Senarathna, D. L. P. "How the level of resources and hospital staff attitude in primary care hospitals in rural Sri Lanka affect poisoning patient outcome."Centre for Clinical Epidemiology and Biostatistics. Newcastle, Australia: University of Newcastle (2006): 1-89.
Background: Deliberately self poisoning with poisonous substances like agrochemicals has become an epidemic in rural parts of developing countries. This situation is common for rural Sri Lankan districts where pesticide poisoning has become one of the first main causes of hospital deaths. A high percentage of patients present initially to peripheral hospitals and are being treated or transferred to secondary care. The lack of facilities, staff and antidotes in peripheral hospitals, lack of training for the management of poisoned patients for hospital staff, difficulties in transferring patients to and between hospitals and the high toxicity of locally available poisons may be the reasons for high mortality. Also the knowledge and attitude of the staff may also affect treatments provided and hence outcome. A baseline evaluation of the available resources and treatment protocols in Peripheral hospitals is required to see how the variations between hospitals affect the patient outcome at the peripheral hospital level. It would help to create a guideline on providing resources to peripheral hospitals.
Methodology: A cross-sectional study with qualitative components included was peformed. All the peripheral hospitals in North Central Province of Sri Lanka and all poisoned patients admitted to those hospitals during six month period were audited. Data was collected on hospitals resources; number of staff, equipment, medication, and resuscitation facilities and treatments protocols from each hospital. Ingested poison details, initial examinations, treatments and outcome details (transferred, died or discharges alive) were retrospectively collected from patient records. In-depth interviews were conducted using unstructured open ended questionnaire guide with individual doctors (15 interviews).
Results: There were 1025 patients admitted to 40 hospitals during six months period. There was a significant difference between poison ingested by males and females. However gender did not affect the transfer rate. 691 were transferred for secondary hospital care, 330 were discharged from peripheral hospitals and only 4 patients died there. 47 patients died after transfer. Except Atropine (100%), other antidotes were not available in few hospitals, the next most common being activated charcoal (45%) and Fullers earth (50%). There were medical officers in 82.5% of hospitals while others run by registered medical officers alone. 70% and 95% hospitals had nurses and attendants respectively. Doctor workload and nurse/attendant workload showed an association with transfer rate. Initials examinations recorded in peripheral hospitals usually limited to BP (65%), Pulse rate (55%) and pupils (51% for organophosphates). Respiratory rate and lung examinations were done only for 8.5% and 9.5%. Gastric Decontamination, Intravenous fluids and atropine (for OP) were common treatments. Other antidote administration was minimal. There was a difference between what doctors stated they wanted to do according to interview results and the real clinical findings. The attitude of the hospital staff is mainly based on the confidence of treatments, interaction with staff and patient relatives and inability to practice free in low resource settings. Conclusion: The availability of antidotes, other medications and equipments were not adequate in peripheral hospitals. Considering treatment protocols, there was a mismatch between recommendations from guidelines and doctors’ practice. The resource parameters act as markers for the level of hospitals care and examination findings and treatments act as causes of transfer decisions. Both markers and causes show direct and indirect effects on patients outcome; mainly transfer rates. Introduction of a minimum antidote list and emergency treatments kits would be useful to increase the level of resources. Education interventions and assessment of the use of current guidelines can results better treatment protocols. Themes revealed from qualitative finding should be used when planing educational and other awareness programs.