2005.

10.Russell CA. Impact of malnutrition on healthcare costs and a cost analysis of oralnutritional supplements. Clin Nutr, in press (this supplement).

11.House of Commons Health Committee. Obesity (volume 1). In: Third report ofsession 2003-2004, editor. London: The Stationery Office Limited, 2004.

12.Pepersack T. “Geriatrics Peer Review: Outcome of continuous processimprovement of nutritional care programme among geriatric units in Belgium”.Presentation to the European Nutrition for Health Alliance Conference, 2005.www.european-nutrition.org

13.Arnaud-Battandier F, Malvy D, Jeandel D, et al. Use of oral supplements inmalnourished elderly patients living in the community: a pharmaco-economicstudy. Clin Nutr 2004; 23:1096-1103.

14.European Nutrition for Health Alliance. Malnutrition within an ageingpopulation: a call for action. Report on the Inaugural Conference of theEuropean Nutrition for Health Alliance, London, 14 September, 2005.www.european-nutrition.org

15.Baeyens JP, Elia M, Greengross S, Rea N. Malnutrition among older people in thecommunity. Policy recommendations for change. A UK policy report byEuropean Nutrition for Health Alliance, British Association for Parenteral andEnteral Nutrition, International Longevity Centre – UK in collaboration with theAssociate Parliamentary Food and health Forum, 2006. www.european-nutrition.org

16.Read M. Opening address at the Inaugural Conference of the European Nutritionfor Health Alliance. London 14 September, 2005. www.european-nutrition.org

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https://www.researchgate.net/publication/11328118_Nutrition_status_in_patients_younger_and_older_than_60_y_at_hospital_admission_A_controlled_population_study_in_995_subjects?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/291782763_The_incidence_and_recognition_of_malnutrition_in_hospital?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/291782763_The_incidence_and_recognition_of_malnutrition_in_hospital?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==


MANAGEMENT: ARCHITECTURE AND DESIGN

We shape our buildings, thenthey kill us: Why health-carebuildings contribute to theerror pandemicKENETH N DICKERMAN ACHA, AIA, FHFIIS NATIONAL RESOURCE ARCHITECT AT LEO A DALY

PROFESSOR PAUL BARACH, MD, MPHIS A PROFESSOR AT UTRECHT UNIVERSITY, NETHERLANDS AND ASSOCIATE PROFESSOR AT THE UNIVERSITY OF

SOUTH FLORIDA

RAY PENTECOST III, DRPH, AIA, ACHAIS A VICE PRESIDENT AND DIRECTOR OF HEALTHCARE ARCHITECTURE AT CLARK NEXSEN ARCHITECTURE &

ENGINEERING

Abstract

Hospitals are complex. The physical environment in which that complexity exists has a significant impact on healthand safety. However, enhancing patient safety or improving quality has not been integrated into aspects of the designof hospital buildings. Despite recent discussions regarding design of ‘patient-centered’ healthcare facilities and‘eveidnece-based design’, there has been little assessment of the impact of the built environment on patientoutcomes. This paper will present a few examples of how changes in design can improve the quality of care.

Hospitals are complex. The physical environment inwhich that complexity exists has a significant impacton health and safety. However, enhancing patient

safety or improving quality has not been integrated intoaspects of the design of hospital buildings. Despite recentdiscussions in architectural literature regarding design of“patient-centred” healthcare facilities and “evidence-baseddesign”, there has been little assessment of the impact of thebuilt environment on patient outcomes. Studies havefocused primarily on the effects of light, colour, views, andnoise, yet there are many more considerations in facilityplanning that can influence the safety and quality of care1.

Analysis of more than 400 research studies shows a directlink between quality of care, patient health, and the way ahospital is designed. Here are a few examples of howchanges in design can improve the quality of care:� Patient falls declined by 75% in the cardiac critical care

unit at Methodist Hospital in Indianapolis, Indiana,which made better use of nursing staff by dispersingtheir stations and placing them in closer proximity topatients” rooms1;

� The rate of hospital-acquired infections decreased 11%in new patient pavilions at Bronson Methodist Hospitalin Kalamazoo, Michigan which was attributed to a design

that featured private rooms and specially located sinks1;� Medical errors fell 30% on two new inpatient units at

the Barbara Ann Karmanos Cancer Institute in Detroit,Michigan, after it allocated more space for theirmedication rooms, re-organised medical supplies, andinstalled acoustical panels to decrease noise levels1;

The evidence is impressive. The health-care environmenthas substantial effects on patient health and safety, careefficiency, staff effectiveness and morale. The US spendsapproximately 17% of its gross national product on healthcare, much of which is provided in hospitals. Yet, despitethis enormous expenditure and the available technologicalresources, today”s hospital care frequently runs afoul of thecardinal rule of medicine – above all else, do no harm.Hospitals also create stress for patients, their families, andstaff. The negative effects of stress are psychological,physiological, and behavioural, and include:� Anxiety, depression, and anger (psychological); � Increased blood pressure, elevated levels of the body”s

stress hormones, and reduced immune function(physiological); and,

� Sleeplessness, aggressive outbursts, patient refusal tofollow doctor”s instructions, staff inattention to detail,



and drug or alcohol abuse (behavioural).

Poor design of the hospital environment contributes to allthese problems. Poor air quality and ventilation, togetherwith placing two or more patients in the same room, aremajor causes of hospital-acquired infection. Inadequatelighting is linked to patient depression as well as tomedication errors. Lack of a strong nursing presence canresult in patient falls.

Seldom does an opportunity emerge to build a newhospital; most hospitals are in a continuous cycle ofremodelling and expanding their existing facilities to adaptto changing demands. The US is in the midst of the largesthospital construction boom in history with over 500hospitals being built, with a staggering $200 billion impact.

We would then ask ourselves several guiding questions:� How and via what mechanisms does the physical

environment participate in patient safety? � How does the environment of the system affect the

safety of patients?� What characteristics are used to describe an

environment? � What process creates the physical environment?� Is it possible to change either the creation process or

the result to improve safety?

Health-care building design historyLouis Sullivan”s famous dictum, “form follows function”,should be rewritten to say, “form follows function and thenfunction follows form”2, to express the essential relationshipbetween buildings and the people who populate them. Theact of making form follow function (or clinical process) isbrief, fraught with difficulties and often incomplete. Theopportunity or limitation placed by the form upon functionis lasting, hidden and inelastic. And the lengthy process of5-8 years from idea inception to facility constructionexacerbates these challenges.

In 1976, John Thompson and Grace Goldin of YaleUniversity wrote the most complete study on the history ofhospital design, A Social and Architectural History of theHospital. While this work principally deals with thedevelopment of nursing wards or units, it sheds light onother key aspects of hospital development. The historicalaspect of the work can be summarised as follows: there isnothing new under the sun. The two essential problems ofhospital design which architects still face are: efficient andsafe removal of human waste and creation of anenvironment that aids rather than hinders healing. Severalexamples will follow to demonstrate the slow pace of changein health-care design.

Greek hospitals – Patient-focusedThe first of these, though perhaps not the first hospital, isthe Greek Asclepieion. These institutions were as much, ifnot more, temples than hospitals. Patients received thebenefit of prayers and sacrificial offerings which wereintended to influence the god of healing Asclepius. Therelationship between god (healer) and patient with

attendants as intermediaries was paramount.

Roman hospitals – Specialty hospitalsThe Romans adopted the Asclepian model, but reformattedit to their own more practical purpose. Since soldiers, andlater slaves, were the foundation of Roman civilization, itwas natural that they should build valetudinaria to serve thelegions. These might be complicated fixed facilities whereRoman rule was well established, or they might be small ormovable structures to accommodate armies on the march.

As the expansion of the empire decreased, capturedslaves became less common and Roman slaveholders wereobliged to take better care of their property. One answerwas to adopt the military approach and build valetudinariafor slaves. Better-heeled elements of Roman society had nosuch institutions available, since the belief structure heldthat illness was due to the anger of the gods and notnatural causes.

The Middle Ages – Charity careDuring the Middle Ages, as Christianity spread throughEurope, the concept of caring for less fortunate members ofsociety became more popular. In Islamic countries, valuewas even placed on the human body with the concomitantconcept of caring for it, whereas Christianity looked at thebody as a repository for the soul. Great pilgrimages and theCrusades occasioned the development of centres to care fortravellers. Located at monasteries such as Cluny in France,these developed from adjunct functions to purpose-builtcomponents of the monastery complex.

The technology of care in these institutions had not madegreat strides since the days of the Greeks, nor had there beengreat advances in the methods of removing waste ordesigning wards that aided healing. Clearly, however, therewas a growing interest in health and public health, includingcreating the types of organisations and institutions thatshould be responsible for public welfare.

During the Renaissance, designers continued to strugglewith the problems of waste removal and ward design. Somesolutions, such as the hospital planned by Filarte in Milan(Figure 1), had a well-developed system of latrines nearpatient sleeping areas. Unfortunately, the waste, onceremoved, was discharged into the principal public waterway,which only relocated, rather than solved, the problem. InFilarte”s ward plan, the latrines were located adjacent topatient beds. Wards were also designed so that patientscould see the altar of the patron saint.

The advent of scientific medicineDuring the 16th, 17th and 18th centuries, the balancebetween religiously dominated belief systems andnaturalistic-driven belief systems (science) underwent apronounced change. As the bulk of scientific knowledgegrew, there was greater interest in experimentation inhealth facility design. Human understanding of diseasehad changed and was forcing new concepts in care inareas such as antisepsis, surgical interventions and otherdrug developments. In many places, it was still common



to have more than one patient per bed and care was morepalliative than remedial. Mental health conditions werestill misunderstood, and although there were some newmodels of mental health care, mental health conditionswere felt to be due to demonic and/or satanicalinfluences. War and military conquests also helped to spurdramatic changes in care.

Florence NightingaleFew stories are more significant in the history of health carethan that of Florence Nightingale and her experience duringthe Crimean war. At the converted Turkish barracks atScutari which the British army used as a hospital (Figure 2),the mortality rate in the hospital is said to have been 47%with infection killing many more soldiers than bullets.

The answer developed for Scutari was a modular hospitalsolution that could be constructed in England,disassembled, shipped to Turkey, and reassembled (Figure2). In addition, it was cheap and made of materials whichcould be easily cleaned.

The patient wards, individual huts for about 50 men, hadother unique features, including a ventilation system whichforced 1,000 cubic feet of air per minute through two ductsunderneath the floor. The air was discharged into the wardthrough grilles in the floor and travelled upward and out.The hospital was a combination of ward huts and special-purpose structures for cooking, cleaning, and other aspectsof care and operation all organised in a grid-like layoutwhich facilitated the placement of water supplies and drains.

An innovative ward plan, founded on a 30-foot wide unitand housing 30 patients, was derived from the Crimeanexperience, and came to be known as the “NightingaleWard” (Figure 3).

Figure 3: British army hospital, Renkioi, plan by Isambard Brunel, from Longmans Green

Figure 1: Ospedale Maggiore, Milan, section by Liliana Grassi

Figure 4: Example of a Nightingale ward, from Notes on Hospitals, F Nightingale

Figure 2: Turkish barracks at Scutari, Illustrated London News, 16 December 1854



Modern hospital design process Global performance, in terms of outcome, risk management,and safety, is influenced by local interactions andsynchronisation of system components (e.g. providers,patients, technologies, information and material resources,physical and temporal constraints). As a result, adverseevents and unintended consequences are impossible tounderstand in terms of simple rational rules.

To date, reductionist approaches towards hospitalconstruction have failed to adequately control risk or reducethe number of adverse events. The conditions in which wework, with fatigue from 24-hour duty rotations, doubleshifts, high workloads, confusing labels, noisyenvironments, look-alike names, poor handwriting, poorlydesigned equipment, and health-care buildings, can lead toerrors. These are open or ill-posed problems bestunderstood through controlled observations, cases study,and modelling, with insights drawn from other complexadaptive systems, such as emerging economies and dynamicsocial systems. This complex system theory can arguably beused as the basis for a new principled approach tooptimising hospital design, performance and outcomes,managing risk and guiding health policy.

The traditional hospital design process requires thatarchitects be given programme objectives (function andprogramme), which are then translated in roomrequirements (a space programme) and followed by thecreation of department adjacencies (block diagrams). Oncethis preliminary information has been provided, room-by-room adjacencies are developed and then a detailed designof each room is completed (schematic and designdevelopment).

Architects then convert room-by-room design toconstruction documents that represent how individuals,equipment and technology in hospitals will functiontogether. Equipment and technology planning generallyoccurs in the later stages of the design process. Typically,discussions of patient safety or designing around adverseevents are rare. This creates an opportunity to repeat latentconditions existing in current hospital designs thatcontribute to active failures (adverse events or sentinelevents)3. Human factors, the interface and impact of

equipment, technology, and facilities is also not typicallydiscussed or explored early in the process.

Patient safety challenge In the early 1990s, researchers such as Leape and Brennanbegan to question the safety of healthcare institutions4. TheInstitute of Medicine report in 2000 posited that between44,000 and 98,000 Americans die in US hospitals due topreventable errors.

There are two possible responses to this challenge – apersonal or a systems approach. Our primary response tothis epidemic has been to focus on the personal approach inwhich after an error or accident we search for the “guiltyparties”. The legal system is most willing to help in this“righteous cause” as it rids the system of “incompetentdoctors” and punishes “bad hospitals”.

The concept of “systems” is important in the discussion ofhealth-care safety and health facility design. A system is a setof components, sometimes called subsystems ormicrosystems, which are related or a complex whole formedfrom related parts, or an organisation of people, tools,resources and environment5. This last term, “environment”,is the focus of this study – specifically the physicalenvironment in which components are housed, as opposedto the cultural environment.

Characteristics of systems A health-care system includes several sub-componentmicrosystems. The foremost are the medical or clinicalprocesses undertaken. Another component is medical andnonmedical technology, including information systems,diagnostic systems, imaging systems and more mundanetechnologies such as floor cleaning equipment, supplyordering and distribution technologies. Next there isorganisation, the administrative arrangement that includespolicies, procedures, strategies and tactics, managementtools and business plans. Humans are another subsystem,which includes professional, technical, administrative,management, patient, public and government. Finally, thedesigned, built environment is a subcomponent. Itpossesses a large number of characteristics.

Charles Perrow undertook a study of major accidents anddiscovered that systems, rather than individuals, were often

Figure 6: Layers of defence systems breached through their latent failures (after Reason8)

LOOSELOW

LOOSEHIGH

TIGHTLOW

TIGHTHIGH

Figure 5: Interdependence characteristics of systems (after Perrow6)



at fault6. Perrow and James Reason redefined how we shouldproceed to understand causes of accidents and fix problems.One of Perrow”s contributions was to describe how thecomponents of systems relate. He defined two scales –complexity and coupling – which explained howcomponents of systems react (Figure 5).

Complexity can range from low complexity to highcomplexity. Making a sandwich is a low complexityundertaking. Flying a fighter jet off an aircraft carrier ishighly complex. Coupling ranges from loose to tight. If anactivity is not highly dependent on the exactness ofpreceding activities, it is loosely coupled. The steps ofmaking a sandwich are loosely coupled. The steps in flyingoff the carrier are tightly coupled. Health care, for example,is a system that is highly complex and tightly interrelated,with many subcomponents, and some hiddencharacteristics, requiring “operators” to use a great deal ofshort-term memory or computing power.

Health-care systems are also tightly coupled in that thereis no “wiggle room” in the connections. If one componentfails, the adjoining components are immediately impacted,sometimes in unforeseen ways.

The illustration above shows the relationships betweencomplexity and coupling.7

Reason’s theory of human errorsReason, in his work Human Error8, teaches that accidents arelatent in systems. This idea speaks to the imperfection of thedesign of systems as much as to the fallibility of the peoplewho operate them. Reason describes a system as having aseries of layers of defence (Figure 6). These might beprocedures, training, teams, organisation and technicalsafeguards. These safeguards, however, are imperfect. Theyeach have holes like a piece of Swiss cheese. The holesrepresent various types of shortcomings peculiar to eachlayer of defence. The location of the holes in each layer isdynamic as subsystems change over time. There are always“triggering events” which penetrate some layers, but aregenerally stopped by others, until that fateful time when allof the defences are breached. This conceptual model helpsus to see that the shortcomings in the defences exist withoutrespect to whether or not there are accidents. They are acharacteristic of the construction and operation of aparticular subsystem or component of the system.

When referring to Reason’s diagram, note that the“defence” against errors is made up of subsystems shown aslayers9. In our review of medical literature to date, when thesource, description, and causes of errors are given there isinvariably a failure to consider the “layer” representing thephysical environment.

Systems and safetyIt is essential that we accept the construct, which states thataccidents are latent in systems and, therefore, safety is acomponent of systems as well as their subcomponents.Richard Cook proposed this concept in his paper, A Tale ofTwo Stories10. It follows that if safety is a component of thesystem, it might also be described as a part of the culture of

the system. The IOM report, To Err is Human, describessafety as an emergent characteristic of systems11. It emergesnot because one subsystem is near perfect, but because theaggregation of subsystems embodies it as a whole.

We offer this additional consideration. The challenge is tochange the traditional hospital design process to incorporatethe safety-driven design principles and to create or enhancethe culture of safety. In planning for the new facility, weapproach the hospital design process with a blank sheet ofpaper, an appreciation of the evidence that there is ampleopportunity to improve hospital patient safety. We believethat improving hospital facility design will not only increasepatient safety directly but also indirectly promote a safety-oriented organisational culture.

The new foundation for understanding human errorconsiders that health-care providers make mistakes becausethe systems, tasks and processes they work in are poorlydesigned. Organisational accidents have multiple causesinvolving many people operating at different levels. Thistranslates into failures at the point of service (e.g. aphysician ordering an allergenic drug for an allergic patient).Based on this idea, exceptional design of health-careinstitutions will provide an environment of patient safety aswell as a safety-oriented organisational culture. It requires afocus on safety by hospital leadership, physicians and staffthat is accomplished through a continuous cycle ofevaluation and improvement of the facility, equipment,technology and processes.

The traditional design concepts can be summarised asfollows:� The physical environment for healing is a shelter, but

has little special interaction with the healing process oroperation. The healing environment is separate, but notparticularly special.

� The physical environment for healing is an “edifice” ormonument signifying the importance of an individual, acommunity or an institution.

� The physical environment for healing is an asset whosevalue is seen in terms of its real estate characteristics.

In contrast, we propose our concept as follows: thephysical environment for healing is an integralsubcomponent of the care delivery process. Like other toolsand resources, its design, use and application eitherpromote or hinder the attainment of the goals of care. Thesesystems and subsystems or microsystems, need to becarefully designed and supported12.

The characteristics of the physical environment interactwith the care process through physiological andpsychological pathways. The interactions may directly orindirectly affect caregivers, patients, support personnel,equipment and operational plans. Improving the physicalenvironment “layer” in Reason’s “Swiss cheese” lies in theprocess by which the physical environment is created. Thatprocess has evolved over time and it now includes severalvariants. Our review of the characteristics of the designprocess, leads us to conclude they should all be consideredas a single process.



Can we change the design process?If we accept the proposition that health care is a system andthat the physical environment is a component of thatsystem, we might then ask whether that part of the systemcould be improved. In other words, is there anything wrongwith the health care physical environment and, if so, canthis layer of cheese have some of the holes filled in?

There are many deficiencies in the design of health-careenvironments that contribute to adverse events. Oneexample relates to patient falls, which is sufficientlysignificant to have been placed on the national list of patientsafety objectives13. The design of the environment has directand indirect impacts on patient falls and yet has beenmostly ignored by regulators. Hospitals have latitude inchoosing which finish materials to use despite clear anddangerous consequences when using slippery surfaces.

Why do deficiencies in the designed physical environmentoccur? While there has been too little peer-reviewed study ofthis question, the design process does have a number ofcharacteristics, which may be at fault. Design professionals,in the course of study for their profession, generally do notstudy ergonomics, human performance science, or thescience of how human beings interact with theirenvironment.

An unstated conclusion of Donald Norman’s book, TheDesign of Everyday Things, is that designers don’t know muchabout everyday users3. Designers study design, not humanbeings. This deficiency manifests itself in the results of theirwork. Aside from not having a rudimentary understanding ofhuman performance and its limitations, such as fatigue, stressand sensory degradation, designers are insulated from users.This happens because designers make assumptions aboutusers based on their own, and not the users’, experience.

Health care building design projects often begin with a

set of assumptions, made by the owners, the designers orothers. These assumptions are not tested before or duringthe design process. For example, a functional programmemay be created by the owner and stipulated to the designeras a given. No opportunity exists to question or test thecontents of this programme or to work with clinicians andothers involved in care to find better methods.

The process of design commonly used in health care islinear. It starts with the architect working with the givens,proceeds to a greater definition of the floor plan andmassing, then adds equipment, information technology,building systems, furnishings and other components. Thereis a natural and financial inclination not to loop back tolook at evolving issues in a holistic light.

If the plan is done, the solution must be a different pieceof equipment, a different furnishing or, even worse, aprocess change. Likewise, after the equipment andtechnology are selected, usually just before constructionbegins, there is resistance to changing any part of the designwhich has been determined before.

These characteristics of the process are exacerbated bythe fact that it is generally led by a single component of thedesign team, most frequently the architect. In alternativescenarios, the team is led by a “programme manager”, a“construction manager” or by an “owner”s representative”.The problem with this form of leadership is that it tends tofocus on one aspect of the project, for example, the budget,the schedule or the “design”, to the detriment of others.

Our search is to find methods which avoid these pitfalls,so that the resulting physical and operational environmentis as safe and effective as possible (see panel box). Ratherthan trying to improve a process, which has demonstrablyyielded inadequate results, we suggest that a new processbe created.

Infection Control� Selection of surface materials� Handwashing station provision� Space for maintenance of sterile technique� Ventilation design – filtration, air flow, temperature,

humidity

Patient Identification� Lighting intensity and quality� Sound/noise – design for aural quality

Surgical technique� Vibration� Noise and acoustic quality� Layout of room for:

- Placement and movement of surgical systems, robots, imaging, etc.

- Staff workflow- Access to supplies and emergency services

� Room environment control design

Staff Accommodation� Minimise stress

Transfer� Physical – provision for patient transfer system� Information – environment for accurate, undistracted

communication

Utility Systems� Design for ease of maintenance and indication of

failure� Clarity of controls, displays and indicators� Standardisation of systems (important in other areas

as well)

Systems coordination� Design of systems to eliminate confusing alarms and

indicators� Testing of systems in simulated surgeries to discover

shortcomings

Critical design factors in the physical environment



Design for patient safetyThe design process for patient safety must include threegoals:� Reduce the risk of health care-associated (caused by

treatment) injury to patients and health-care providers.� Remove or minimise hazards, which increase risk of

health care-associated injury to patients.� Educate the design team in the complexity of designing

health care settings for safe outcomes.

The strategy advocated for achieving these goalsincorporates the following concepts14:� Treat the creation of safety as part of a process that

addresses the safety and integration of all systemcomponents, as part of the culture.

� Involve users and stakeholders at all levels of theinstitution in the “creation of safety process” involves.

� A complete array of disciplines and knowledge isnecessary at the project start.

� Use of a wide range of tools. These include: failuremodes effect analysis (FMEA), root cause analysis(RCA), mock-ups, simulation, testing, and data analysis.

� Create and require team education about the patientsafety problem, about the process of building design,and about the process of collaboration with others toderive effective and efficient solutions.

� Gain appreciation that designing for safety is an iterativeprocess.

These strategies apply to all areas of health-care facilities.The first part of this task is to define the characteristics of theenvironment from the perspective of design. On top of theaccommodation of new systems and procedures, patientsafety teams must deal with the environments and processessurrounding those which are already in use. The buildingcodes and regulations need to be modified to allow for thesechanges. Building design-related contributors to hospital-acquired infections can include: inadequate maintenance offilters; use of floor, wall or ceiling materials which are hardto clean; poor placement of hand-washing stations;insufficient space to maintain sterile separation.

Reiling wrote: “Creating a process to evaluate the interplaybetween equipment, technology, and facility to create safetyat the beginning of the design process was challenging.”15

The process he used emphasised “focus and commitment tosafety-driven design principles”.

Cultural challengesThe health-care design process needs to be radicallychanged to address patient safety issues. Creating anenvironment in which a culture of patient safety can flourishis, however, daunting and requires a willingness to thinkoutside the constraints of convention, and to challenge theintellectual and cultural stagnation which characterisesmany of our professional and commercial institutions. �

References

1. Ulrich R, Quan X, Zimring C, Joseph A, Choudhary R. The role of the physicalenvironment in the hospital of the 21st century: A once-in-a-lifetimeopportunity. Concord CA: The Center for Health Design; 2004 Sept.

2. Sullivan LH. The tall office building artistically considered. Lippincott’s Magazine;1896 Mar.

3. Norman DA. The design of everyday things. New York: Basic Books; 2002. 4. Leape LL.. Error in medicine. JAMA 1994. 272(23):1851-7.5. Barach P, Johnson J. Safety by design: Understanding the dynamic complexity of

redesigning care around the clinical microsystem. Qual Saf Health Care 2006; 15(Suppl 1): i10-i16.

6. Perrow C. Normal Accidents: Living with high-risk technologies. New York: BasicBooks; 1984.

7. Dickerman KN. Interdependence characteristics of systems – Chart based onCharles Perrow’s theory of complexity and coupling; 2005.

8. Reason J. Human error. New York: Cambridge University Press; 1990.

9. Reason J, Dickerman K. Theory of mistakes, swisscheeserevenv.jpg, Editor. 2005.10. Cook RI, Woods DD, Miller C. A tale of two stories: Contrasting views of patient

safety. Chicago: National Patient Safety Foundation; 1998.11. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer

health system. Institute of Medicine report. Washington, DC: National AcademyPress; 2000.

12. Mohr J, Barach P. Understanding the design of health care organizations: The roleof qualitative research methods. Environment & Behavior 2008; 40:191-205.

13. JCAHO. 2006 Joint Commission National Patient Safety Goals. 2006.14. Dickerman K, Nevo I, Barach P. Incorporating patient-safe design into the design

guidelines. Am Inst Arch J. 2005; October:7.15. Reiling JG, Knutzen BL, Wallen TK, McCullough S, Miller R, Chernos S.

Enhancing the traditional hospital design process: a focus on patient safety. JtComm J Qual Saf 2004. 30(3):115-24.

https://www.researchgate.net/publication/233969551_INCORPORATING_PATIENT-SAFE_DESIGN_INTO_THE_GUIDELINES?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

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https://www.researchgate.net/publication/237520974_The_Role_of_the_Physical_Environment_in_the_Hospital_of_the_21st_Century_A_Once-in-A-Lifetime_Opportunity?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/8669434_Enhancing_the_traditional_hospital_design_process_A_focus_on_patient_safety?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/270819200_The_Design_of_Everyday_Things?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/235700816_The_Tall_Office_Building_Artistically_Considered?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/235700816_The_Tall_Office_Building_Artistically_Considered?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/245232055_Normal_Accidents_Living_With_High_Risk_Technologies?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/245232055_Normal_Accidents_Living_With_High_Risk_Technologies?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/6655626_Understanding_the_complexity_of_redesigning_care_around_the_clinical_microsystem_Quality_Safety_in_Health_Care_151_i10-i16?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==




MANAGEMENT: PANDEMICS

Avian influenza has been documented in over 331humans since 2003 with 203 associated deaths1.While either non-existent or extremely rare, human-

to-human transmission of H5N1 influenza has generatedconcern among health-care workers (HCW) and the generalpopulation. If human-to-human transmissibility were tobecome widespread, it is feared that a pandemic would

Knowledge and anticipatedbehaviour of health-care workers in response to an outbreak ofpandemic influenza in GeorgiaMAIA BUTSASHVILI DEPARTMENT OF INFECTIOUS DISEASES AND CLINICAL IMMUNOLOGY, REHABILITATION CENTER REA, TBILISI, GEORGIA

WAYNE TRINER SCHOOL OF PUBLIC HEALTH, UNIVERSITY AT ALBANY, STATE UNIVERSITY OF NEW YORK AND ALBANY MEDICAL

COLLEGE, ALBANY, NY, USA

GEORGE KAMKAMIDZE DEPARTMENT OF INFECTIOUS DISEASES AND CLINICAL IMMUNOLOGY, REHABILITATION CENTER REA, TBILISI, GEORGIA

MAIA KAJAIA DEPARTMENT OF INFECTIOUS DISEASES AND CLINICAL IMMUNOLOGY, REHABILITATION CENTER REA, TBILISI, GEORGIA

LOUISE-ANNE MCNUTT SCHOOL OF PUBLIC HEALTH, UNIVERSITY AT ALBANY, STATE UNIVERSITY OF NEW YORK AND ALBANY MEDICAL

COLLEGE, ALBANY, NY, USA

Abstract

Background: Avian influenza has been documented in over 331 humans since 2003 with 203 associated deaths.Health Care Workers (HCWs) have been shown to be at personal risk during other highly virulent outbreaks with ahigh attack rate. This study aimed to determine the magnitude and factors associated with absenteeism of hospitalbased health care workers (HCWs) in Georgia associated with a potential highly virulent influenza pandemic.Methodology: This was a cross-sectional study of how HCWs responded to a potentially highly virulent influenzapandemic in two urban hospitals in Georgia. Hospital-based physicians and nurses were studied. Data was collectedutilizing a survey instrument. The survey was either self-administered or interviewer administered based upon thepreference of the respondent. Results: There were 288 HCWs surveyed. The study suggested a 23% rate of worker absenteeism, predominatelyamong women and nurses. The majority of the respondents (58.1%), mostly HCWs less than age 35, were opposed toforced isolation or quarantine of staff during a highly virulent influenza pandemic. Seventy-six percent ofrespondents correctly reported that the strain of virus that was responsible for the outbreaks in the neighboringcountries was H5N1. Only 15.5% of respondents, however, correctly identified influenza as the culprit virus. Conclusions: The rate of work absenteeism suggested by this study represents a significant workforce reduction.There are specific groups who would choose not to attend work in the face of a flu pandemic. This information mayallow planners to target these specific groups for education and social support services to encourage greaterinclination to attend to clinical duties.

ensue. Such an event would challenge the health caredelivery infrastructure with workforce issues, materialshortages, and markedly increased health care seekingbehaviour in the population. Health-care workers (HCWs)have been shown to be at personal risk during a highlyvirulent outbreak with a high attack rate as shown duringthe SARS epidemic2,3,4. Compounding this risk is evidence



hospitals were located in Tbilisi and Kutaisi. These representthe largest cities in the country. Participants were selected byrandom sampling from the list of the staff in each hospital.

Enrollment into the study continued until we had fulfilledthe predefined target number of participants from eachinstitution. Physicians were divided into those 35 years andyounger and those over age 35 years to determine behaviouraldifferences between the younger and older cohorts.

Data was collected utilizing a survey instrument. Theinstrument was developed by all of the authors. Pilot testingwas carried out in Georgia to insure readability andcontextual appropriateness. The survey was eitherselfadministered or interviewer administered based uponthe preference of the respondent. The survey instrumentwas designed to identify demographic and professionalcharacteristics.

Additional information was collected regarding thewillingness to report to work if an influenza pandemic weresuspected or in progress, the perceived efficacy of infectioncontrol measures and basic understanding of the etiology ofavian influenza. This survey was nested in a larger projectassessing awareness of other aspects of hospital transmissionof infectious diseases. Institutional Research Board approvalwas obtained from the overseeing agencies. Data analysiswas conducted using SPSS 13.0 (Chicago, IL USA).

ResultsThere were 288 HCWs surveyed. Characteristics of studyparticipants are shown in Table 1. The majority of therespondents (58.1%) were opposed to being forced intohospital isolation or quarantine during a highly virulentinfluenza pandemic. Respondent age was associated withdifferences in attitudes regarding enforced quarantine. Fifty-

seven percent of respondents age 35and younger did not favour enforcedquarantine compared to 26% of thoseover age 55 not favouring enforcedquarantine (OR=3.7, CI:1.37- 10.0).Eighty percent reported that specialsuits and masks would be required toprevent transmission of avian influenzato HCWs; 10% doubted that therewould be any effective means ofpreventing transmission to HCWs.Seventy-six percent of respondentscorrectly reported that the strain of virusthat was responsible for the outbreaks inthe neighboring countries was H5N1.Only 15.5% of respondents, however,correctly identified influenza as theculprit virus.

When posed with the hypotheticalsituation that the incidence of infectionin HCWs was twice that of the generalpopulation, 76% reported that theywould continue to report to work.Features associated with unwillingness toreport to work are displayed in Table 1.

Characteristics Unwillingness to report to workN N(%) RR CI

GenderFemales 242 62 (25.6) 2.95 1.13-7.70Males 46 4 (8.7) 2.95 1.13-7.70

Age<=35 59 14 (23.7) 1.05 0.62-1.75> 35 229 52 (22.7) 1.05 0.62-1.75

Marital statusMarried 174 38 (21.8) 0.89 0.58-1.36Unmarried 114 28 (24.6) 0.89 0.58-1.36

OccupationNurse 158 47 (29.7) 2.04 1.26-3.29Physician 130 19 (14.6) 2.04 1.26-3.29

PositionReanimation 59 13 (22.0) 0.95 0.56-1.63Others 229 53 (23.1) 0.95 0.56-1.63

that a large proportion of HCWs are not fully informed onessential elements of serious infectious diseases5. Issues ofillness, personal safety, childcare, infectious diseasetransmission to household cohorts, and competingprofessional demands between couples may result in HCWabsenteeism. Some estimates place worker absenteeism ashigh as 40%6. Human cases of H5N1 influenza wereidentified in Turkey in January of 2006 and Azerbaijan inMarch of 2006. Both outbreaks were associated with highcase fatality rates. Georgia shares boarders with both of thesecountries. Furthermore, H5N1 influenza has been identifiedin Georgian poultry. As a result, there is a high degree ofawareness of the personal health risk associated with H5N1influenza throughout the country.

In order to effectively plan for national and internationalresponses to widespread public health emergencies, it isimportant to understand the resources likely to be availableduring such crises. Though there may be a large number ofHCWs, if they become unavailable for any reason, responsestrategies would need to address the workforce reduction.Furthermore, if there are predictable factors leading to highabsenteeism during such emergencies, advanced planningand education may mitigate them. This study wasundertaken to determine the factors associated with likelyabsenteeism of hospital based HCWs associated with apotential influenza pandemic. We focused the survey onhuman-to-human transmitted avian influenza due to theknowledge of and concerns raised by regional outbreaks.

Materials and methodsThis was an observational, cross-sectional study of HCWsconducted in two urban hospitals in Georgia. Hospitalbased physicians and nurses were studied. The study

Table 1: Characteristics of respondents and features associated with unwillingness toreport to work in the event of avian flu pandemic



Overall, women were more likely to report discontinuationof work compared to men (RR=2.95, 95% CI:1.13-7.7);however, this association substantially attenuated when thecomparison was limited to physicians only (RR=1.79, 95%CI:0.63-5.06). If a family member were to become ill withan illness consistent with avian influenza, 84% of HWCsindicated they would seek care in a hospital setting asopposed to 1.3% who would actively avoid hospital or clinicsettings for treatment.

DiscussionThe overall 23% work absenteeism suggested by this studyrepresents a significant workforce reduction. During normalhospital operations, such an attrition rate would result in amajor alteration in scheduling and may not be sustainable.In the face of a public health emergency such as pandemicinfluenza, this rate of absenteeism would be considered acrisis unto itself. This absentee rate does not take intoaccount the possibility that a significant proportion of healthcare workers may fall ill as well, either as a function of publicexposure or as a result of their clinical activities. The resultsof this survey reveal that there are specific groups whowould choose not to attend work in the face of a flupandemic. Female nurses are less likely to continue clinicalwork than are male physicians during epidemic periods. Asnurses have very low wages, the lost income may have thesmallest impact on household income. Also, similar to mostcountries, women have substantial care-givingresponsibilities at home, including the need to care for sickchildren and elderly parents. Thus, these competingdemands are the most likely reason for the gender differencein projected absenteeism.

An important regional finding for this former Sovietrepublic is that forced quarantine of staff is unacceptableamong the majority of younger professionals. While unlikelyto be an important issue for pandemic influenza where softerquarantine procedures may be developed and implemented(e.g., limit contact with family members), quarantine hasbeen an important component of disease control, mostrecently with the SARS epidemic7. Thus, understanding howto negotiate and develop quarantine plans for staff in thispost-Soviet era is important as part of a comprehensivepreparedness protocol.

All studies have caveats. A limitation of this study is itshypothetical, survey design. It is probable that respondentswere influenced in part to respond in a socially altruistic orpositive manner to please the investigators. We are, however,not aware of any data that would allow actuarial analysisfrom previous highly virulent pandemic events from this orother eastern European countries. If this weakness does biasour results, the proportion of absenteeism would be higherthan the results presented in our study. This informationmay allow planners to target the groups predisposed forabsenteeism for further education, social support services,and safety training/development to encourage them toattend to clinical duties. Additionally, disaster relieforganizations may need to alter human resource planning, ifpossible, to address this expected absenteeism. �

AcknowledgementsThis project was supported by NIH Research Grant # D43TW00233 funded by the Fogarty International Center (PrincipalInvestigator: Jack A DeHovitz) and by Civilian Research andDevelopment Foundation (CRDF) grant # GEB2-2636-TB-05.

References

1. Cumulative Number of Confirmed Human Cases of Avian Influenza A (H5N1)Reported to WHO 13 November 2006<http://www.who.int/csr/disease/avian_influenza/en/> accessed 27 Nov, 2006.

2. Ho AS, Sung JJ, Chan-Yeung M (2003) An outbreak of severe acute respiratorysyndrome among hospital workers in a community hospital in Hong Kong. AnnIntern Med 139 (7): 564-7.

3. Dwosh HA, Hong HH, Austgarden D, Herman S, Schabas R (2003) Identificationand containment of an outbreak of SARS in a community hospital. CMAJ 168(11): 1415-20.

4. Chan-Yeung M (2004) Severe acute respiratory syndrome (SARS) and healthcare

workers. Int J Occup Environ Health 10(4): 421-7.5. Tice AD, Kishimoto M, Dinh CH, Lam GT, Marineau M (2006) Knowledge of

severe acute respiratory syndrome among community physicians, nurses, andemergency medical responders. Prehospital Disaster Med (3):183-9.

6. United States Department of Health and Human Services. PandemicFlu.gov<http://www.pandemicflu.gov/index.html> accessed 4 Dec 2006.

7. Svoboda T et al. (2004) Public health measures to control the spread of thesevere acute respiratory syndrome during the outbreak in Toronto. N Engl J Med350 (23): 2352-61.

https://www.researchgate.net/publication/10739556_Identification_and_containment_of_an_outbreak_of_SARS_in_a_community_hospital?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



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https://www.researchgate.net/publication/9062757_An_outbreak_of_Severe_Acute_Respiratory_Syndrome_SARS_among_hospital_workers_in_a_Community_Hospital_in_Hong_Kong?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



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https://www.researchgate.net/publication/8029701_Severe_Acute_Respiratory_Syndrome_SARS_and_Healthcare_Workers?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==


MANAGEMENT: TRAINING

The burden of chronic diseases continues to increase inAfrica, and numbers of new skilled health personnelare not keeping pace. Training and increasing the

number of health-care personnel, therefore, remains apriority in African countries. In an attempt to meet thehuman resource challenges, developed countries (e.g. theUnited States of America) have offered a number ofscholarships to help increase the number of personnel; and

Training the public health work-force at the National School ofPublic Health: Meeting Africa’sneedsKEBOGILE MOKWENADEPARTMENT OF SOCIAL AND BEHAVIOURAL HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF

LIMPOPO, SOUTH AFRICA

MATHILDA MOKGATLE-NTHABUDEPARTMENT OF SOCIAL AND BEHAVIOURAL HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF


SPHIWE MADIBADEPARTMENT OF ENVIRONMENTAL AND OCCUPATIONAL HEALTH, UNIVERSITY OF LIMPOPO, SOUTH AFRICA

HELEN LEWISDEPARTMENT OF SOCIAL AND BEHAVIOURAL HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF


BUSI NTULI-NGCOBODEPARTMENT OF SOCIAL AND BEHAVIOURAL HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF


Abstract

Problem The inadequate number of trained public health personnel in Africa remains a challenge. In sub-SaharanAfrica, the estimated workforce of public health practitioners is 1.3% of the world’s health workforce addressing 25%of the world’s burden of disease.Approach To address this gap, the National School of Public Health at the then Medical University of Southern Africacreated an innovative approach using distance learning components to deliver its public health programmes.Compulsory classroom teaching is limited to four two-week blocks.Relevant changes Combining mainly online components with traditional classroom curricula reduced limitationscaused by geographical distances. At the same time, the curriculum was structured to contextualize continentalhealth issues in both course work and research specific to students’ needs.Lessons learned The approach used by the National School of Public Health allows for a steady increase in the numberof public health personnel in Africa. Because of the flexible e-learning components and African-specific researchprojects, graduates from 16 African countries could benefit from this programme. An evaluation showed that suchprogrammes need to constantly motivate participants to reduce student dropout rates and computer literacy needs tobe a pre-requisite for entry into the programme. Short certificate courses in relevant public health areas would bebeneficial in the African context. This programme could be replicated in other regions of the continent.

for a long time the training of public health professionals inthe African continent depended on such scholarships. Thesescholarships required that the students leave their homecountries and study public health in foreign settings, wherethe systems are based on foreign health policies and underdifferent economic situations. Moreover, the acceptance ofscholarships abroad provided its own challenges, likesettling in a foreign country (uprooting or disrupting

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Africa and the sub-Saharan region. The school accepted thefirst cohort of master of public health (MPH) students inJune 1998.

Since then the NSPH has produced the highest number ofMPH graduates compared to other MPH programmes inSouth Africa (Table 1). It is also the only programme in thecountry that offers the doctor of public health (DrPH)degree. Despite these apparent successes (due largely todistance learning), studies have not been conducted toassess the contribution of this programme to the training ofthe public health workforce in Africa.

This paper aims to provide some data on the school’seffectiveness by showing how public health trainingprogrammes at the NSPH contribute to the public healthworkforce in Africa.

The status of public health education and trainingin AfricaIn sub-Saharan Africa, the estimated health workforce(including public health practitioners, doctors, nurses andallied health workers) is 1.3% of the world’s healthworkforce; these health professionals are responsible foraddressing 25% of the world’s burden of disease.4 Healthgains cannot be made under such circumstances. Thesefigures highlight the need for educating and training morepublic health workers.4 Education efforts have beenhampered by a shortage of data: until recently there was verylittle information on public health education and training inAfrica, mainly due to lack of a useable database on publichealth training. It was only in 2003 that AfriHealthpublished results of a survey of public health institutionsacross the continent. The survey was conducted in 56countries and the results showed that only 19 (33%) hadschools that offered graduate training in public health; 32(57%) had no such training and five (9%) did not respond.5,6

In South Africa there are Schools of Public Health at thefollowing universities: Limpopo (where the NSPH ishoused), KwaZulu-Natal, Witwatersrand, Pretoria, CapeTown, Western Cape, Venda and South Africa.

Effectively targeting public health education andtraining effortsThe discipline of public health acknowledges that theprevalence of certain diseases is often an indication of whereto focus interventions, that the affected individuals are unitsin an intricate system of health administration, social

families) and loss of scholarship recipients to permanentresettlement abroad (brain drain).

Despite these challenges, such scholarships provided asignificant contribution to the preparation of the publichealth workforce in Africa, and they continue to offervaluable services. In a way, overseas training was directlyinstrumental in starting the training programme at theNational School of Public Health (NSPH), because the firstfour founding academics of the school all received theirpublic health training in the USA, three of them having beenrecipients of overseas scholarships. Additionally, afoundation funded the school to initiate a regionalfellowship programme. Over and above fellows’ fees, thisfunding played a role in advancing the growth and quality ofthe academic programmes of the school.

The increase in demand for health professionalsworldwide has also placed pressure on institutions of higherlearning that are engaged in the training of healthprofessionals. The white paper for the transformation of thehealth system in South Africa1 highlighted the need to notonly increase the number of health professionals, but also toreorient their training so that there is a significant shift andexpansion of focus from curative measures to diseaseprevention and health promotion. The AIDS pandemic hasalso intensified the need for health promotion strategies andqualified health personnel. Meaningful public healthtraining programmes need to accommodate individuals whocurrently work full-time in health and welfare services.

This would allow health personnel to implement newskills2 in their current positions. Implementing this in Africahas been difficult. Clearly Africa needs public healthprofessionals with the knowledge and skills to deal withmyriad public health challenges. One solution is distancelearning. For example, in Who will keep the public healthy?distance education is advocated as a method of “… enablingworkers to continue in their work responsibilities bycompleting self-paced coursework … this approach reducesthe burden overworked and understaffed agencies feel astheir staff members participate in educational programs”.3

In response, the then Medical University of SouthernAfrica (MEDUNSA) established a Faculty of Public Health,which was called the National School of Public Health. Theschool set out to develop public health educationprogrammes that would accommodate health-care workersin South Africa who must study while still employed, as wellas respond to public health human resource needs in South

Institution Period Number of graduatesUniversity of Cape Town 2000–2006 81University of KwaZulu-Natal 2002–2007 15University of Limpopo National School of Public Health 2001–2007 202University of Pretoria 2002–2007 87University of South Africa 2004–2007 6University of Venda 2002–2007 20University of the Western Cape 1997–2006 107University of the Witwatersrand 2000–2007 85 Others

Table 1: Number of MPH graduates in South African universities




structures and economy. The South African National HealthAct (2003)7 indicates the need to reorient health-caretraining so that there is a strong focus on disease preventionand health promotion. This reorientation is best met bypublic health training programmes. The role of suchprogrammes in health care is therefore an integral part ofhealth service delivery in any country. The trainingprogrammes should therefore address gaps in acomprehensive offering of health care, while at the sametime enabling more access to health services.

Online distance education in public healtheducation and training During the past 10 years the Internet has radically alteredthe practice of distance education; applying the benefits ofinformation and communication technology (ICT) to highereducation has improved the quality and cost-effectiveness oflearning experiences.8 This includes the area of publichealth, where “…[t]here is an increasing view amongeducators and medical practitioners that information andcommunication technology (ICT) in general has thepotential to revolutionize the way health-care professionalsare trained, and to boost their performance on the job”.4

Background of the National School of Public HealthThe mission of the NSPH is the improvement of the healthof all South Africans through education, research andstrategic intervention in public health in partnership withcommunities, constitutional structures, and a national andinternational network of teachers, scholars and public healthagencies. Early rapid growth has led the school to becomean international institution in public health education andresearch, in part due to the growth of the Internet. Theschool was conceptualized before the Internet becamepopular worldwide, but has utilized it and interest indistance learning fully. The NSPH is the first school in SouthAfrica to offer all its programmes and courses online. Allcourses are delivered using a blend of classroom and onlinelearning.

The online curricula has steadily expanded, and due toincreased ICT needs, the NSPH is now outsourcing thefunctions related to delivery of its online courses to EmbanetCorporation, a Canadian-based company that hosts,maintains and supports the school’s computer network.One of the primary reasons for the increasing interest in theschool’s programme is the growing need on the part ofstudents (often working health-care professionals) to accessinstruction whenever and wherever it is convenient for themto do so. This is made possible by the asynchronous natureof the virtual classroom facility, which constitutes asignificant part of the programme.

The school’s innovative teaching approachThe online programme at the NSPH offers students theopportunity to study all public health disciplines:epidemiology, biostatistics, environmental and occupationalhealth, social and behavioural health sciences, and healthsystems management. Students are required to complete

four semesters over two years and take a total of 10 coursesfrom all the disciplines of public health, seven of which arecore and three are track-specific. A main component of theprogramme is the course on “Research Methods in PublicHealth”. It enables students to conduct research usingpublic health methodologies that have a positive impact onthe health of African societies.

Compulsory classroom teaching takes place during fourtwo-week on-campus blocks. During the classes, studentsare introduced to the online teaching system, the disciplineof public health, the semester courses offered, and all otheractivities that require a classroom approach (e.g. computerlaboratory sessions for biostatistics). Classroom contact isintegral to the teaching of public health at the NSPH, wherestudents and lecturers debate on current public healthissues and form networks.

Online teaching forms a significant aspect of theprogramme (70%) and is based on the principle ofcontinuous learning. For each course offered, students aredivided into groups of 10 and online interaction occurswithin the group. The online teaching platform consists ofthe following facilities: an e-mail facility where students andlecturers can communicate freely; a library with journals,books, research documents and other written materials; anotice board with news of public health events (academicmeetings, conferences, international gatherings), officehours of lecturers and other school information; and acourse area.

The course area has seven components:� Course materials contains specific course content.

Courses are divided into several units, each of whichconsists of several lessons. Each unit focuses on a themeand each lesson focuses on a subunit of the theme.

� About the course provides a summary of the coursegrading requirements, objectives and content.

� Course schedule outlines the schedule of the course,including dates for all lessons, assignments and exams.Details of how students are to be evaluated and markedare provided here.

� News flash contains relevant subsidiary material, suchas copies of printed articles and past (or upcoming)television programmes.

� Submission area is where students submit individualassignments, projects and exams.

� Chat facility is used for live discussions betweenstudents and lecturers and/or other people who haveaccess to the system (e.g. administrators).

� The virtual lecture room is where weekly submissionsof course work are made and assessed electronically viaa platform called the “white board”. Discussionsubmissions to lessons by individual students, as well ascomments from the responsible lecturer are posted here,and are accessible by the whole class. This interactiveprocess, which frequently includes group discussionsvia the customized chat room, enriches theteaching/learning process and allows for continuousevaluation as the lesson discussions are posted weekly.




As the course area illustrates, the design, development andimplementation of the programme is based on active learning(social constructivism). Assessment is continuous andintegrated. The relevance of the programme to health issuesin Africa The MPH programme was designed to preparepublic health professionals to draw on the knowledge andskills from a variety of disciplines to define, critically assessand resolve the public health problems facing Africa. TheNSPH has successfully achieved this objective through theapproach of facilitating learning of public health content andteaching research. The programme has enabled professionalsfrom various disciplines to find solutions to public healthproblems in Africa and apply them in their communities. Forexample, doctors and nurses jointly running HIV/AIDSservices in communities not only utilize skills obtained intheir primary professions, but those they learned through theprogramme: public health approaches that integrate thesocial aspects of the disease.

The NSPH’s contribution to increasing the publichealth workforce in AfricaThe online approach used by the NSPH has resulted in theability to recruit and train public health professionals fromcountries other than South Africa, thus increasing the overallpublic health workforce on the continent. Besides SouthAfrica, graduates are from Botswana, Cameroon, theDemocratic Republic of Congo, Eritrea, Ghana, Kenya,Lesotho, Malawi, Mozambique, Namibia, Nigeria,Swaziland, Uganda, Zambia and Zimbabwe. The majority ofthe graduates come from countries that benefited from afellowship programme that ran from 1999 to 2003, thesebeing in decreasing numbers: South Africa (68%), Botswana(11%), Namibia (10%), Swaziland (7%) and Lesotho (2%).Students from other countries that make up the remaining2% were not covered by the fellowship. The high numbersof non-South African students could be initially attributed to

the foundation, but when funding ended with the 2003class, international students continued to enrol because theschool was meeting the needs for public health training inAfrica. This is shown by the fact that international studentsconstitute 40% of the 2007 MPH class. Since its inception,the school has produced 202 MPH graduates and 76graduates in the postgraduate diploma in public health(Tables 2 and 3). Of the total number of MPH graduates,68% (n = 138) are from South Africa and 32% (n = 64) areinternational. The increase in the number of graduatinginternational graduates in 2003 was made possible byfellowship grants.

Evaluation of the programmeIn 2005, a major supporter of the MPH programmecommissioned and sponsored an evaluation among the 56students who it had funded. The 52 students whoresponded (93%) rated the academic programme good toexcellent; and most appreciated the ability to contactlecturers electronically.

Most students responding to the survey also appreciatedthe e-learning approach. Twenty-seven (48%) rated theirexperience with the e-learning approach excellent; and 21(38%) rated it good. Students also felt that the e-learningapproach had an added benefit of increasing their computerskills which they could utilize in their everyday life.

When lecturers were specifically asked about e-learning,eight of the 10 expressed the view that for public healthtraining, e-learning was better than traditional forms ofinstruction for several reasons: interaction between lecturerand students, and among students increased; informationwas constantly available; students had constant access toonline tools such as libraries and journals; and flexibility, asstudents learned course material and completed courseworkin their own settings and according to their own dailyschedules; for example, while working full-time.

Academic year Total number Number of South South African Number of Internationalof graduates African graduates graduates (%) international graduates graduates (%)

2001 15 10 67 5 332002 28 14 50 14 502003 33 10 30 23 70Total 76 34 45 42 55

Table 3: Graduates of the NSPH postgraduate diploma in public health programme, by nationality

Academic year Total number Number of South South African Number of Internationalof graduates African graduates graduates (%) international graduates graduates (%)

2001 31 31 100 0 02002 22 22 100 0 02003 25 14 56 11 442004 38 21 55 17 452005 33 17 52 16 482006 25 16 64 9 362007 28 17 61 11 39Total 202 138 68 64 32

Table 2: Graduates of the NSPH Master of Public Health programme, by nationality




ChallengesA persistent challenge to the programme is student dropout,which comes about for various reasons, includinginadequate social support for students and time constraintsdue to busy lives. Given the nature of e-learningprogrammes and programmes involving students raisingfamilies or working full-time, this challenge is to be expectedto some degree. The dropout rates at NSPH, which rangedfrom 14% to 28% per group of students between 2001 and2005,9 were lower than the rates of up to 70% worldwidereported by Brown.10

The lack of computer skills, especially in the first year ofstudy, was the biggest challenge at NSPH. This is beingresolved in two ways: computer literacy is now a pre-requisite for admission into the programme, and studentsare tested prior to entrance; also, as the use of technologyspreads, computer skills are increasing among the generalpopulation and among NSPH students as well.

Poor time management remains a challenge because mostof the students have not been engaged in formal studies forsome years prior to enrolment. For some students buildingand maintaining adequate levels of motivation remains achallenge.

Another challenge is the demand of the programme on

academic staff; they are required to work harder because theonline feedback and assessment process requires individualattention to each student’s contribution.

Conclusion, lessons learned and recommendationsThe NSPH is unique; its online courses allow students tostudy at their own pace, in their own homes and countries.Moreover the programme is structured in a way that theycan apply what they learn to the solutions of healthproblems in their communities. The research developmentand implementation is also contextualized, and studentsconduct research that is relevant to health issues in Africaand in their communities.

This innovative approach in South Africa has beensuccessful in delivering human resources to meet the needs ofthe continent. It is therefore recommended that thisprogramme be replicated in other African countries and thatregional collaboration be strengthened in the establishment ofsuch programmes. The NSPH should also develop shortcertificate courses online to respond to specific needs (e.g.evaluations of health programmes, use of antiretroviral drugsto manage HIV, implementation of health promotionprogrammes in schools), and other postgraduate programmesthat target specific groups of health professionals. �

References

1. White paper for the transformation of the health system in South Africa. SouthAfrican Department of Health: 1997. Available at:http://www.info.gov.za/whitepapers/1997/health.htm

2. Beaglehole R, Sanders D, Dal Poz M. The public health workforce in Sub-SaharanAfrica: challenges and opportunities. Ethnicity and Disease, 2003,13[suppl.2]:S24–30.

3. Institute of Medicine Committee on Educating Public Health Professionals for the21st Century. Gebbie K, Rosenstock L and Hernandez LM, eds. Who will keep thepublic healthy? Educating public health professionals for the 21st century. The NationalAcademies Press; 2003. Available at: http://www.nap.edu/catalog/10542.html

4. Addressing Africa’s health workforce crisis. An avenue for action. High-levelForum on the Health Millennium Development Goals; 2004. Available at:http://www.hlfhealthmdgs.org/Documents/AfricasWorkforce-Final.pdf

5. Ijsselmuiden C. AfriHealth: increasing public health capacity in Africa. Universityof Pretoria: South Africa; 2002. Available at:

http://www.globalforumhealth.org/forum_6/sessions/3Thursday/7Plenary6MonitoringIjsselmuinden.pdf

6. Ijsselmuiden C. Mapping public health education in and for Africa. 2003.Available at: http://afrihealth.up.ac.za/database/database.htm

7. South African National Health Act, No. 61 of 2003. Available at:http://www.polity.org.za/attachment.php?aa_id=1359

8. Anderson T, Elloumi F et al. Theory and practice of online learning. AthabascaUniversity; 2004. Available at: http://cde.athabascau.ca/online_book/

9. Rosenberg A and Mokwena K. e-Learning for the expansion of public healtheducation in southern Africa: an evaluation of the Secure the Future fellowshipprogram at MEDUNSA [unpublished study]. Poster presented at the 8th AIDSScience Day Conference, 16 April 2007 in New Haven, CT, USA.

10. Brown E. Online learning: retention is everyone’s issue. Available at:http://weirdblog.wordpress.com/2007/05/01/online-learning-retention-is-everyones-issue


https://www.researchgate.net/publication/9889897_The_public_health_workforce_in_sub-Saharan_Africa_challenges_and_opportunities?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==




CLINICAL CARE: SURGERY

Surgical site infections in anabdominal surgical ward atKosovo Teaching HospitalLUL RAKA NATIONAL INSTITUTE FOR PUBLIC HEALTH OF KOSOVA, PRISHTINA, KOSOVA; SCHOOL OF MEDICINE,

PRISHTINA UNIVERSITY, PRISHTINA, KOSOVA

AVDYL KRASNIQI DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF KOSOVA, PRISHTINA, KOSOVA;

SCHOOL OF MEDICINE, PRISHTINA UNIVERSITY, PRISHTINA, KOSOVA

FATON HOXHA DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF KOSOVA, PRISHTINA, KOSOVA,


RUUSTEM MUSA DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF KOSOVA, PRISHTINA, KOSOVA

GJYLE MULLIQI NATIONAL INSTITUTE FOR PUBLIC HEALTH OF KOSOVA, PRISHTINA, KOSOVA; SCHOOL OF

MEDICINE, PRISHTINA UNIVERSITY, PRISHTINA, KOSOVA

SELVETE KRASNIQI NATIONAL INSTITUTE FOR PUBLIC HEALTH OF KOSOVA, PRISHTINA, KOSOVA; SCHOOL OF


ARSIM KURTI NATIONAL INSTITUTE FOR PUBLIC HEALTH OF KOSOVA, PRISHTINA, KOSOVA; SCHOOL OF


ANTIGONA DERVISHAJ NATIONAL INSTITUTE FOR PUBLIC HEALTH OF KOSOVA, PRISHTINA, KOSOVA; SCHOOL

OF MEDICINE, PRISHTINA UNIVERSITY, PRISHTINA, KOSOVA

BEQIR NUHIU DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF KOSOVA, PRISHTINA, KOSOVA

BATON KELMENDI DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF KOSOVA, PRISHTINA,

KOSOVA

DALIP LIMANI DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF KOSOVA, PRISHTINA, KOSOVA;


ILIR TOLAJ SCHOOL OF MEDICINE, PRISHTINA UNIVERSITY, PRISHTINA, KOSOVA; NATIONAL INSTITUTE FOR

PUBLIC HEALTH OF KOSOVA, PRISHTINA, KOSOVA; DEPARTMENT OF SURGERY, UNIVERSITY CLINICAL CENTRE OF

KOSOVA, PRISHTINA, KOSOVA AND SCHOOL OF MEDICINE, PRISHTINA UNIVERSITY, PRISHTINA, KOSOVA

Abstract

Background: Abdominal surgical site infections (SSI) cause substantial morbidity and mortality for patientsundergoing operative procedures. We determined the incidence of and risk factors for SSI after abdominal surgeryin the Department of Abdominal Surgery at the University Clinical Centre of Kosovo (UCCK).Methodology: Prospective surveillance of patients undergoing abdominal surgery was performed betweenDecember 2005 and June 2006. CDC definitions were followed to detect SSI and study forms were based on EuropeLink for Infection Control through Surveillance (HELICS) protocol.Results: A total of 253 surgical interventions in 225 patients were evaluated. The median age of patients was 42 yearsand 55.1% of them were male. The overall incidence rate of SSI was 12%. Follow-up was achieved for 84.1% of theprocedures. For patients with an SSI, the median duration of hospitalization was 9 days compared with 4 days forthose without an SSI (p<0.001). Surgical procedures were classified as emergent in 53.3% of cases. Superficialincisional SSI was most common (55%). Clinical infections were culture positive in 40.7% of cases. Duration ofoperation, duration of preoperative stay, wound class, ASA score >2, use of antibiotic prophylaxis and NNIS class of>2 were all significant at p <.001. The SSI rates for the NNIS System risk classes 0, 1 and 2-3 were 4.2%, 46.7% and100%, respectively.Conclusions: SSI caused considerable morbidity among surgical patients in UCCK. Appropriate active surveillanceand infection control measures should be introduced during preoperative, intra-operative, and postoperative care toreduce infection rates. Key Words: Kosova, nosocomial infections, surgical site infections.

32-6 Clinical care kosovo:clin care Kosovo 8/7/08 12:26 Page 32



Nosocomial infections constitute a major publichealth problem worldwide. They result in highmorbidity and mortality, prolonged hospital stays,

greater use of antibiotics, and increased costs1,2.Surgical-site infections (SSI) along with pneumonia, urinary

tract infections, and bloodstream infections are the mostcommon nosocomial infections3. Although SSIs are notassociated with a high mortality rate, they are a significantsource of morbidity among surgical patients.

Approximately 500,000 episodes of SSI occur in the UnitedStates every year, accounting for an average of 7.3 excesshospital days and more than 1.6 billion dollars of extrahospital charges. Surveillance programmes can lead toreduction of SSI rates of 35-50%4,5.

Infection control in Kosovo is in its infancy compared withinfection control programmes in other countries. There arenot yet established surveillance programmes for nosocomialinfections. This situation is due to the lack of national policiesand protocols regarding this issue and limited human andfinancial resources. Reports about the incidence of and riskfactors for acquiring SSI are absent for all hospitals in Kosovo.The first article published in the field of nosocomial infectionwas on bacteraemia amongst paediatric patients in Kosovo in

2002, and showed a crude mortality rate of 31% amongstnewborns6. A descriptive prevalence study on nosocomialinfections in targeted high-risk areas was undertaken inDecember 2003 in the University Clinical Centre of Kosovo7.This study showed an overall prevalence rate of 17.4%.

Infection control activities were limited to passivemonitoring activities, and actions were only initiated as aresponse to late stages of outbreaks. Within UCCK and someother regional hospitals, hospital infection control committeesexisted solely on paper. The awareness for nosocomialinfection increased during 2006, when the Ministry of Healthof Kosovo established the National Committee for Preventionand Control of Nosocomial Infections as the executive bodyto combat this modern challenge of health care. This studyaimed to determine the incidence of SSI in the abdominalsurgical ward of the UCCK in Pristine, Kosovo, and to identifyrisk factors associated with the development of SSI. Data fromthis study might help to design intervention studies for allhospitals in our country.

Materials and methodsThe study was conducted at the University Clinical Centre ofKosovo (UCCK), in Pristine, the capital city of Kosovo, a city

Risk factors Results SSI (n) No SSI Total OR (p)Age (years) 25 2 71 73 0.115

25-60 19 88 107 (0.52)>60 6 39 45

Gender Male 11 113 124 0.115Female 16 85 101 (0.52)

Preoperative stay (days) <7 9 152 161 6.62≥7 18 46 64 (<0.001)

Endoscopy Yes 8 14 22 5.53No 19 184 203 (<0.001)

Wound class Clean 2 62 64 5.4Clean contaminated 14 129 143 (<0.001)Contaminated 6 7 13Dirty/infected 5 0 5

Duration of operation hours >T time* 24 99 123 8.0≤T time 3 99 102 (<0.001)

Type of intervention Emergent 11 99 110 0.38Elective 16 99 115 (0.6)

ASA score 1 4 136 140 6.372 15 50 65 (<0.001)3 8 11 194 0 1 15 0 0 0

Antibiotic prophylaxis Yes 20 93 113 3.23No 7 105 112 (0.008)

Drain Yes 18 53 71 6.5No 9 173 182 (<0.001)

Surgical procedure Cholecystectomy 5 (5.4%) 87 92Colon surgery 8 (12.1%) 58 66Appendectomy 6 (7.7%) 73 78

SSI=surgical site infections, OR= odds ratio, ASA=American Society of Anesthesiologist, T-time=75th percentile of distribution of procedure duration

Table 1: Distribution of surgical site infections based on risk factors




with 500,000 inhabitants. The centre has 2,100 beds withapproximately 60,000 admissions per year and serves as theonly referral tertiary care centre for a population ofapproximately 2.1 million. Approximately 3,000 differentsurgical interventions are performed monthly at the UCCK.The abdominal surgery department has a surgery ward with75 beds and an ambulatory clinic. Prospective cohort studyfor surveillance of SSI was conducted from 15 December2005, to 15 June 2006. All patients who requiredabdominal surgery were enrolled in the study. Patients wereexcluded from the cohort by the following criteria: deficientmedical records; having undergone surgical interventions atanother hospital and then referred to UCCK; or death aftersurgery or within the following 30 days. Three surgeryresidents were previously trained for this study and werepart of the teams who performed the surgical intervention.They closely observed and examined the patients duringhospitalization and searched daily for SSI and potential riskfactors. Data regarding SSI were obtained on a daily basisduring the patients’ hospitalization and until 30 days aftersurgical intervention. If the patients were discharged prior to30 days, the clinical evaluation in the ambulatory clinicwithin the hospital was used. There was no telephonecontact in post-discharge surveillance. The median wascalculated for duration of hospitalization to avoid biases ofsome patients with prolonged hospitalization due tocomorbidities not related to surgical interventions.

The study forms were based on Hospital in Europe Linkfor Infection Control through Surveillance (HELICS)protocol for surveillance of SSI8. CDC definitions were usedto detect SSI9. The data were grouped into three categories:general data; stratification and preoperative data; andinfection data. General data comprised age, gender,operative procedure, date of admission, date of operation,date of discharge or date of last follow-up post discharge,discharge status, and operation codes (NNIS and ICD-9-CM). Stratification and preoperative data consisted ofendoscopic procedure, wound contamination class (clean,clean contaminated, contaminated, dirty/infected), durationof operation (minutes), type of surgery (urgent vs. elective),The American Society of Anesthesiologists (ASA) Physicalstatus classification (healthy, mild systemic disease, severesystemic disease, incapacitating systemic disease ormoribund patient)10 and use of antibiotic prophylaxis. Thefollowing infection data were collected: type of SSI(superficial, deep incisional, and organ/space); date ofinfection; and causative microbial agent in culture positiveresults. Laparoscopy was performed in another specialized

unit and was not included in the study. The NNIS Systemrisk index was calculated based on three risk factors, eachworth one point: contaminated or dirty surgical wound, ASAscore greater than 2, and duration of surgery greater than the75th percentile for a specific group of surgical procedures11.The NNIS System index ranges from 0 to 3. Use of drainagewas also recorded.

Laboratory diagnosis of microbiological samples was donein the Department of Microbiology within the NationalInstitute of Public Health of Kosovo. Standard tests foridentification were performed. Antimicrobial susceptibilitytests were performed using the Kirby-Bauer method12.Analyses were based on 225 patients with SSI. In statisticalanalysis, discrete variables were expressed as percentages.Categorical variables were compared using chi-square test orFisher’s exact test as needed. A p value of less than 0.05 wasconsidered significant. Relative risks and 95% confidenceintervals (95% CI) were calculated using APIC CD-room forstatistical analysis for infection control.

ResultsBetween December 2005 and June 2006, a total of 253surgical interventions in 225 patients were evaluated. Themedian of the cohort was 42 years (range 8 to 88 years), and55.1% of patients were male. The overall incidence rate ofSSI was 12%. There were a total of 27 SSIs, seven (25.9%)of which were identified after discharge. A complete 30-dayfollow-up was achieved for 213 (84.1%) of the procedures.For patients with an SSI, the median duration ofhospitalization was 9 days compared with 4 days for thosewithout an SSI (p<0.001).

Table 1 lists selected potential risk factors related topatient and procedure with their associated SSI rates.Surgical procedures were classified as emergent in 53.3% ofcases and appendectomy was the most common surgicalprocedure (30.8%). Eleven SSI (10.0%) occurred in patientswho had undergone emergency procedures and 16 (13.9%)occurred in patients who had undergone electiveprocedures.

The incidence rate of SSI differed by wound classification:3.1% for clean (n=64), 9.8% for clean-contaminated(n=143), 46.1% for contaminated (n=13), and 100% fordirty infected wounds (n=5). The relative risk ofdevelopment SSI for contaminated wounds was 5.4-foldhigher than for clean wounds. The duration of theprocedure had a significant effect on the incidence of SSI.The incidence of SSI for procedures lasting longer than onehour was six times as high as that for procedures of less than

NNIS System No of Patients Incidence rate per 100 RRrisk index procedures with SSI interventions (95% CI)0 190 8 4.2 11 30 14 46.7 (12.91-2,3 5 5 100 23.7)1SSI=surgical site infections, RR=relative risk, CI =95% confidence interval.

Table 2: The incidence of surgical site infections according to the NNIS System risk index




one hour (p<.001). Most common interventions associatedwith SSI were cholecystectomy, colon surgery, andappendectomy (70.4%).

Antibiotic prophylaxis was used for 50.2% of the patients.Drains were used in 71 (28.1%) of the procedures. Somepatients had more than one drain. Superficial incisional SSIswere most common with 15 cases, 11 were deep incisional,and one was organ–space. Clinical infections were culturepositive in 40.7% of cases and three of them werepolymicrobial infections. The most frequently isolatedmicroorganisms in the three most common procedures wereEscherichia coli (36.4%) and Staphylococcus aureus(14.6%). Among E. coli isolates, resistance rates forceftazidime, ciprofloxacine and gentamycine were 52.4%,11.9% and 24.3%, respectively. The incidence of SSIaccording to the NNIS System risk index is provided in Table2. An increase in the incidence of SSI and in the relative riskto develop SSI was observed as the NNIS System risk indexincreased. The SSI rates for the NNIS System risk classes 0to 3 were 4.2% (8 of 190), 46.7% (14/30) and 100.0%(5/5), respectively. The relative risk for SSI was 12.9 in thegroup with an NNIS System risk class less than 2, whereas,for NNIS risk classes 2 or more the RR were 23.7.

There was no significant correlation between SSIincidence and sex and type of intervention. However,duration of operation, duration of preoperative stay, woundclass, ASA score >2, use of antibiotic prophylaxis and NNISclass of >2 were all significant at p<0.001.

Discussion As in many developing countries, no surveillance orfeedback of SSI rates have been implemented in Kosovo Theobserved incidence rate of SSI (12%) was higher thanincidence rates reported from developed countries inWestern Europe, such as the United Kingdom (3.1%) andthe Netherlands (4.3%);13-15. The incidence rate of infectionsaccording to surgical procedures was higher than thosereported from European countries in HELICS8. Colonsurgery was accompanied by infections in 12.1% of casesand cholecystectomy by infections in 5.4% of casescompared to 8.1% and 1.4%, respectively in HELICS. Thefinancial situation of the public health system in Kosovo isvery poor with an overall budget dedicated to health care ofonly 30 euros per capita per year. This seems to be the majorproblem in upgrading health care capacities in the onlytertiary care centre of Kosovo. Other causative factors werealso poor management in this institution, inadequatenumbers of trained personnel working in infection control,

overcrowded wards, and insufficient equipment andsupplies.

One quarter of infections was detected after discharge andalmost 20% were not covered by post-dischargesurveillance. The main reasons for loss of follow-up werevisits to regional family care centers or private clinics andimproper records in ambulatory clinics within the hospital.Preoperative length of stay was relatively long, mainly due toirrational usage of bed capacity, lack of material, orunavailability of an operating room. Patients had to buyantibiotics and very often their own surgical equipment.Nevertheless, the excess length of stay for patients with SSIwas in line with reports elsewhere14-15.

The main risk factors for SSI were similar to thoseidentified in other studies. This study confirms theassociation between SSI and ASA score, duration ofprocedure, and wound class. We found a good correlationbetween the NNIS System risk index and the developmentof SSI. The relative risk of developing SSI increasedsignificantly with increase of risk index p<.001). In contrastto other reports, the SSI in our study was three times morepredominant in surgical procedures preceded by antibioticprophylaxis. This might be explained by the fact that thesewere contaminated wounds with increased risk of infection.There is, as yet, no consensus among surgeons regarding thewritten guidelines for antibiotic prophylaxis in abdominalsurgery.

From this study, the following steps emerged as prioritiesto set in the near future: definition of the antibioticprophylaxis policy; reduction of preoperative length of stay;increased follow up surveillance and setting up systematicsurveillance; and reduction of the length of proceduresthrough adequate training of the staff on proper surgicaltechniques and intra-operative infection control measures.An initiative for the establishment of an infection controlcommittee at UCCK has been promoted recently. Inconclusion, the high rates of nosocomial infections amongsurgical patients emphasize that control and prevention ofSSI should be a priority in UCCK and other regionalhospitals in Kosovo.�

AcknowledgementsWe thank Prof. Richard Hunt for critical reading and correction ofthe manuscript.

Published with the kind permission of the Journal of Infection inDeveloping Countries, December 2007 - Vol. 1, No. 3: 337-341




References

1. Wenzel RP (2003) Global perspectives of infection control. In: Prevention andcontrol of nosocomial infections 4th ed. Philadelphia LWW. 14-33.

2. Bennet JV and Brachman PS (1998) In Hospital Infections. 4th ed. Baltimore,Williams & Wilkins.:5-56.

3. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR (1999) Guideline forprevention of surgical site infection. Hospital Infection Control PracticesAdvisory Committee. Infect Control Hosp Epidemiol 20: 250-280.

4. Martone W, Jarvis W, Edwards J, Culver D, Haley R (1998) Incidence and natureof endemic and epidemic nosocomial infections. In Bennett JV, Brachman PS,eds. Hospital Infections. Philadelphia: Lippincott- Raven; 461- 476.

5. Emori T. Gaynes R (1993) An overview of nosocomial infections, including therole of microbiology laboratory. Clin Microbiol Rev 6: 428-442.

6. Raka L, Mulliqi GJ, Dedushaj I, Pittet D, Binishi R, Ahmeti S. (2003) Nosocomialbacteraemia among paediatric patients in Kosovo. Clin Microbiol Infect 9: 192.

7. Raka L et al. (2006) Prevalence of nosocomial infections in University ClinicalCentre of Kosovo. Infect Control Hosp Epidemiol 27: 421- 423.

8. Hospitals in Europe Link for Infection Control through Surveillance (HELICS).Hospitals in Europe Link for Infection Control through Surveillance (HELICS)Protocol: Surgical Wound Infection Surveillance. Brussels: Institute of Hygieneand Epidemiology. 1994.

9. Horan TC, Gaynes RP, Martone WJ, Jarvis WR, Emori TG (1992) CDC definitionsfor nosocomial surgical site infections, 1992: a modification of CDC definitionsof surgical wound infections. Infect Control Hosp Epidemiol 13: 606-608.

10. Owens WD, Felts JA, Spitznagel ELJ (1978) ASA physical status classifications: a

study of consistency of ratings. Anesthesiology 49: 239-243.11. Culver DH et al. (1991) Surgical wound infection rates by wound class, operative

procedure, and patient risk index: National Nosocomial Infections SurveillanceSystem. Am J Med 91: 152S.

12. National Committee for Clinical Laboratory Standards. Performance Standardsfor Antimicrobial Disk Susceptibility Tests, Approved Standard, 6th ed. Wayne,PA: National Committee for Clinical Laboratory Standards. 1997.

13. Communicable Disease Surveillance Centre (2000) NINSS reports on surgicalsite infection and hospital acquired bacteremia. CDR Wkly10: 213-216.

14. Geubbels E, Mintjes-de Groot AJ, van den Berg JM, de Boer AS (2000) Anoperating surveillance system of surgical-site infections in the Netherlands:results of the PREZIES National Surveillance Network. Infect Control HospEpidemiol 21: 311-318.

15. Wagner MB, da Silva NB, Vinciprova AR, Becker AB, Burtet LM, Hall AJ (1997)Hospital-acquired infections among surgical patients in a Brazilian hospital. JHosp Infect 35: 277-285.

Corresponding Author: Lul Raka, “Emin Duraku”No=166, 71000 Kaçanik, Kosova; Phone:+3813829080666 and +37744368289e-mail: [email protected]

Conflict of interests: The authors declare that they have no conflictof interests.


https://www.researchgate.net/publication/14930687_An_Overview_of_Nosocomial_Infections_Including_the_role_of_the_Microbiology_Laboratory?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/14930687_An_Overview_of_Nosocomial_Infections_Including_the_role_of_the_Microbiology_Laboratory?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/21820698_CDC_Definitions_of_Nosocomial_Surgical_Site_Infections_1992_A_Modification_of_CDC_Definitions_of_Surgical_Wound_Infections?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/12493645_An_Operating_Surveillance_System_of_Surgical-Site_Infections_in_the_Netherlands_Results_of_the_PREZIES_National_Surveillance_Network?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==




https://www.researchgate.net/publication/238201602_Surgical_wound_infection_rates_by_wound_class_operative_procedure_and_patient_risk_index_National_Nosocomial_Infections_Surveillance_System_Am_J_Med_91152S?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/13100694_Guideline_for_Prevention_of_Surgical_Site_Infection_1999_Centers_for_Disease_Control_and_Prevention_CDC_Hospital_Infection_Control_Practices_Advisory_Committee?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/22445385_ASA_Physical_Status_Classification_A_Study_of_Consistency_of_Ratings?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/22445385_ASA_Physical_Status_Classification_A_Study_of_Consistency_of_Ratings?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/246453324_Incidence_and_nature_of_endemic_and_epidemic_nosocomial_infections?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/14065382_Hospital-acquired_infections_among_surgical_patients_in_a_Brazilian_hospital?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==



https://www.researchgate.net/publication/289801682_Nosocomial_Bacteremia_Among_Pediatric_Patients_in_Kosova?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==

https://www.researchgate.net/publication/289801682_Nosocomial_Bacteremia_Among_Pediatric_Patients_in_Kosova?el=1_x_8&enrichId=rgreq-b5ec4915-d4d5-4724-bc94-483f3dcbfa81&enrichSource=Y292ZXJQYWdlOzU1NzQzNDA7QVM6OTkwNjQ0NzM0NTY2NDJAMTQwMDYzMDIxOTQzMA==


E-HEALTH SUPPLEMENT: PATIENT SAFETY INCIDENTS REPORTING

information on patient safety incidents3,4,5,6,. TechnologyThe software was developed as a traditional form database byexploiting the simple ASP (Active Server Pages) programmingtechnology created by Microsoft. A database was set up on aVTT server for reporting patient safety incidents. The serverfunctions on a national level and reports are submittedthrough the Internet. The development work aimed atsimplicity and usability. A text-based, relatively simple formdatabase allows for wide use of the system, even without highserver efficiency. The database contains both structured andopen questions and fields.

A database and an administrator account were set up forevery participating health care organisation. The persons incharge of each organisation used an administrative tool todefine the adverse event reporting organisation and therelevant persons in charge. The organisations were given log-in links to access the database with. The log-in links weremade available on the intranet pages of the organisationsand in the patient information systems, where they could beeasily located. The links give access to reporting patientsafety incidents and processing submitted reports. Toimprove data security, IP identification was employed,directing reports to the correct database and making themaccessible only through each organisation’s own intranet.

Adverse events in patient care are common. Accordingto estimates, an adverse event occurs in relation toevery tenth hospitalisation period. Serious harm is

caused to one out of a hundred admitted patients, and deathor permanent injury to one out of a thousand1,2. Statutorypatient insurance which compensates for patient injuries wasintroduced in Finland in 1987. Over 8000 claims are filedinto the system each year. The public sector’s unearnedpremium reserves in 2007 amounted to a total of 159 millioneuros, i.e. 30 euros per inhabitant. In addition to the costs,there are complex consequences to the injuries. They affectthe health of patients and the welfare of staff.

The Finnish patient insurance system does not cover mildincidents and near misses. Bringing up and reporting that sortof events is a good method for establishing an atmosphere ofpatient safety, as well as a means for learning from mistakesand improving patient safety within an organisation. The VTTTechnical Research Centre of Finland has, in cooperation withthe Ministry of Social Affairs and Health, the National Agencyfor Medicines, and various hospitals, developed an internet-based national reporting system. The goal was to create anational, easy-to-use tool for processing different patientsafety incidents. Before the completion of the reportingsystem for patient safety incidents (HaiPro), hospital unitshave used mainly paper-based systems for collecting

Increased patient safetywith an Internet-basedreporting systemTIMO KEISTINEN MD, PhDMEDICAL DIRECTOR, VAASA HOSPITAL DISTRICT AND INSTITUTE OF HEALTH SCIENCES, UNIVERSITY OF

OULU, FINLAND

MARINA KINNUNEN, MSc, RGN PATIENT SAFETY OFFICER, VAASA HOSPITAL DISTRICT, FINLAND

Abstract

An efficient, goal-directed and positive approach allows learning from medical errors. The systematic analysis ofpatient safety incidents increases initiative and innovation in problem solving. In Finland, a nationally implementedInternet-based, voluntary reporting system provides a tool for the development of patient safety. The system is usedby over 40 health care organisations. Vaasa Hospital District includes over 100 units and 3500 employees fromspecialty wards to primary care clinics and ambulances. All employees may submit reports which are processed bythe chief medical officer and head nurse of each unit. The processing officers are able to intervene immediately toproblems underlying a patient safety incident immediately. Classifying incidents according to an agreed structurecreates an electronic database that serves a tool for hospital management. The strength of an Internet-basedreporting system is its simplicity and usability. It can help in promoting safety culture in health care.

37-9 eHealth IHF18:e-health supplement: patient safety 8/7/08 12:27 Page 37



The system is separate from patient data systems and thepatient’s identification information is not used whenreporting a patient safety incident.

The participating organisations defined different usergroups, such as reporters and processing officers. Allemployees of each organisation may act as reporters. Tosubmit a report, no additional account is needed. Thereporter receives a case ID number for the submitted report,allowing them to follow the processing of their report andpossible additional information requests from the processingofficer. Reporters are able to submit reports to all units in thesame database.

Processing officers need a user account and a password,and they have various privileges in the system. Theprocessing officers have access to processing and can notonly read reported incidents that took place in their ownunit, but also follow the activity of the whole organisation atreport level. They are authorised to submit reports ofincidents in their own area of management to theadministration of units and larger entities, and to accessindividual incidents if necessary. The system administratorsare in charge of creating an organisation map, where theunits are defined, and of distributing the necessary accountsto the different user groups. The Patient Safety Officer hasaccess to all information. Her task is to analyse the overallsituation and report measures necessary for increasingpatient safety to the administration of the organisation andunits. This also helps create a good culture of patient safety.

The reporting system created in Finland meets the WHOcriteria for a good adverse incident reporting system andincludes the various functions defined for reportingsystems7. The system emphasizes confidentiality, freedomfrom sanctions and voluntariness. Reports are analysed bypeople familiar with the place where an incident hasoccurred. The system allows reporters to receive quickfeedback from their reports, and the processing functionemphasizes developing the system instead of changingindividual people. The Patient Safety Officer is able to issuerecommendations on the basis of reports and implementnecessary changes quickly, if needed.

Mode of operation in Vaasa Hospital DistrictIn Finland, the software has been introduced in over 40health care organisations, many of which are large and coverboth primary care and specialized health care. VaasaHospital District previously employed a paper-basedreporting system for monitoring patient safety incidents. Itwas only used incidentally, and often information about theincidents came to the attention of unit heads only by wordof mouth. There was no systematic follow-up. Creation of anorganisation-wide quality system in the hospital districtrequired a follow-up system of patient safety incidents.Therefore, the atmosphere was good for introducing thereporting tool in May 2007. During the first stage, it wasadopted by all wards and clinics of Vaasa Central Hospital.Because the tool allowed transferring reports of patientsafety incidents between units, the hospital moved quicklyto involve all auxiliary units, e.g. equipment maintenance

and the kitchen. Next units to become involved were patienttransport and ambulances as well as active units in primarycare. Less than a year after introduction, over 100 units areinvolved and 3500 employees are able to submit a report ofa patient safety incident. During the first year, the number ofreported incidents is rising close to 1500. Most commonincidents reported were ones concerning medication (34%).Second most common were problems in communicationand data management (20%) and various accidents, such asfalls (12%). Half of these cases were near misses and theother half led to some degree of harm. The harm wasclassified as serious in 1.3% of all reported cases.

In each unit, the chief medical officer and the head nursehave been assigned the task of processing officers. They arenotified by e-mail for each patient safety incident that takesplace in their unit, and receive a link to the database towhich the report has been submitted. They are also notifiedof a report submitted from another unit but concerning theirunit. This is particularly important in developingcooperation between units and ensuring that information ofdeveloping measures reaches both units. The reports arealways processed in the unit where the incident has takenplace. The processing officers analyse each incident andenter it into the database according to an agreedclassification structure. Both processing officers are able toprocess the same report at different times. All pairs ofprocessing officers decide between them on how to dividethe processing of reports. In many units, the head nurseprocesses the reports concerning nursing care, the chiefmedical officer processes those concerning the medicalprofession, and they work together on reports relating toboth. The system allows the processing officers to forward areport to the administration level for further measures. Headphysicians, head nurses and directing officers have readingaccess to reports concerning their units and they can use thereporting tool for drafting summaries of the reports.

The Patient Safety Officer is in charge of forming an overallpicture of safety within the organisation on the basis ofreports and summaries and, in cooperation with theadministration, seeking and implementing necessarychanges for improving patient safety.

Reporting a patient safety incident with the HaiPro systemprogresses as follows:� A reporter submits a report about a patient safety

incident they have observed.� The processing officers are notified by e-mail, they

analyse and classify the report and decide on furthermeasures. They bring the matter up for discussion inthe working unit.

� The reporter receives immediate feedback from thesystem once the report has been processed.

� Head nurses and heads of division regularly discussreports in their management groups.

� The Patient Safety Officer brings up issues relevant to allunits from the whole organisation’s reports.

� Organisations arrange different learning forums for bothprocessing officers and reporters.




How the reporting of patient safety incidents hasadvanced

The strength of the implemented Internet-based systemfor reporting patient safety incidents is its usability. Finnishhealth care has switched almost entirely over to the use ofelectronic health record systems, so all professional groupshave access to information technology8. Submitting reportscan be taught in 10 minutes. This allows training resourcesto be focused on establishing a culture of patient safety. Thebringing up of errors, instead of the accustomed coveringup, is new in health care, so a change of culture is necessarybefore staff reaches an active reporting rate. Denmark hasalready attained an annual increase in the number ofreports9.

In Finland there is ongoing discussion on the type of toolsto adopt for reporting. An Internet-based reporting systemfor patient safety incidents serves well by itself at the level ofworking units, with the input of the Patient Safety Officeralso at organisation level, and through national networkingit serves the whole country. Serious incidents should beanalysed more carefully, and an obligation to report suchincidents to a national system, together with a voluntarysystem, would surely constitute a complementary whole10.

An active reporting culture can not be reached unless thestaff feels they benefit from reporting. Benefit can only begained by immediate feedback, which in turn can only beobtained from persons who are familiar with the modes ofoperation in the unit. The mere collection of data is notenough for the development of patient safety; it can onlyprovide indicative trends.

The use of this system in Vaasa Hospital District hasalready resulted in other positive effects to the patient safetyculture, in addition to learning from mistakes. The staff hasexperienced the system as a possibility to exercise influence.It has increased multiprofessional development and enabledquick information exchange between units. The system hasenabled bringing up patient safety culture issues fordiscussion.

Evolution of the software requires tighter networkingbetween participating organisations, which in turn allowslearning from others to improve patient safety. Theclassification of incidents needs to be developed further, inorder to become a strong component of patient safety incontinuity of care pathways. Transferring reports betweenunits makes this possible. In the development of the HaiProtool it should be noted that, at present, the strength of theprogram is its clarity and usability. Complicating thesubmission and processing of reports may lead to a situationwhere the system no longer serves patient safety sufficiently.The development process of such systems should allowreporters of incidents to bring up their own developmentideas. This would help involve staff in decision-making.Inclusion of patients, their family, and health care studentsin reporting patient safety incidents should also be broughtup for discussion.

Adverse incident reporting systems are helpful tools inadvancing developing patient safety. Developing the ways ofoperation, as well as learning, is most important. Theinformation that can be gained from an easy-to-use, internet-based reporting system for patient safety incidents providesa cornerstone for development work and for a good cultureof patient safety. �References

1. Van Dyck C, Baer M, Frese M, Sonnentag S. Organizational Error ManagementCulture and Its Impact on Performance: A Two Study Replication. J ApplPsychology 2005, Vol.90.No, 6, 1228-1240.

2. Errors in health care: a leading cause of death and injury. In book: Kohn L,Corrigan JM, Donaldson MS. To err is human: building a safer health system.Washington, D.C, National Academy Press, 2006, 26-48.

3. VTT Technical Research Centre of Finland: http://www.vtt.fi/?lang=en4. Finnish Ministry of Social Affairs and Health: Homepage

http://www.stm.fi/Resource.phx/eng/index.htx5. National Agency for Medicines: http://www.nam.fi/6. HaiPro-Project: http://haipro.vtt.fi/ (Pages in Finnish)7. World Health Organization. World alliance for patient safety. (2005) WHO draft

guidelines for adverse event reporting and learning systems; WHO Press,Switzerland. Available at:http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf

8. Hämäläinen P, Reponen J, Winblad I. eHealth of Finland Checkpoint 2006.Available at: http://www.stakes.fi/verkkojulkaisut/raportit/R1-2007-VERKKO.pdf

9. National Board of Health 2007. Danish Patient Safety Database. Copenhagen, 8.Available at: http://www.sst.dk/upload/tilsyn/utilsigtede_haendelser/patientsafety_db_en.pdf

10. Error Reporting Systems. In book: Kohn L, Corrigan JM, Donaldson MS. To err ishuman: building a safer health system. Washington, D.C, National Academy Press,2006, 86-131


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FORMATION DU PERSONNEL AU SERVICE DE LASANTE DES POPULATIONS PAR L’ECOLE NATIONALEDE SANTE PUBLIQUE D’AFRIQUE DU SUD : UNEREPONSE AUX BESOINS DE L’AFRIQUEPROBLEMATIQUE (TRAINING OF PUBLIC HEALTH WORKFORCE AT THENATIONAL SCHOOL OF PUBLIC HEALTH: MEETINGAFRICA’S NEEDS)Le manque de personnel formé à la santé publique demeureun grand problème en Afrique. Dans la partie sub-sahariennede ce continent, on estime que l’effectif du personneltravaillant pour la santé publique représente 1,3 % de la main-d’oeuvre mondiale au service de la santé et doit cependant faireface à 25 % de la charge de morbidité mondiale.

Démarche Pour remédier à cette insuffisance, l’Ecolenationale de santé publique de la Faculté médicale d’Afriquedu Sud a mis au point une démarche innovante, utilisant desmodules d’enseignement à distance, pour délivrer sonprogramme de santé publique. L’enseignement magistralobligatoire est limité à quatre unités de deux semaines.

Modifications pertinentes La combinaison de modulesd’apprentissage principalement en ligne avec des programmesd’enseignement magistral traditionnel permet de réduire lesobstacles dus aux distances géographiques. Dans le mêmetemps, le programme d’enseignement a été structuré demanière à contextualiser les problèmes de santé du continentafricain dans des cours et des travaux de recherche répondantaux besoins spécifiques des étudiants.

Enseignements tirés L’approche adoptée par l’Ecolenationale de santé publique permet un accroissement constantdes effectifs au service de la santé publique en Afrique. Grâceaux modules flexibles d’enseignement en ligne et aux projetsde recherche consacrés spécifiquement à l’Afrique, desdiplômés de 16 pays africains ont pu bénéficier de ceprogramme. Une évaluation a montré que des programmes dece type devaient constamment motiver leurs participants pourlimiter le taux d’abandon et que pour être admis dans lecursus, les étudiants devaient avoir au préalable desconnaissances en informatique. Dans le contexte africain, desformations courtes, sanctionnées par un certificat, seraientutiles. Le programme présenté pourrait être reproduit dansd’autres régions du continent.

INFECTIONS DE SITE OPERATOIRE DANS UN SERVICEDE CHIRURGIE ABDOMINALE D’UN CHU DE KOSOVO(SURGICAL SITE INFECTIONS IN AN ABDOMINALSURGICAL WARD AT KOSOVO TEACHING HOSPITAL)Contexte : Les infections de site chirurgical abdominal (surgicalsite infections, SSI) sont cause de morbidité et de mortalitéimportantes chez les patients soumis à des traitementschirurgicaux. Nous avons établi l’incidence des facteurs derisque de SSI après chirurgie abdominale dans le service dechirurgie abdominale du Centre Hospitalier Universitaire deKosovo (UCCK).

Procédure : Une surveillance prospective des patients ayant

subi une intervention chirurgicale abdominale a été menée dedécembre 2005 à juin 2006. Des définitions CDC étaientadoptées pour dépister les SSI et les formulaires d’étude étaientbasées sur le protocole Europe Link for Infection Controlthrough Surveillance (HELICS).

Résultats : Au total, 253 interventions chirurgicales sur 225patients ont été évaluées. L’âge moyen des patients était de 42ans et 55,1% d’entre eux étaient du sexe masculin. Le tauxglobal d’incidence de SSI était de 12%. Un suivi a été assurépour 84,1% des procédures. Pour les opérés atteints de SSI, ladurée moyenne d’hospitalisation était de 9 jours contre 4 jourspour les personnes exempts de SSI (p<0,001). Les procédureschirurgicales étaient classées comme émergentes dans 53,3%des cas. Les SSI d’incisions superficielles étaient les plusfréquentes (55%). Les infections cliniques donnaient descultures positives dans 40,7% des cas. La durée desopérations, la durée du séjour préopératoire, la catégorie deplaie, le score ASA >2, l’administration d’une antibiothérapieet une catégorie NNIS (National Nosocomial InfectionSurveillance System) de >2 étaient tous significatifs à p <0,001. Les taux de SSI pour les catégories de risques NNIS decatégorie 0, 1 et 2-3 étaient respectivement de 4,2%, 46,7% et100%.

Conclusions : Les SSI sont cause de morbidité considérableparmi les patients opérés au UCCK. Des mesures adéquates desurveillance active et de prophylaxie devraient être introduitesau niveau des soins préopératoires, opératoires et post-opératoires pour abaisser le taux d’infection.

Mots clef: Kosovo, infections nosocomiales, infections desite opératoire

CONNAISSANCE ET PREVISION DU COMPORTEMENTDES TRAVAILLEURS DE SANTE EN REPONSE A UNEEPIDEMIE DE GRIPPE PANDEMIQUE EN GEORGIE (KNOWLEDGE AND ANTICIPATED BEHAVIOR OFHEALTH CARE WORKERS IN RESPONSE TO ANOUTBREAK OF PANDEMIC INFLUENZA IN GEORGIA)Contexte : Depuis 2003, la grippe aviaire a été documentéechez plus de 331 humains avec plus de 203 décès associés.D’autres épidémies hautement virulentes ont établi que lestravailleurs de santé (TS) sont personnellement exposés avecun taux élevé d’atteinte. Cette étude vise à déterminerl’ampleur et les facteurs associés à l’absentéisme chez les TShospitaliers en Géorgie lors d’une pandémie potentiellementtrès virulente

Procédure : Il s’agit d’une étude croisée sur la réponse desTS à une pandémie de grippe potentiellement fortementvirulente dans deux hôpitaux urbains de Géorgie. Desmédecins et infirmiers hospitaliers ont été soumis à l’enquête.Les données ont été réunies à l’aide d’un outil de sondage.L’enquête était soit autogérée soit gérée par des enquêteurs, auchoix du répondant.

Résultats : L’enquête a été menée sur 288 TS. L’enquêterévélait un taux d’absentéisme des travailleurs de 23%,notamment chez les femmes et infirmières. La plupart des

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World Hospitals and Health Services 2008 Volume 44 Number 2 Résumés en Français


40-2 Abstracts IHF18:ihf18 8/7/08 12:28 Page 40

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répondants (58,1%), essentiellement des TS de moins de 35ans, s’opposaient à l’isolation ou à la quarantaine obligatoiredu personnel en cas de pandémie de grippe hautementvirulente. 76% des répondants ont correctement rapporté quela souche de virus responsable des foyers épidémiques dans lespays voisins était H5N1. Mais 15,5% seulement desrépondants ont correctement identifié la grippe comme étantle virus impliqué.Conclusions : Le taux d’absentéisme au travail indiqué parcette étude représente une diminution importante detravailleurs. Des groupes de personnes spécifiques choisiraientde ne pas aller au travail en cas de pandémie de grippe. Cesdonnées peuvent permettre aux planificateurs de cibler cesgroupes particuliers au niveau de l’éducation et des servicesd’appui social pour les encourager à être plus attentifs à leursdevoirs médicaux.Mots clef : Grippe, H5N1, travailleurs de santé

NOUS CREONS NOS BATIMENTS, ET ENSUITE ILSNOUS TUENT : POURQUOI LES BATIMENTS CREESPOUR LA SANTE CONTRIBUENT A UNE PANDEMIEPAR ERREUR (WE SHAPE OUR BUILDINGS, THEN THEY KILL US: WHYHEALTHCARE BUILDINGS CONTRIBUTE TO THE ERRORPANDEMIC)Les hôpitaux sont des structures complexes. L’environnementmatériel qui sous-tend cette complexité a des répercussionsimportantes sur la santé et la sécurité. Toutefois, lerenforcement de la sécurité des patients ou l’amélioration de laqualité n’ont pas été prévus dans certains aspects de laconception des bâtiments hospitaliers. Malgré les discussionssur la conception d’installations de santé ciblant le patient etles “concepts reposant sur des preuves”, il n’existe guèred’évaluation de l’impact de l’environnement bâti sur l’issue dela maladie des patients. Cet article présente quelques exemplessur la façon dont certaines modifications de conceptionpeuvent améliorer la qualité des soins.

AMELIORATION DE LA SECURITE DES PATIENTSGRACE A UN SYSTEME DE DECLARATION PARINTERNET(INCREASED PATIENT SAFETY WITH AN INTERNET-BASED REPORTING SYSTEM)Une approche efficace, positive et bien ciblée permetd’apprendre d’après les erreurs médicales. C’est un systèmed’analyse systématique des incidents de sécurité des patients

développe l’initiative et l’innovation en matière de résolutiondes problèmes. En Finlande, un système de déclarationvolontaire implanté à l’échelle nationale sur Internet fournit uninstrument de développement de la sécurité des patients. Cesystème est utilisé par plus de 40 organismes de soins de santé.L’hôpital de district de Vaasa comporte plus de 100départements et 3500 employés allant des services spécialisésjusqu’aux consultations de soins primaires et ambulances.Tous les employés peuvent soumettre des rapports qui sonttraités par le médecin chef et l’infirmière en chef de chaqueservice. Les responsables peuvent intervenir immédiatementpour les problèmes mettant en jeu la sécurité d’un patient.Une classification des incidents en fonction d’une structureétablie permet de créer une base de données électronique quiest un outil de gestion hospitalière. La force d’un système dedéclaration par Internet réside dans sa simplicité et sa facilitéd’utilisation. Il peut promouvoir de bonnes pratiques desécurité en matière de soins de santé.

LA NUTRITION MEDICALE SUR LA SCENEINTERNATIONALE: ACTIONS DE L’ALLIANCEEUROPEENNE POUR LA SANTE(PUTTING MEDICAL NUTRITION ONTO THEINTERNATIONAL AGENDA: ACTIONS BY THEEUROPEAN NUTRITION FOR HEALTH ALLIANCE)Dans l’Union Européenne, en matière de nutrition, le public,les décideurs et les campagnes de promotion de la santé sontessentiellement focalisés sur l’obésité qui jusqu’à récemment,a éclipse un autre aspect de la malnutrition, souvent lié à lamaladie : une prise alimentaire insuffisante qui entraîne uneperte de poids, des dysfonctionnements corporels et unmauvais pronostic clinique. La malnutrition non seulementcompromet les guérisons en affectant la réponse auxtraitements médicaux, retardant la guérison et augmentant lamortalité, mais a aussi des retentissements graves sur le fardeauéconomique et social pesant sur les agents et les systèmes desanté. Un groupe de personnes concernées couvrant toute lascène médicale européenne vient de créer l’Alliance de lanutrition européenne pour la santé (ENHA) dans un effortconcerté visant à sensibiliser l’opinion concernant l’importanceet l’urgence du problème de la malnutrition et pour préparerun plan d’action au niveau européen et à l’échelon de chaquepays.. Mots clé : malnutrition, vieillissement, santé publique, partiesprenantes, alliance, partenariats.

World Hospitals and Health Services 2008 Volume 44 Number 2 Resumen en Español

CAPACITACION DEL PERSONAL DE SALUD PUBLICAEN LA ESCUELA NACIONAL DE SALUD PUBLICA:COMO SATISFACER LAS NECESIDADES DE AFRICA(TRAINING OF PUBLIC HEALTH WORKFORCE AT THENATIONAL SCHOOL OF PUBLIC HEALTH: MEETINGAFRICA’S NEEDS)Problema: el número insuficiente de personal capacitado ensalud pública en Africa continúa siendo un problema. En el

Africa subsahariana el número estimado de médicos de lasalud pública representa el 1.3% del personal sanitario a nivelmundial, ocupándose del 25% de la carga mundial deenfermedades.

Planteamiento: con el fin de cerrar esta brecha, la EscuelaNacional de Salud Pública de la que por entonces era laUniversidad de Medicina de Africa del Sur diseñó un métodoinnovador haciendo uso del aprendizaje a distancia con el que



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impartir sus cursos de salud pública. La educación presencialobligatoria se limitaba a cuatro periodos de dos semanas.

Reformas pertinentes: la combinación de la conexióndirecta con el ordenador y el plan de estudios presencialtradicional reduce las restricciones ocasionadas por ladistancia geográfica. Al mismo tiempo, el plan de estudiosestaba estructurado para contextualizar los temascontinentales relacionados con la salud, tanto en cuanto alesquema del curso como a la investigación específica a lasnecesidades de los estudiantes.

Lecciones aprendidas: el método utilizado por la EscuelaNacional de Salud Pública deja un margen para un aumentoconstante del número de empleados de la salud pública enAfrica. A causa del elemento flexible de la educaciónelectrónica y los proyectos de investigación específicos paraAfrica, estudiantes graduados de 16 países de Africa tuvieronacceso a este programa. En una evaluación quedó demostradoque este tipo de programas tiene que utilizar técnicas demotivación constantemente entre los participantes para evitarla deserción escolar y que la competencia en la informática esuno de los requisitos previos para acceder a este programa.Los certificados de algún curso a corto plazo en temaspertinentes de salud pública serían muy útiles en el contextoafricano. Este programa podría repetirse en otras regiones delcontinente.

INFECCIONES CONTRAIDAS EN EL QUIROFANO DEUNA SALA PARA PACIENTES DE CIRUGIAABDOMINAL EN UN HOSPITAL DOCENTE DE KOSOVO(SURGICAL SITE INFECTIONS IN AN ABDOMINALSURGICAL WARD AT KOSOVO TEACHING HOSPITAL) Antecedentes: las infecciones contraídas en un quirófano (eninglés SSI) son motivo de un alto índice de morbosidad ymortalidad para los pacientes que se someten a cirugíaabdominal. Estudiamos la incidencia y los factores de riesgode estas infecciones tras la cirugía abdominal en el servicio decirugía abdominal del Centro Médico Universitario deKosovo.

Metodología: desde diciembre de 2005 hasta junio de2006, los pacientes que fueron sometidos a cirugía abdominalestuvieron bajo una vigilancia prospectiva. Se siguieron lasdefiniciones del CCE (Centro para el Control deEnfermedades) con el propósito de detectar las SSI y losformularios del estudio se basaron en los protocolos de la RedHELICS (Red de Hospitales Europeos para el Control deInfecciones mediante la Vigilancia.

Resultados: se evaluaron 253 intervenciones quirúrgicas y225 pacientes. La edad media de los pacientes era 42 años delos que el 55.1% eran hombres. La tasa global de incidenciasde SSI fue del 12%. Se consiguió hacer un seguimiento del84.1% de las intervenciones. Entre los pacientes quecontrajeron SSI, la estancia media en el hospital fue de 9 díasen comparación con los 4 días que permanecieron los que nocontrajeron una infección (p<0.001). En el 53.3 de los casosse detectó una intervención quirúrgica. Las SSI más frecuentesfueron las contraídas por incisiones superficiales (55%). Lasinfecciones clínicas dieron un resultado en el 40.7% de loscasos confirmados por cultivo. La duración de la intervención,la duración de la estancia preoperativa, el tipo de herida, la

valoración ASA (Sociedad Americana de Anestesiología) >2,el uso de la profilaxis antibiótica y la categoría NNIS (en inglésNational Nosocomial Infection Surveillance) >2 fueron todasmuy significativas en p<.001. La tasa de SSI para lascategorías 0, 1 y 2-3 de riesgo, según el sistema de NNIS,fueron del 4.2%. el 46.7% y el 100% respectivamente.

Conclusiones: las infecciones contraídas en el quirófano decirugía abdominal fueron motivo de una morbilidad muyconsiderable entre los pacientes del Centro MédicoUniversitario de Kosovo. Este centro debería adoptar medidasde vigilancia pertinentes para el control de infeccionesdurante los cuidados preoperatorio, intraoperatorio ypostoperatorio con el fin de reducir la tasa de infección.

Palabras clave: Kosovo, infecciones nosocomiales,infecciones contraídas en el quirófano.

CONOCIMIENTOS Y COMPORTAMIENTO ESPERADOPOR PARTE DEL PERSONAL DE LOS SERVICIOS DESALUD COMO RESPUESTA A UNA EPIDEMIA DEGRIPE DE PROPORCIONES PANDEMICAS ENGEORGIA(KNOWLEDGE AND ANTICIPATED BEHAVIOR OFHEALTH CARE WORKERS IN RESPONSE TO ANOUTBREAK OF PANDEMIC INFLUENZA IN GEORGIA) Antecedentes: según informes, la gripe aviar ha afectado amás de 331 personas desde 2003, habiéndose registrado203 muertes relacionadas con esta enfermedad. Ha quedadodemostrado que el personal de los servicios de salud correun gran peligro en otros brotes excesivamente virulentos conun índice muy alto de exposición. Con este estudio seintenta determinar la magnitud y los factores relacionadoscon el absentismo del personal sanitario del hospital enGeorgia, con relación a una posible pandemia de gripeextremadamente virulenta.

Metodología: se hizo un estudio transversal sobre la maneraen la que el personal de los servicios de salud reaccionó anteuna posible pandemia de gripe extremadamente virulenta endos hospitales urbanos de Georgia. Con este fin, se estudió elcomportamiento de diversos médicos y enfermeroshospitalarios. La recopilación de datos se llevó a cabomediante el uso de un cuestionario. La encuesta se realizóbien mediante un test administrado por el mismo sujeto o através del entrevistador, según la preferencia del entrevistado.

Resultados: se entrevistaron 288 profesionales y el estudióarrojó un resultado del 23% de absentismo laboral,predominantemente entre el sexo femenino y el personal deenfermería. La mayor parte del personal (58.1%), en sumayoría empleados en edades inferiores los 35 años se opusoal aislamiento forzoso o a la cuarentena del personal sanitariodurante una pandemia de gripe de proporciones muyvirulentas. El 76% de los encuestados comunicócorrectamente que la cepa de virus responsable del brote degripe aviar en los países vecinos se trataba de H5N1. Sinembargo, tan sólo el 15.5% de los entrevistados identificócorrectamente el virus de la influenza como el virusresponsable de la gripe.

Conclusiones: el índice de absentismo laboral que esteestudio planteó representa una reducción muy considerablede la mano de obra. Hay grupos específicos que preferirían no


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Vol. 44 No.1 | World Hospitals and Health Services | 43

ir a trabajar ante una pandemia de influenza. Esta informaciónpuede servir para que los planificadores elijan a estos gruposespecíficos como objetivo a la hora de planear los programasde educación y los servicios de asistencia social, con el fin deestimular una mayor disposición hacia las obligacionesmédicas.

Palabras clave: influenza, H5N1, personal de los serviciosde salud.

DAMOS FORMA A NUESTROS EDIFICIOS Y ELLOSACABAN CON NOSOTROS: ¿PORQUE LOSESTABLECIMIENTOS SANITARIOS CONTRIBUYEN ALA EPIDEMIA DEL ERROR?(WE SHAPE OUR BUILDINGS, THEN THEY KILL US: WHYHEALTHCARE BUILDINGS CONTRIBUTE TO THE ERRORPANDEMIC)Los hospitales son edificios muy complicados. El entornofísico en el que se encuentran tiene unas repercusiones muytrascendentales sobre la salud y la seguridad del paciente. Sinembargo, a la hora de diseñar los edificios hospitalarios no setienen en cuenta esos aspectos. A pesar de los recientesdebates sobre el diseño de las instalaciones ‘centradas en elpaciente’ y el ‘diseño basado en los hechos’, no se han hechomuchas evaluaciones sobre las repercusiones de losestablecimientos sanitarios con respecto a la evolución de lospacientes. Esta ponencia expone diversos ejemplos sobre lamanera en la que unos cambios en el diseño pueden mejorarla calidad de los cuidados de salud.

AUMENTO DE LAS MEDIDAS DE SEGURIDAD DELPACIENTE MEDIANTE UN SISTEMA DEPRESENTACION DE INFORMES BASADO EN ELINTERNET(INCREASED PATIENT SAFETY WITH AN INTERNET-BASED REPORTING SYSTEM)Un método eficaz, positivo y enfocado hacia un fin permiteaprender de los errores médicos. El análisis sistemático de losincidentes por razones de seguridad del paciente aumenta lainiciativa y la innovación en la solución de problemas. EnFinlandia, un sistema voluntario de presentación de informes,basado en el internet y puesto en práctica a escala nacionalsirve de instrumento para fomentar la seguridad del paciente.Este sistema es utilizado por más de 40 organizaciones de laatención de la salud. El Distrito Hospitalario de Vaasacomprende más de 100 unidades, además de 3.500

empleados, desde salas de especialidad hasta clínicas deatención primaria y ambulancias. Todos los empleadospueden presentar un informe que es tramitado por el directormédico o el jefe de enfermería de cada departamento. Losresponsables de tramitar estos informes están en situación deintervenir inmediatamente para solucionar los problemascuando se produce un incidente relacionado con la seguridaddel paciente. La clasificación de incidentes de acuerdo conuna estructura convenida previamente sirve para crear unabase electrónica de datos que se utiliza como instrumentopara la dirección hospitalaria. El punto fuerte del sistema depresentación de informes a través de internet radica en susimplicidad y facilidad de uso. Este sistema puede ayudar apromover una conciencia cultural en cuanto a la seguridad delpaciente en la atención de la salud.

LA INCLUSION DE LA ALIMENTACION MÉDICA EN ELORDEN DEL DIA INTERNACIONAL: MEDIDASADOPTADAS POR LA ALIANZA EUROPEA PARA LAALIMENTACION A BENEFICIO DE LA SALUD (PUTTING MEDICAL NUTRITION ONTO THEINTERNATIONAL AGENDA: ACTIONS BY THEEUROPEAN NUTRITION FOR HEALTH ALLIANCE)En la Unión Europea, el público, los responsables de formularla política y las campañas de promoción de la salud centrancasi toda su atención en la obesidad. Hasta hace muy poco,esto ha eclipsado la otra faceta de la alimentación deficiente,por la que la ingesta nutricional inadecuada –a menudorelacionada con las enfermedades- conduce a la pérdida depeso, deterioro de las facultades corporales y unos resultadosclínicos deficientes. La mala alimentación no sólo pone enpeligro el estado de la salud al menoscabar la reacción altratamiento médico, retrasando la recuperación yaumentando la tasa de mortalidad, sino que además afectaseriamente a la carga económica y social de los cuidadores ylos sistemas de salud. Un grupo de expertos de todo el ruedoeuropeo de la salud ha formado recientemente la AlianzaEuropea para la Alimentación a beneficio de la salud (en inglésENHA) en un esfuerzo unido por concienciar al público de laimportancia y la urgencia del problema de la malaalimentación y la necesidad de elaborar un programa deacción, tanto a nivel europeo como a nivel individual de cadapaís.Palabras clave: mala alimentación, envejecimiento, saludpública, expertos, alianza, sociedades



OPINION MATTERS

precarious, current estimates indicate that a million or morepeople will be displaced for every centimetre of rise. As theymove, the economic production sectors they havecontributed to will be affected.

Drought, desertification, sea-level rise, coastal floodingand the deterioration of living conditions will not be limitedto the poorest parts of the world, however. Many parts ofEurope, North America, and countries such as China andIndia stand to be confronted by these changes as well.

What will differentiate some regions from others will betheir capacity to manage the impact of climate change andreduce the need for people to move. But to some degree oranother, flight in the face of climate change and increasinglyadverse conditions will occur everywhere.

How many people will be forced to move, how far theywill have to flee before they find security, what will be thesocial and health impact of their migration, and how hostcountries will go on to accommodate them are questionsthat must be taken up.

A changing political landscapeAlthough the exact parameters of what will occur areimpossible to predict with precision, a number of optionscan be foreseen. Each carries with it different political,societal and health implications. Massive migration fromrural areas to urban centres is one of the options that willinevitably emerge. Cities everywhere have always been seenby people as a safe haven, and many people will inevitablyfollow what is now a welltrodden rural-urban migrationpathway. Unfortunately, cities in many developing countriesare already over-populated and incapable of providingresidents with even the most basic services needed tosustain healthy life. If these cities are to be furtherchallenged by massive numbers of climate refuges, urban

Climate change, especially global warming, is likely toaffect global society in different ways. Foodproduction and food scarcity will be one of them.

The rapid spread of old diseases and the emergence of newones will probably be another. Against this backdrop, themassive forced displacement of people will be one of themost far-reaching consequences, and will in turn bring withit further ramifications for health and development,including patterns of food production and consumption.

Migration is not new. It has always been one of the waysin which people have responded to the presence of social,economic, political and environmental threats. In thecontext of accelerating global warming, however, themagnitude of population displacement could go beyondanything that has been seen before.

Physical and social impactDesertification and drought in some regions, rising sea levelsand flooding in others, could together force 200 millionpeople into becoming “climate refugees” by the middle ofthe century.

Although global warming is likely to affect all parts of theworld, some regions stand to be more affected than others.Tragically it will probably be the poorest parts of the worldthat will have the greatest difficulty coping with climatechange in ways that would make it less necessary for peopleto move.

Many of these regions have long been climaticallychallenged, and they are also the ones that have had theleast access to the type of technology needed to mitigateclimate stress. Some are already critically short of water, andfurther shortages will make even the most basic subsistenceagriculture impossible. Elsewhere in coastal areas and riverdeltas where periodic flooding has long since made life

Climate change, migration and healthDR MANUEL CARBALLOTHE INTERNATIONAL CENTRE FOR MIGRATION, HEALTH AND DEVELOPMENT

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OPINION MATTERS

public health will become even more fragile, and epidemicsof diseases that to date have been otherwise prevented ormanaged could occur.

Internal migration will not be the only answer, however;millions of “climate refugees” will probably seek safetyacross national borders, and move to countries where theyfeel environmental security and quality of life can be moreassured. As they do, they will confront the resistance tomigrants and migration that is intensifying all over theworld, and which is making the opportunities for socialinsertion and for a healthy life more difficult. Inevitably, theywill also impose new and at times difficult to meet demandson receiving societies.

Migration and its complicationsOther complications will inevitably emerge too, becausemigration is never easy. Uprooting and moving involvesdifficult choices as to who and what to take, and who andwhat to leave behind. Not all people, especially the elderlyand the disabled, are able to move easily or quickly. Whenthey cannot, families are broken up in ways that oftentraumatise those that leave and those that stay. Theimplications of this for social and economic developmentcan be serious because in many cases they prevent thepeople who move being able to so with an open mind andbeing able to re-settle and look forward to better things aspart of the societies that host them.

Climate change-related migration, moreover, will occur ata time when natural resources such as water and arable landare becoming scarce everywhere, even in temperate zonesand richer parts of the world. Where this happens,competition for natural resources may well be exacerbatedand could easily degenerate into open struggles for space,food, water, housing and other goods.

The politics and economics of these changes will exercisenational authorities and international organizations in waysthey have previously never had to confront, and which manyof them are possibly not prepared for.

Migration and healthNor is migration without its intrinsic implications for health.Climate refugees, as do all other migrants, will move withtheir health prints and medico-cultural histories. They willalso risk developing new problems according to thecircumstances under which they are forced to move and the

socio-geo-ecological terrain theyeventually cover. The further theyhave to move, and the longer they areon the road, the more they will beexposed to new health risk factorsand problems that will potentiallyhave an impact on their personalhealth and that of the people theycome into contact and live with.

Some climate refugees will movewith diseases that are poorlyunderstood in the communities theywill move into, and to which to date

there is little herd immunity. Local medical practice andhealth systems may also find themselves unprepared torespond quickly to them if and when these diseases domaterialize. Conversely others climate refugees may beforced to move to zones where they are the ones who will beexposed to health threats they have not previouslyencountered, and for which they have little or nopreventative or a therapeutic experience.

SummaryIn summary, climate change of the magnitude that is nowbeing talked about promises to invoke major changes in thenature of the world we live in. From an agricultural and foodproduction perspective new challenges are already emergingand many countries, regional organizations andinternational agencies are ill-prepared to deal with them.From the perspective of the forced emergence of newdiseases. There may also be complex struggles for scarceresources including land, water, food and housing. To whatextent these will translate into social and political instabilityis not clear, but the potential for instability within andbetween countries should not be under-estimated; norshould the scarcity of selected commodities. Understandingthese complex dynamics and planning for them in timelyand comprehensive ways is essential. Preparedness bygovernments, the international community and the privatesector, will help accommodate some of the changes that arealready taking place and many others which are still tomaterialize.

About ICMHDThe International Centre for Migration, Health andDevelopment is a multi-disciplinary research, training andpolicy institute dedicated to helping governments, UNagencies, regional and other international bodies, non-governmental organizations and the private industry sectorto respond to the health and development impact of humanmobility. ICMHD has a world-wide network of cooperatingpartners and can respond readily to demands by concernedparties. �

For further information please contact: Dr Manuel Carballo,ICMHD, 11, Route du Nant d’Avril, 1214 Vernier, Switzerland,Tel. + 41 22 783 1088, Fax. + 41 22 783 1087 or email:[email protected]

47-8 Opinion matters:Opinion Matters IHF18 8/7/08 12:30 Page 48

Training of public health workforce at the National School of Public Health: Meeting Africa's needs

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