M. Preziosi MD, K.Lee MD, M. Tomas MD, T. Paunde MD, C. PaivaMD, S. Kinlin MD, R. Bene MD, H.Lopes MD, R. Ryder MD, E.VNoo...
Top 10” HIV prevalence   Zimbabwe 25.84%   Botswana 25.10%   Namibia 19.94%   Zambia 19.10%   Swaziland 18.50%   South Afr...
Top Causes of Mortality   Malaria ( 29%)   AIDS( 27%)   Perinatal causes ( 7%)   Diarrhea ( 4%)   Pneumonia ( 4%)   ...
Bacteremia Study Design                                               Clinical LabsAdmitted to Internal MedicineWard?Axill...
Medical Records   Paper charts   Illegible   Incomplete   Hard to find or lost   Hematology                           ...
How do you do a prospectiveobservational study in thisenvironment and havereliable data?
1. Create a Team   Residents   Nurse   Lab tech   ID attending   American    collaborators
2. Use touch screen devices andwebpage to collect and organize data
3. Repeated QI Cycles Identify areas for quality improvement Propose solutions Implement and Measure Review Data and R...
Initial QI Projects Increase enrollment Reduce contamination rate Improve documentation of CD4 counts  in charts Impro...
Preliminary Results- BacteremiaPatient enrolled: 43575 % HIV (Avg CD4=120, 44% on ARVs)42 bloodstream infections (Staph au...
Blood culture contaminationrate in study vs. hospital 60 50 40 30                              Study                      ...
Percentage of Enrolled Patientswith documented CD4 count  100   90   80   70   60   50   40   30   20   10    0        Sep...
Percentage of patients with documented outcome100908070605040302010 0      October   November   December   January   Febru...
Infectious Diagnoses other thanHIV                        N= 320
Microbiologic Confirmation?
Use of Empiric Antibiotics is Common,and Antibiotics are Rarely Changed
Antibiotic Use in Known BacteremiaCases
Outcomes
Lessons learned Think more about sepsis/bacteremia in  differential diagnosis Empiric antibiotic choices are often  wron...
Clinical Care Quality Improvement in a Mozambique Hospital
Clinical Care Quality Improvement in a Mozambique Hospital
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Clinical Care Quality Improvement in a Mozambique Hospital

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Quality improvement using touch-screen devices and a team-based approach at an urban hospital in Mozambique

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Clinical Care Quality Improvement in a Mozambique Hospital

  1. 1. M. Preziosi MD, K.Lee MD, M. Tomas MD, T. Paunde MD, C. PaivaMD, S. Kinlin MD, R. Bene MD, H.Lopes MD, R. Ryder MD, E.VNoormahomed MD, PhD, E.A Spencer MD PhD, T. Zimba MD
  2. 2. Top 10” HIV prevalence Zimbabwe 25.84% Botswana 25.10% Namibia 19.94% Zambia 19.10% Swaziland 18.50% South Africa 16.70% Malawi 14.92% Moçambique 11.5% Tanzania 9.42% Lesotho 8.35%
  3. 3. Top Causes of Mortality Malaria ( 29%) AIDS( 27%) Perinatal causes ( 7%) Diarrhea ( 4%) Pneumonia ( 4%) Trauma( 4%) Tb( 3%) CVA ( 3%) Neoplasias(1%) Sepsis(1%) Mozambique- INE 2009
  4. 4. Bacteremia Study Design Clinical LabsAdmitted to Internal MedicineWard?Axillary temp ≥ 38C?HIV status known? Enrollment Identify problemsNo antibiotics started? in workflowConsent? Quality improvement Inter Medicine Wards
  5. 5. Medical Records Paper charts Illegible Incomplete Hard to find or lost Hematology Lab Retrospective studies not possible Chemistry Lab Microbiology Lab Serventes Patient Chart TB Reference Lab Immunology Lab Pathology
  6. 6. How do you do a prospectiveobservational study in thisenvironment and havereliable data?
  7. 7. 1. Create a Team Residents Nurse Lab tech ID attending American collaborators
  8. 8. 2. Use touch screen devices andwebpage to collect and organize data
  9. 9. 3. Repeated QI Cycles Identify areas for quality improvement Propose solutions Implement and Measure Review Data and Repeat
  10. 10. Initial QI Projects Increase enrollment Reduce contamination rate Improve documentation of CD4 counts in charts Improve clinical follow-up in hospital
  11. 11. Preliminary Results- BacteremiaPatient enrolled: 43575 % HIV (Avg CD4=120, 44% on ARVs)42 bloodstream infections (Staph aureus andNon- Typhoidal Salmonella most common.)BSI 20 % in hospital-mortality
  12. 12. Blood culture contaminationrate in study vs. hospital 60 50 40 30 Study Hospital 20 10 0 P < .001
  13. 13. Percentage of Enrolled Patientswith documented CD4 count 100 90 80 70 60 50 40 30 20 10 0 Sept Oct Nov Dec Jan Feb March April May June July August P < .001
  14. 14. Percentage of patients with documented outcome100908070605040302010 0 October November December January February March April May June
  15. 15. Infectious Diagnoses other thanHIV N= 320
  16. 16. Microbiologic Confirmation?
  17. 17. Use of Empiric Antibiotics is Common,and Antibiotics are Rarely Changed
  18. 18. Antibiotic Use in Known BacteremiaCases
  19. 19. Outcomes
  20. 20. Lessons learned Think more about sepsis/bacteremia in differential diagnosis Empiric antibiotic choices are often wrong Blood culture is a useful test QI is possible at MCH Requires multidisciplinary organization, great communication

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