Chapter 5 – Inpatients
activity
Introduction
Matany Hospital in-patient service has the function of referral for the District and also for a wider functional catchment area for referral of emergency surgery. The Hospital bed strength at the end of the year was 220 bed over 5 Wards: Male Ward and Female Ward with 41 beds each (medical and surgical mixed together), Maternity Ward with 25 beds (ante-natal, post-natal, septic patients), Paediatric Ward with 55 beds including 5 beds for premature intensive care and 10 isolation beds, TB Ward with 58 beds. As remarked in OPD, the utilisation of the Hospital In-patient service dropped in August 97 while an higher increase has been registered overall FY 98/99, probably due to several factors, the increase of morbidity of Malaria, the Cholera epidemic and the reduction of fees of September 98.
The global bed occupancy rate of FY 98/99 is 95%, showing a remarkable increase of utilisation compare to Fy 97/98 when it was 66%.
Workload
The graphic 5A show the inpatients attendance for the financial years 96/97, 97/98 and 98/99, while table A offers an overview of the Inpatient workload of the last 5 years. It appears very clear that FY 98/99 has been the year with the highest workload: 7730 patients discharged, the highest in the history of Matany Hospital.
Graphic 5A: INPATIENTS ATTENDANCE Jul 96-Jun 99
The overall increased utilisation in all of the wards and especially in children and maternity wards can be explained with several factors:
· the worsening of Malaria Epidemic with the increased number of children up to 4313.
· The measles epidemic that affected all the District in the last quarter of FY 98/99.
· The training and monthly follow-up of 150 TBAs since 98, and therefore more sensitisation of the pregnant patients to deliver in the Hospital (as shown by the lowest percentage of abnormal deliveries)
· The reduction of fees of September 98 has made “too” affordable the Hospital services(?), especially if we consider that about 20% of the adults inpatients are from other Districts.
With regard to the drop of utilisation of the services in August 97, it can be noticed that the total number of patient discharge in FY 97/98 does not look so bad if compared with previous years. It should be remembered that this was because of Cholera epidemic that occurred in April-July 98 which accounted for about 500 Hospital admissions. A more detailed analysis of Cholera epidemic is reported in Annex 2. At this point it can be mentioned the low case fatality rate achieved, because of is implication in the overall mortality rate in male and female ward in FY 97/98.
INPATIENT |
1993 |
1994 |
1995 |
1996/97 |
1997/98 |
1998/99 |
WARDS |
|
|
|
|
|
|
|
Male
ward (41beds) |
952 |
830 |
848 |
993 |
731 |
1,005 |
|
Female
ward (41 beds) |
809 |
703 |
813 |
1,041 |
806 |
1,057 |
|
Children
ward (55 beds) ( with Isol.) |
1,723 |
2,253 |
2,154 |
3,432 |
2,321 |
4,313 |
|
Isolation
ward (with CW since ’96) |
335 |
4 |
89 |
95 |
137 |
184 |
|
Maternity
ward ( 25 beds ) |
475 |
468 |
578 |
564 |
518 |
838 |
|
TB
Adult ward ( 58 beds ) |
313 |
310 |
250 |
272 |
193 |
225 |
|
TB
Paed. Ward ( with CW since ’96 ) |
145 |
100 |
52 |
108 |
94 |
108 |
|
TOTAL (220) |
4,452 |
4,668 |
4,784 |
6,505 |
4,800 |
7,730 |
SURGERY |
|
|
|
|
|
|
|
Major |
525 |
493 |
461 |
480 |
336 |
432 |
|
Emergencies
(%) |
28% |
27% |
29.9% |
17.7% |
32.4% |
37% |
|
Minor |
2,214 |
2,128 |
2,335 |
2,621 |
1,904 |
1,474 |
MATERNITY |
|
|
|
|
|
|
|
Deliveries
(Total) |
396 |
344 |
431 |
418 |
364 |
548 |
|
Deliveries
(Abnormal) |
114 (29%) |
124 (36%) |
171 (40%) |
111(26.6%) |
85(23.4%) |
111(20%) |
|
Live
births |
406 |
344 |
456 |
408 |
340 |
525 |
|
Premature |
67 (17%) |
41 (12%) |
74 (16%) |
44 |
25 |
43 |
|
Natural
Family Planning counselling |
- |
- |
- |
- |
- |
- |
|
Table
A: workload of years 1993-’99. |
||||||
Utilisation Indicators:
All utilisation indicators (Bed Occupancy Rate, Turnover Interval and Throughput Per Bed) have been calculated on the number of discharged patients. The following formulas were used:
|
Bed Occupancy rate = Dur.n of stay (all pts)
No. of beds x 365 |
Throughput per bed = No. pts. Discharged
No. of beds |
Turnover Interval = (N. Beds x 365)-Dur..n of stay
No. of pts. Discharged. |
The results for all wards are indicated in the following table:
|
Male WARD (41 Beds) |
96/97 |
97/98 |
98/99 |
Female WARD (41 Beds) |
96/97 |
97/98 |
98/99 |
|
Patients Discharged |
993 |
731 |
1,005 |
Patients Discharged |
1,041 |
806 |
1,057 |
|
Duration of stay (No. of days) |
14,878 |
9,552 |
13,364 |
Duration of stay (No. of days) |
13,063 |
8,705 |
11,735 |
|
Avg. duration of stay (No. of days) |
15 |
13 |
13 |
Avg. duration of stay (No. of days) |
13 |
11 |
11 |
|
Bed Occupancy Rate (%) |
99% |
64% |
89% |
Bed Occupancy Rate (%) |
87% |
58% |
78% |
|
Turnover Interval (No. of days) |
0 |
7 |
2 |
Turnover Interval (No. of days) |
2 |
8 |
3 |
|
Throughput Per Bed (No. of patients) |
24 |
18 |
25 |
Throughput Per Bed (No. of patients) |
25 |
20 |
26 |
|
Paediatric WARD (55 Beds) |
|
|
|
Maternity WARD (25 Beds) |
|
|
|
|
Patients Discharged |
3,527 |
2,458 |
4,497 |
Patients Discharged |
564 |
518 |
838 |
|
Duration of stay (No. of days) |
22,650 |
18,938 |
32,531 |
Duration of stay (No. of days) |
2,939 |
3,917 |
6,342 |
|
Avg. duration of stay (No. of days) |
6 |
8 |
7 |
Avg. duration of stay (No. of days) |
5 |
8 |
8 |
|
Bed Occupancy Rate (%) |
113% |
94% |
162% |
Bed Occupancy Rate (%) |
32% |
43% |
70% |
|
Turnover Interval (No. of days) |
-1 |
0 |
-3 |
Turnover Interval (No. of days) |
11 |
10 |
3 |
|
Throughput Per Bed (No. of patients) |
64 |
45 |
82 |
Throughput Per Bed (No. of patients) |
23 |
21 |
34 |
|
T.B Adults WARD (58 Beds) |
|
|
|
OVERALL indicators: |
|
|
|
|
Patients Discharged |
272 |
193 |
225 |
|
|
|
|
|
Duration of stay (No. of days) |
15,986 |
11,610 |
12,486 |
Overall B.O.R = |
87% |
66% |
95% |
|
Avg. duration of stay (No. of days) |
59 |
60 |
55 |
Turnover
interval = |
1.6 |
6 |
0.5 |
|
Bed Occupancy Rate (%) |
76% |
55% |
59% |
Throughput per
bed = |
30 |
22 |
35 |
|
Turnover Interval (No. of days) |
19 |
50 |
39 |
|
|
|
|
|
Throughput Per Bed (No. of patients) |
5 |
3 |
4 |
|
|
|
|
It is clear that the overall indicators show for this FY a good efficiency of the utilisation of the Hospital with a B.O.R. of 95% and a throughput per bed of 35 patients (if we consider “good” when BOR>=80% and throughput per bed >=35).
In the following graphic 5B shows that this is not so for some of the Wards: TB ward is the more inefficient ward, probably because of the high number of hospital beds compared to the number of TB patients.
The patients have reduced over the years and will probably reduce further if DOTS will be introduced.
Children ward is clearly on the other side but too far from the average, which means an over-loaded ward with a risk of compromising the quality of care and the outcome.
Quality Indicators
Few quality indicators are available. Those available are based on the outcome of the patient’s admission and classified as follows:
· Recovery rate (patients Improved or Recovered on discharge)
· Death rate (patients who died in the course of the admission)
· Self discharge rate (patients who abandoned the ward after admission, assuming that they did so because they were dissatisfied by the service given)
· Maternal Deaths (on the admission in Maternity - the existing information system does not allow to evaluate intra-hospital deaths of pregnant women admitted in Female or TB Wards).
· Fresh Stillbirth rates (the proportion of fresh stillborn over the total number of intra-hospital deliveries; it is assumed that no fresh stillbirth will occur if proper care is delivered). Medical audit has started for all fresh stillbirths in July 98; an evaluation of it is presented under quality assurance paragraph. The comparison with previous years raises the question of the accuracy of the data collected before the auditing exercise started.
The available data are reported in the following table are self explanatory.
|
Male
WARD |
96/97 |
97/98 |
98/99 |
Female
WARD |
96/97 |
97/98 |
98/99 |
|
Recovery Rate |
77 |
79.3 |
77.8 |
Recovery Rate |
80 |
84 |
84 |
|
Death Rate |
11 |
8.6 |
7.6 |
Death Rate |
8.6 |
5.9 |
3.8 |
|
Self Discharge Rate |
2.7 |
1.6 |
2.6 |
Self Discharge Rate |
2 |
0.6 |
0.5 |
|
Paediatric
WARD |
|
|
|
Maternity
WARD |
|
|
|
|
Recovery Rate |
88.7 |
96 |
85.4 |
Fresh Stillbirth Rate* (%) |
8.1 |
6 |
1.2 |
|
Death Rate |
9.1 |
7.2 |
9.2 |
Maternal Deaths |
2 |
2 |
4 |
|
Self Discharge Rate |
2 |
1.4 |
2.4 |
Self Discharge Rates |
0.7 |
- |
0.1 |
|
TB
Adults WARD |
|
|
|
ALL WARDS |
|
|
|
|
Recovery Rate |
93 |
88.6 |
85.7 |
Recovery Rate |
85.3 |
87.7 |
85.6 |
|
Death Rate |
4 |
8.8 |
11.1 |
Death Rate |
8.2 |
6.5 |
7.5 |
|
Self Discharge Rate |
0.7 |
2 |
- |
Self Discharge Rate |
1.9 |
1.1 |
1.9 |
Epidemiology
In this report a different epidemiological analysis will be presented. Using the fees structure we are now able to distinguish patients from the immediate catchment area (pts of the System: Lopei, Lokopo and Matany subcounties) from all the others. Therefore an analysis of the 5 top causes of admission in each ward has been done and is presented in the following table :
|
FIVE TOP
CAUSES OF ADMISSION
BY WARD |
||||||
|
|
Patients
of the System 4524 (58%) |
Patients
outside of System 3206 (42%) |
||||
|
|
Disease |
No. |
% |
Disease |
No. |
% |
|
406pts from System (40%) |
Trauma
|
66 |
16.2% |
Trauma |
141 |
23.5% |
|
LRTI |
64 |
15.7% |
TB |
73 |
12.1% |
|
|
Muscle-skeletal diseases |
35 |
8.6% |
Muscle-skeletal diseases |
49 |
8.1% |
|
|
TB |
33 |
8.1% |
Digestive
system |
49 |
8.1% |
|
|
Digestive
system |
32 |
7.8% |
LRTI |
39 |
6.5% |
|
|
FEMALE WARD: 508 pts from System (48%) (52%) |
LRTI |
64 |
12.5% |
Trauma |
58 |
10.5% |
|
Malaria |
62 |
12.2% |
TB |
53 |
9.6% |
|
|
Trauma |
45 |
8.8% |
LRTI |
48 |
8.7% |
|
|
Cholera |
44 |
8.6% |
Malaria |
28 |
5.1% |
|
|
TB |
30 |
5.9% |
Gyaenecol. diseases |
21 |
3.8% |
|
|
PAEDIATRIC WARD: 3018 pts from System (67%) 1477 pts out of System (33%) |
Malaria |
1541 |
50.4% |
Malaria |
646 |
43.7% |
|
LRTI |
461 |
15% |
LRTI |
212 |
14.3% |
|
|
Measles |
142 |
4.6% |
Anaemia |
84 |
5.6% |
|
|
Anaemia |
123 |
4% |
Diarrhoea |
72 |
4.8% |
|
|
Sepsi |
100 |
3.2% |
Malnutrition |
71 |
4.8% |
|
|
MATERNITY WARD: 439 pts from System (52%) 399 pts out of System (48%) |
Normal delivery |
229 |
52% |
Normal delivery |
141 |
35.3% |
|
Abn. Del. and complications |
78 |
17.7% |
Abn. Del. and complications |
137 |
34.3% |
|
|
Abortion |
50 |
11.3% |
Abortion |
39 |
9.7% |
|
|
Malaria |
30 |
6.8% |
Malaria |
17 |
4.2% |
|
|
UTI |
15 |
3.4% |
UTI |
9 |
2.2% |
|
It should be noticed the very high number of inpatients coming from the immediate catchment area. This poses the question: if 4524 are people who needed admission in an area, where the total population is estimated to be around 40000 inhabitants, how many will be in need of admission in the rest of the District?
With a simple calculation (4524/40000*200000) we can estimated that there are 22620 people in need of admission!!! If we consider that 66% of these are children of which 50% are admitted with malaria, where in the District did these children receive the treatment?
An other interesting comparison can be done concerning the mortality in these two different groups. Some data is presented in the following table:
|
|
Pts from the System |
Pts out of the System |
|
Overall mortality |
6.8% (311/4524) |
8.5%
(272/3206) |
|
Malaria |
4.8% (86/1789) |
6.5% (53/812) |
|
LRTI |
7.5% (46/607) |
7.2% (23/318) |
|
Sepsi |
30% (32/105) |
42% (22/52) |
|
Meningitis |
40% (18/45) |
43% (10/23) |
The interpretation of these differences is very difficult and only with communities surveys could an explanation be found. It can be noticed that the closer the Hospital is to the communities, appears to have a positive impact on the mortality.
Concerning the cause of morbidity it is clear that trauma is the first cause of admission, related mainly to gun shot wounds for the adults, while malaria is the first in children ward and malaria accounts for almost 50% of the admissions. A more detailed analysis of malaria morbidity and mortality over the years is presented in Annex 3.
In maternity ward it can be noticed that the percentage of abnormal deliveries is double for patients coming from outside the system, probably in relation with the referral function of the Hospital.
Quality assurance
Perinatal death
During the
last financial year, a medical audit took place for all the fresh stillbirths.
The term stillbirth refers to any baby who is born after the 28th week of pregnancy that does not afterwards breathe or show any sign of life.
The stillbirth rate is defined as the number of stillbirths per 1000 total births.
The data are reported in the following table:
Causes of perinatal death
|
Early neonatal deaths* |
Fresh stillbirths
|
|
Birth trauma and stress
asphyxia |
3 |
3 |
Antepartum haemorrhage
|
|
3 |
|
Maternal disease |
3 |
1 |
|
Fetal abnormality |
2 |
|
|
Prematurity (cause unknown) |
14 |
|
Other**
|
4 |
|
Total
|
26 |
7 |
*= Babies born alive who die within the first week after birth
**= Infections, Rh and ABO incompatibilities, neonatal tetanus etc…
Comments
The fresh stillbirth rate calculated is 12,7/1000 births.
Among
the 7 fresh stillbirths, 6 babies were already dead at time of admission,
therefore the “real” Hospital fresh stillbirth rate was only 1/548 (~2/1000
births).
Only one mother was admitted at 30 weeks of gestation for severe anaemia with the baby still alive. The Hb value at admission was 5.5 g/dl and raised to 7.9 g/dl with pharmacological treatment.
She had a preamature rupture of the membranes at 33 weeks and 2 days later she delivered a fresh stillbirth of 2.5 Kg.
Most perinatal deaths are due to prematurity (42.4%) and the causes of prematurity are in most cases unknown. (50% of the babies were delivered at home). Therefore we highlight the importance of a more extensive and intensive action to identify pregnancies at risk and to refer them earlier to the hospital.
|
Postoperative wound infectionsDuring the financial year 432 major operation were performed (see chapter 6 table 6.2) of which 37% were emergencies. The total infection rate (over 321 operation) has resulted 20%. In the following table is presented the infection wound rate for specific operation: |
|||||
|
|
|||||
Type of Operation |
elective |
Emergency |
Wounds infected |
Infection wound rate |
|
|
|
Caesarian section |
5 |
78 |
14 |
16.8% |
|
|
|
Hinguino- femoral hernia |
18 |
2 |
0 |
0% |
|
|
|
Others hernia |
7 |
0 |
0 |
0% |
|
|
|
Splenectomy for ruptured spleen |
0 |
6 |
1 |
16.6% |
|
|
|
Hysterectomy for fibroid/ca |
17 |
1 |
5 |
27% |
|
|
|
Thyroidectomy |
6 |
0 |
0 |
0% |
|
|
|
Internal fixation of fractures |
10 |
0 |
2 |
20% |
|
|
|
Laparotomy for digestive system |
28 |
34 |
14 |
22.5% |
|
|
It is clear that the infection wound rate is failry high in caesarian section, even though this can be related to the high numebr of them performed in emergency and because of obstrcuted labour with ruptured membrane for more than 24 hours. In fact the infection wound rate appears very low or even zero for clean and elective operations as hernia’s repair and thyrodectomy.
Intravenous drugs use and epidemiology
In April 99 it was noted an increase in consumption from the store issues of scalp vein sets for children. Therefore an analysis on intravenous drugs used in Children ward was carried out and related to the epidemiology and compared with the previous year.
The following table shows the consumption of different i.v. drugs in two different periods:
|
|
JUN98-AUG98 |
MONTLHY CONSUPTION |
MAR99-APR99 |
MONTHLY CONSUPTION |
APR99 ONLY |
X-PEN
|
450 vials |
150/m |
500 vials |
250/m |
350 vials |
|
Ampicillin |
90 vials |
30/m |
150 vials |
75/m |
100 vials |
|
CAF |
150 vials |
50/m |
100 vials |
50/m |
100 vials |
|
Gentamicin |
25 vials |
8/m |
50 vials |
25/m |
30 vials |
|
Quinine |
410 vials |
136/m |
100 vials |
50/m |
50 vials |
|
Scalp
Vein Needle |
1900 |
633/m |
1600 |
800/m |
1300 |
It appears that the consumption of scalp vein needles has double in April 99 compared to the average of the previous year, mainly because of a double consumtion of all the antibiotics. To understand the reason of this increase in consumption of injectable antibiotics an analysis of the epidemiology of the diseases in which such drugs are required, was carried out in the two different periods, as shown by the following table:
|
|
Jun98 |
Jul98 |
Aug98 |
Mar99 |
Apr99 |
Malaria
|
126 |
274 |
233 |
42 |
120 |
|
A.R.I. |
42 |
59 |
41 |
65 |
87 |
|
Measles |
|
|
|
5 |
20 |
|
Cholera |
54 |
23 |
5 |
1 |
|
|
Total
Children |
312 |
492 |
418 |
213 |
340 |
|
%
of the 4 above diseases/Total |
71% |
72% |
66% |
53% |
66% |
|
CAF/Total
children |
|
0.12 |
|
|
0.29 |
|
X-pen/Total
children |
|
0.36/child |
|
0.7/child |
1.02/child |
|
Quinine/Total
children |
|
0.33/child |
|
0.23/child |
0.14/child |
|
Scalp
Vein needle/total children |
|
1.5/child |
|
1.4/child |
3.8/child |
From the data it appears that there is not a remarkable increase in morbidity and in the number of children treated for such conditions but for ARI. It appears that the prescription of antibiotics has tripled, but not really justified by an increased morbidity.
This data and conclusions were presented to the Medical and Clinical officers and discussed.
Point of action
for next FY:
· Establish more and effective routine quality assurance data collection
· To study solutions for a more efficient utilisation of TB and children wards
· Introduce culture sensitivity to study antibiotic resistance.