Professional Documents
Culture Documents
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23/3/10
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25/3/10
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Page 1
International
Hospital
ICT DEVELOPMENTS
Federation
068
IInternational
In
nte
oXXXXXX
nnaal
al H
Ho
Hospital
ospiittal
os
ta Federation
ta
atioonn | Fdration Internationale
nnttteeern
rrnnnaaattitiiooonnnaaale
alle des Hpitauxx | FFederacin Internacional de Hospitales
XXXXXXXXXXXXXXXX
Hospital
H
o
and Healthcare Innovation Book
2009/2010
www.ihf-fih.org
Pro-Brook Publishing
The International
Hospital
Federation
Reference
Book
2008/2009
International
Hospital
Federation
Reference
Book
2008/2009067
1
25/3/10
16:12
Page 2
Introduction
See-Through Peel
Pouches & Rolls
Wrapping Sheets:
Paper & Nonwoven
Chemical Indicator
Products and Tapes
NE
Helix
Challenge Test
Daily Control
B & D Type Test Pack
Seal
Control Sheet
Operational qualication
of a sealing process
required by ISO standard.
www.wipak.com
www.steriking.info
e-Mail: steriking@wipak.com
26/3/10
14:00
Page 3
Contents
Contents
07
09
Foreword
54
Burn management
M Davey, B Ayeni, Y Ying and MJ Duncan
68
76
81
88
90
109
112
118
Introduction
Eric de Roodenbeke
14
17
25
28
34
41
46
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Page 4
Contents
Healthcare transformation
We'll take
you there.
Your radiology department and your path to digital is unique. Yet, your goal to provide the highest level of
care is shared worldwide. We know. Found in 1 of every 2 hospitals, Agfa HealthCare works alongside
radiologists every day. Our systematic steps to integrated digital radiology allow you to advance at your own
pace, without jeopardizing current systems or investments. This allows you to choose the solutions you want:
advanced imaging systems, integrated RIS/PACS/Reporting, sophisticated data management, or integrated
digital workflows for radiology, mammography, cardiology and the healthcare enterprise. So as you consider
your chosen path, let our proven experience support your next step, and every step after that.
Learn more about our proven solutions. Visit www.agfa.com/healthcare.
Agfa and the Agfa rhombus are trademarks of Agfa-Gevaert N.V. or its affiliates. All rights reserved.
26/3/10
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Page 5
Contents
IHF reference
120
132
136
137
139
IHF Members
144
127
Editorial Staff
Subscription Office
Executive Editor:
Eric de Roodenbeke, PhD
Desk Editor:
Sheila Anazonwu, BA(Hons), MSc
Editorial Board
ISBN 0 900590 40 8
Dr Ren Peters
Dutch Hospital Association
Norberto Larroca
Camara Argentina de Empresas de Salud
Dr Harry McConnell
Griffith University School of Medicine (Australia)
Dr Persephone Doupi
STAKES
Editorial Office
Immeuble JB SAY,
13 Chemin du Levant,
01210 Ferney Voltaire, France
Email: info@ihf-fih.org
Internet: www.ihf-fih.org
Copyright
Text International Hospital Federation or
otherwise stated 2009
Project1:Layout 1
26/3/10
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Page 1
Internation
nal Hospital Federa
F
tion
Hospital and Healthccare Association
n Leadership Summit
u
1-2 June 2010
Palmer Ho
H use Hotel, Chicaggo (USA)
The 2nd IHF Hospital and Health
t care Association Leadership Summit, will take place June 1st to
2 , 2010, in the Palmer House hotel in Chicago (USA).
Thiss event is an opportunity to
o share experiences and kn
nowledge with colleagues from around
the world an
a d will help to strengthen ties
t between hospital leaderrs. It is both a unique occassion to meet
other leader
e s of hospital and healthcarre organizations as well as a platform for free exchange of ideas - a
priority for IHF (Constitution, article 1.3
3).
Thee event is open to IHF Full Members (maximum 2 people from each organization). Associate
members are als
l o welc
l ome, but sub
bjectt to availilability
it . IHF Co
C rporate
t Partners
t
are allso
o in
i vited
it d to
participate in the 2-day event
nd
Program
mme
Day One: Tuesday, 1 June
Hospi
s tal Safety and Disaster prepar
e edness
Role of first-line hospitals
Perrspective of globalization of car
c e
Role of healthcare facilities for education
25/3/10
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Page 7
Foreword
Foreword
JOSE CARLOS DE SOUZA ABRAHAO, MD
President, International Hospital Federation
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Page 67
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Page 9
Introduction
Introduction
ERIC DE ROODENBEKE, PhD
Chief Executive Officer, International Hospital Federation
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Page 10
Introduction
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11:00
Page 11
14
17
25
28
34
41
46
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Page 14
Creativity may be one of the most misunderstood topics in management. Creativity is usually associated with artists,
those rare people who seem to be endowed with a mystical ability to make aesthetic sense out of colour, texture, shape
and form. In the managers world, creativity is typically limited to picking out artworks for the walls of a new office or
selecting a designer to develop a new logo.
Why innovate?
One area where artists and healthcare managers can agree is that
the world is changing. Change is constant. Futurists tell us that
knowledge is increasing at exponential rates and that we must get
accustomed to the idea of change with increasing speed. In a
single generation, we have seen the development of personal
computers, faxes, email and the internet, with each creation
bringing us closer to real-time transactions and communication
options unimagined a few decades earlier. Change is the one
constant in every aspect of our work and relationships.
Change is often disruptive. It challenges routine ways of thinking
and working. It makes us uncomfortable and requires us to adopt
unfamiliar processes as we adapt to a new ways of thinking and
working. Health care delivery seems to be at the apex of disruptive
change. Laparoscopic surgical techniques are making some
open-incision methods obsolete. New pharmaceutical options are
reducing the length of hospital stays. A global recession is proving
to challenge personal values and adjust priorities for funding
agencies.
Change can also stimulate creativity. Artists sometimes look for
opportunities by studying contrasts and conflicts between light
and dark, young and old, clean and dirty. Healthcare managers
can also look for opportunities brought about by change. Eastern
bloc countries are finding opportunities to improve healthcare
14 Hospital and Healthcare Innovation Book 2009/2010
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Page 15
Examples
Innovators can be found in the executive suites and on the front
I think I can
If ingenuity doesnt come naturally, you are not alone; but the good
news is that creativity appears to be a learned behavior. Creativity
begins with a positive attitude, confidence and belief in your
Hospital and Healthcare Innovation Book 2009/2010 15
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Page 16
References
Everett M Rogers, Diffusion of Innovations, New York: The Free Press, 2003
Quint Studer, Hardwiring Excellence, Fire Starter Publishing, 2003
John Black with David Miller, The Toyota Way to Healthcare Excellence, Health Administration
Press, 2008
4.
Based on personal conversations with Mark Jacobson, MD, Administrator at Selian Lutheran
Hospital, Arusha, Tanzania in 2006
5.
Roger von Oech, A Whack on the Side of the Head, Creative Think, 1983
1.
2.
3.
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
This article looks at risk management in hospitals and the management of emergencies and disasters. It
considers the models and policies that exist in private companies and the core components of a risk
management strategy for hospitals. Building on this knowledge the author puts forward a new plan for
hospitals called the Comprehensive Risk and Emergency Management Programme (CREMP) and explains the
advantages of this approach.
Page 17
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
Page 18
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
Figure 2: Comprehensive risk and emergency management programme Source: HDCA 2008
Page 19
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
Page 20
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
Page 21
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
Page 22
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
16:28
Administrative support
Logistic support
The two Sub-Programmes require resources (from back-up
systems and equipment to sophisticated technology). The
rationalization of the acquisition, mobilization, monitoring of
resources must be a continuous effort, including necessary
training of staff.
Information management
The management of information in both Sub-Programmes is a
complex issue as it involves different systems. For integration of
these systems the following issues need to be discussed:
i. data: selection, processing, reporting;
ii. software and IT;
iii. ongoing surveillance activities and special surveillance
during health crisis (e.g. syndromic based, active reporting);
iv. links with the national observatory for hospital risks;
v. links with national policy making;
vi. links with quality assurance and accreditation.
Management of information also includes sharing of information
with the MoH (health system and its management). This includes
the mechanisms for sharing the information and development of
new structures53 at national level, to enable management of the
information gathered by hospitals. Development of a CREMP will
involve many stakeholders from different programmes (quality
assurance; blood safety, etc..) and therefore require integration of
all efforts and existing systems into a cohesive whole. This does
not mean that the various existing programmes are no longer
necessary. They need to be complementary and coordinated. The
development of a more comprehensive and more coordinated
policy on all these issues will contribute to the development of
CREMP by hospitals.
Monitoring process
Monitoring will consist of a complex set of activities in this new
concept of CREMP. The main elements that would need
addressing are:
assessment of implemented risk treatment options (in both
Sub-Programmes)
assessment of the Programme, involving
Hospital and Healthcare Innovation Book 2009/2010 23
Page 23
17-24 comprehensive risk and emergency management programme for hospitals- a new approach:2009 IHF ref 5
25/3/10
In WHO vision there are three main categories of vulnerabilities : structural ; non structural ;
and functional vulnerabilities
2.
Which goes much beyond the management of communicable diseases only
3.
E.g. in France, these laws and regulations are regularly updated and completed: Scurit
sanitaire dans les tablissements de sant: rglementation applicable version n 5 juillet
2005
4.
Conformity of the practices with the existing legal framework
5.
Many different names are used such as crisis management, emergency management,
disaster management.
6.
A comprehensive emergency management programme. A model for state & territorial courtsColorado 2007
7.
Decentralization of the response capacity is a common finding in these countries
8.
The University Hospital of Houston has a well defined CEMP
9.
Mass Casualty Management Systems: strategies and guidelines for building health sector
capacity. WHO; 2007
10.
Often these plans are called Disaster Plans . The national policy of the MOH on Hospital
Disaster Plan for Mass Casualty Management is to link pre-hospital and hospital activities
11.
Usually a comprehensive approach (from prevention to recovery) and all hazards
12.
Although these programmes are usually not comprehensive for they target only limited
risks such as regulated risks
13.
State University of New York Upstate Medical University; University Hospital, Syracuse. 2008
14.
Examples of regulated risks: blood safety; nosocomial infection prevention ; fire procedures
15.
identifying and preventing exposure of patients, visitors or employees to risks that could
either cause injury in hospitals, jeopardize safety and security or result in costly claims and
lawsuits.
16.
Developped by the MoH in its normative role
17.
Usually the focus in on requirements for accreditation only. An audit in Canada in 2004
shown that ERP fulfilling criteria for accreditation were not functional plans. These checklist
do not guarantee that the ERP will be effective.
18.
For example: Health Care Risk Management: Training Programme organized by Ontario
Hospital Association (September 2008)
19.
Medical Professional Liability. by the American Academy of Orthopedic Surgeons. 2006
20.
WHO / WPRO Toolkit on Hospital Emergency Response Plan , 2009
21.
Safer hospitals: WHO campaign 2008-2009
22.
Safer hospital: WHO campaign 2008-2009
23.
E.g. in some programmes risk (harmful consequences) is mixed up with the source of risk
(hazard)
24.
roles and responsibilities of the various management structures; organisation of work during
crisis; triage protocols, etc.
25.
The same situation than for managing EMS Systems (the introduction of modern IT is a very
important step forward)
26.
When the ERP is activated
27.
which is often not yet included into RMP in hospitals.
28.
In some HRMP the components are called functions of the Programme
29.
Overview. There are many books on that particular issues
30.
the hospitals risk management programme, policies are adopted by both the governing
board and hospital administration
31.
So called although this programme do not include the management of services during
disasters so that there is no link between this comprehensive programme and the ERP
and contingency plans
32.
Four categories of indicators are usually used: process; activities; structure; results
References continued
33.
The risk manager in a healthcare organization must maintain sufficient authority and respect
to enact the changes in clinical practice, policy, and procedures and in employee and
medical staff behaviors that are necessary to fulfill the essential functions of the risk
management programme. The American Academy of Orthopedic Surgeons, 2004.
34.
The American Academy of Orthopedic Surgeons, 2004.
35.
Developed by HDCA-Geneva (Health Development Counseling and Audit)
36.
Some frequent methods: Qualitative and Quantitative Failure Modes and Effects Analysis
FMEA. Failure Modes, Effects, and Criticality Analysis FMECA provides information to
quantify, prioritize and rank failure modes. Qualitative and Quantitative Fault Tree Analysis
(FTA). Probabilistic Risk Assessment (PRA). Delphi Technique
37.
Of the systems ; procedures ; human behavior ; skills and abilities of medical staff ; etc.
38.
In many countries these risks and the medical activities are precisely defined by the MOH
through a bulk of laws and regulations
39.
This is not limited to only costly equipment but also to equipment that is critical for ensuring
quality medical care and services (e.g. power backup system ; refrigeration towers, etc.)
40.
For instance that the equipment for intubation is available and adequate ; that the theater
room has a backup system for electrical power, etc.)
41.
Here again the identification of indicators is critical. Precursor events are important for they
should prompt an early treatment option (mitigation, response, etc.) while countermeasures
can control the risks generated by the events before they develop into a severe situation
42.
Many software are available that integrate all components (functions) of HRMP and that
allow for managing information in a systematic and holistic way
43.
Some hospitals have only one ERP and contingency procedures instead of separate
contingency plans
44.
Mass Casualty Management Systems: strategies and guidelines for building health sector
capacity. WHO; 2007
45.
Proposed by HDCA - Geneva
46.
E.g. the use of the concept of Incident Management System
47.
Under the concept of critical services during disasters more and more MOH also include
the services needed by people suffering from chronic non-communicable diseases requiring
regular treatment (haemodialysis, severe cardiac conditions, etc.).
48.
Critical infrastructure emergency risk management and assurance, 2003.
49.
Strategy and Recommendations in Developing EMS Systems; ADPC, 2005
50.
For instance in more and more countries Hospital are regrouped in network
51.
Disasters or critical adverse events can be seen as primarily a failure to adequately
manage information (WPRO).
52.
Hospital Safety Index, PAHO, 2007 (computerized system). Free download possible.
16:28
Page 24
25/3/10
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Page 25
Problem: A multinational company with operations in several African countries was committed to offer antiretroviral treatment
to its employees and their dependants. Approach The Accelerating Access Initiative (AAI), an initiative of six pharmaceutical
companies and five United Nations agencies, offered the possibility of obtaining brand antiretroviral drugs (ARVs) at 10% of
the commercial price. PharmAccess, a foundation aimed at removing barriers to AIDS treatment in Africa, helped to establish
an HIV policy and treatment guidelines, and a workplace programme was rolled out from September 2001.
Local setting: Private sector employers in Africa are keen to take more responsibility in HIV prevention and AIDS care. An
important hurdle for African employers remains the price and availability of ARVs.
Relevant changes: The programme encountered various hurdles, among them the need for multiple contracts with multiple
companies, complex importation procedures, taxes levied on ARVs, lack of support from pharmaceutical companies in
importation and transportation, slow delivery of the drugs, lack of institutional memory in pharmaceutical companies and
government policies excluding the company from access to ARVs under the AAI.
Lessons learned: The launch of the AAI enabled this multinational company to offer access to ARVs to its employees and
dependants. The private sector should have access to these discounted drugs under the AAI. A network of local AAI offices
should be created to assist in logistics of drugs ordering, purchase and clearance. No taxes should be levied on ARVs.
Approach
In May 2000 five United Nations organizations United Nations
Population Fund (UNFPA), United Nations Childrens Fund
(UNICEF), WHO, The World Bank and the Joint United Nations
Programme on HIV/AIDS (UNAIDS) announced a partnership
25/3/10
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Page 26
p g
company,
Table 1: Test results
and20012008
treatment uptake in six sub-Saharan African countries in the workplace programme of a multinational company,
20012008
Countries with
operating companies
with operational HIV
workplace programme
Burundi
Congo
Democratic Republic
of the Congo
Nigeria
Rwanda
Sierra Leone
Total
Adult target
population as of
1 January 2008
Number of HIV
tests done in
adults a
Number of
HIV infections
diagnosed
Male/female
ratio of HIV
diagnoses
Cumulative number
of patients who
started ARV therapy
as of 25 July 2008
Male/female
ratio of
patients on
ARV therapy
1059
1214
3040
1283
980
3828
77
68
64
1.40
1.61
1.06
57
38
28
1.38
1.85
1.42
3889
1000
130
10 332
5605
949
64
12 709
154
115
4
482
1.33
1.74
only male
1.45
77
73
0
273
1.19
1.25
0
1.34
ARV, antiretroviral
a Some people might have been tested more than once. Due to turnover of the workforce, it cannot be calculated which proportion of the current workforce has been tested
Challenges
After some time it became possible in some countries to purchase
ARVs (both generic and brand) locally. If the drugs were
prequalified by WHO, the OPCOs obtained ARVs locally through
government agencies. The Ministry of Health in one country felt
that drugs purchased with a grant from the Global Fund to fight
AIDS, Tuberculosis and Malaria should not be re-sold, so it
stopped the provision of drugs to the OPCO. The same
government declined to provide free ARVs to the OPCO, arguing
that a for-profit private company should not have access to free
26 Hospital and Healthcare Innovation Book 2009/2010
Lessons learned
The AAI was set up as a public sector, country-led process.7 This
implied that the private sector in most African countries could not
benefit from the AAI. We argue that allowing the African private
sector employers, private clinics and private health insurance
companies to obtain ARVs through AAI will contribute to more
sustainable access for all patients in sub-Saharan Africa.8
Private sector employers in Africa are keen to take more
responsibility in HIV prevention and AIDS care.9 An important
hurdle for African employers remains the price of ARVs; allowing
them access to ARVs under the AAI would make a big difference.
The overstretched African public health care sector would
indirectly benefit from this, allowing increased access for the poor.
The second sector that would benefit from AAI support is the
private health care sector. Private clinics in Africa provide care to a
substantial and increasing part of the population.10 National
governments should allow these clinics to use ARVs obtained
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Page 27
Recommendations
The AAI has led to substantial price reductions of brand drugs and
increased access to ARVs. Administrative, logistical and regulatory
hurdles have meant that the full potential of the AAI has not been
fulfilled. The following four recommendations are made to
strengthen the AAI and increase access to affordable good quality
drugs in sub-Saharan Africa. (i) AAI eligibility should be extended
beyond the public sector. Local private clinics, health insurers and
health maintenance organizations should get access to AAI ARVs,
under specific conditions. (ii) Governments should waive taxes on
ARVs, simplify and harmonize the drug registration process and
certify private clinicians. (iii) Private companies and non-profit
organizations that wish to provide ART to their employees and
dependants should be encouraged to do so and should benefit
from AAI. (iv) The pharmaceutical companies within AAI should
support the creation of a network of local AAI distributors of ARVs.
International donor funds should invest in this network. J
Acknowledgements
JMA Lange & TF Rinke de Wit are also affiliated with the Center
for Poverty-related Communicable Diseases (CPCD),
Academic Medical Center (AMC), University of Amsterdam,
Meibergdreef 9, 1100 DE Amsterdam, the Netherlands. The
pharmaceutical companies in the AAI were, initially, BoehringerIngelheim, Bristol Myers Squibb, GlaxoSmithKine, Merck&Co
and F Hoffman-LaRoche. Abbott Laboratories joined in 2001
Hospital and Healthcare Innovation Book 2009/2010 27
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Page 28
The emergence of a novel strain of influenza virus A (H1N1) in April 2009 focused attention on influenza surveillance
capabilities worldwide. In consultations before the 2009 outbreak of influenza subtype H1N1, the World Health Organization
had concluded that the world was unprepared to respond to an influenza pandemic, due in part to inadequate global
surveillance and response capacity. We describe a sentinel surveillance system that could enhance the quality of influenza
epidemiologic and laboratory data and strengthen a countrys capacity for seasonal, novel, and pandemic influenza detection
and prevention. Such a system would 1) provide data for a better understanding of the epidemiology and extent of seasonal
influenza, 2) provide a platform for the study of other acute febrile respiratory illnesses, 3) provide virus isolates for the
development of vaccines, 4) inform local pandemic planning and vaccine policy, 5) monitor influenza epidemics and
pandemics, and 6) provide infrastructure for an early warning system for outbreaks of new virus subtypes.
the need for systems that can reliably produce these estimates.
Furthermore, global strategies to address other vaccinepreventable diseases have acknowledged the importance of
establishing local disease burden (effects, severity, amount of
illness, and costs) as a first step toward decisions about the
introduction of vaccines into new countries. We describe a generic
guideline for collecting data on severe acute respiratory infection
(SARI), influenza-like illness (ILI), and laboratory-confirmed
influenza that can be implemented in limited-resource settings.
Current situation
Global Influenza surveillance
For 60 years, the WHO Global Influenza Surveillance Network
(GISN) has provided virologic information used in the biannual
process of selecting strains for the Northern and Southern
Hemisphere influenza vaccine formulations. However, its capacity
to provide epidemiologic data or an alert of an emerging pandemic
is limited. GISN currently comprises 122 National Influenza
Centers in 87 countries and 4 WHO Collaborating Centres for
Reference and Research on Influenza10. Although this system has
proven to be valuable, tropical and resource-limited countries
(particularly in Africa) are underrepresented11.
Influenza in developing countries
Virus transmission or clinical presentation may be altered by
i
A prior version of this protocol was presented in poster form at the Options for the
Control of Influenza Conference in Toronto, Ontario, Canada, 17 June, 2007.
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Objectives
The
most
efficient
process
for
producing
high-quality
CASE
DEFINITION CRITERIA
Influenza-like illness
EITHER
IMCI criteria for pneumonia
Any child 2 mo to 5 y of age with cough or difficult breathing and:
breathing faster than 60 breaths/min (infants <2 mo)
breathing faster than 50 breaths/min (212 mo)
breathing faster than 40 breaths/min (15 y)
OR
IMCI criteria for severe pneumonia
Any child 2 mo to 5 y of age with cough or difficult breathing and any of the following general danger signs:
unable to drink or breastfeed
vomits everything
convulsions
lethargic or unconscious
chest indrawing or stridor in a calm child
AND
Requires hospital admission
*Surveillance guidelines use the existing World Health Organization (WHO) case definition for Influenza-like Illness (19), and incorporate WHO guidance
to define severe acute respiratory infection in adults and children (9,18,19). IMCI, Integrated Management of Childhood Illness.
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1. Timeliness
a. Several time intervals are appropriate for routine
measurement as quality indicators. These include the
duration of time from
i. Target date for data reporting from the sentinel site to the
next administrative level until the actual reporting date
ii. Target date for data reporting from the next
administrative level to the national level until the actual
reporting date
iii. Date of specimen collection at facility until shipment to
laboratory
iv. Date of result availability in laboratory until date of report
to referring institution and physician
v. Date of receipt of specimen in the laboratory until result
availability
b. Metrics. Two metrics can be used to reflect timeliness
indicators:
i. Percentage of time that a site achieves target for
timeliness
ii. Average number of days for each interval over time for
each site
2. Completeness
a. Percentage of reports received from each site with complete
data
b. Percentage of data reports that are received
c. Percentage of reported cases that have specimens
collected
3. Audit. Regular field evaluations and audits at facility level of a
subset of medical records to ensure
a. Cases are being counted appropriately and not being
underreported
b. Reported cases fit the case definition
c. Epidemiologic data are correctly and accurately abstracted
d. Respiratory samples are being taken, stored, processed,
tested, and shipped properly and in a timely fashion from all
those who meet sampling criteria
e. Sampling procedures are being done uniformly without
evidence of bias
4. Data to be followed and observed for aberrations over time
a. Number of cases reported by month for each site
b. Number of specimens submitted by month for each site
c. Percentage of specimens that are positive for influenza
d. Number and percent of ILI and SARI cases tested
*ILI, influenza-like illness; SARI, severe acute respiratory illness.
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Conclusions
Surveillance for SARIs can provide critical understanding of the
contribution of influenza infection to the global burden of disease,
provide a platform for the study of other common respiratory
pathogens, and strengthen public health infrastructure. Such a
system should be a part of a routine surveillance program to
provide data needed for allocation of scarce healthcare
resources. J
Acknowledgements
We thank the following people for their help with this project:
Lynnette Brammer, Clovis Heitor Tigre, Thais Dos Santos, Melania
Flores, Erika Garcia, Diane Gross, Monica Guardo, Ann Moen, Josh
Mott, Camelia Savulescu, David Shay, Tim Uyeki, John C. Victor,
and the manuscript peer reviewers. Dr Ortiz is a research fellow at
the University of Washington and PATH (Program for Appropriate
Technology and Health). His research interest is the clinical
epidemiology of respiratory infections found in tropical regions.
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Since its widespread introduction, the hepatitis B vaccine has become an essential part of infant immunization programmes
globally. The vaccine has been particularly important for countries where the incidence of hepatitis B virus-related
hepatocellular carcinoma is high. Effective treatment options for individuals with chronic hepatitis B infection were limited
until 1998 when lamivudine, the first nucleoside analogue drug, was introduced. As a single treatment agent, however,
lamivudine has a significant drawback: it induces lamivudine-resistant hepatitis B virus strains that may pose a risk to the
global hepatitis B immunization programme. Mutations associated with drug treatment can cause changes to the surface
antigen protein, the precise part of the virus that the hepatitis B vaccine mimics. However, the emergence of antiviral drug
associated potential vaccine escape mutants (ADAP-VEMs) in treated patients does not necessarily pose a significant,
imminent threat to the global hepatitis B immunization programme. Nonetheless, there is already evidence that current
treatment regimens have resulted in the selection of stable ADAP-VEMs. Treatment is currently intended to prevent the longterm complications of hepatitis B virus infection, with little consideration given to potential adverse public health impacts.
To address individual and public health concerns, trials are urgently needed to find the optimal combination of existing
drugs that are effective but do not induce the emergence of ADAP-VEMs. This paper examines the mechanism of antiviral
drug-selected changes in the portion of the viral genome that also affects the surface antigen, and explores their potential
impact on current hepatitis B immunization programmes.
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Discussion
In this article we raise the possibility of a threat to the global
hepatitis B immunization programme because of the use of
lamivudine and other nucleoside or nucleotide analogue
therapeutic agents to treat individuals with chronic hepatitis B
infection. Although the threat is theoretical, there is already
evidence that current treatment regimens have resulted in the
selection of stable ADAP-VEMs. Even though the transmission of
ADAPVEMs to individuals immunized with HBV vaccine has been
observed in only one case,36 VEMs generated by hepatitis B
vaccine have spread more widely and caused infection in
previously immunized individuals.
Knowing this, what should our response be now? At the very
least, we must learn more about ADAP-VEMs, their transmissibility
and their potential to cause infection and disease in immunized
individuals. This will require virological surveillance and clinical
follow-up of infected individuals and those undergoing treatment,
and also, possibly, surveillance of their close contacts. The initial
focus of these activities should be highrisk settings until the level
of risk is defined and understood better. Incident cases of HBV in
these situations could also be examined for VEMs, especially if a
new case is epidemiologically linked to an individual undergoing
treatment for chronic hepatitis B infection. Follow-up of such
cases of HBV, however, would depend on the availability of testing,
and currently no suitable commercial tests are available.
At present, treatment aims to prevent the long-term
complications of HBV infection, with little consideration given to
potential adverse public health impacts. The number of potent
antiviral agents is limited, their development by manufacturers is
episodic and trials that have evaluated combination therapies are
lacking. Because of these factors, monotherapy remains the usual
practice in most settings. As with other infections, more potent
combination therapies for HBV would reduce the chance of
drugresistance and lead to early and longer-lasting control of HBV
replication. Such therapies would not only benefit the individual
but would also simultaneously reduce the likelihood that ADAPVEMs of global public health significance will emerge. Trials are
urgently needed to identify the optimal combination of existing
drugs that can address both individual and public health needs.
International therapeutic guidelines for chronic hepatitis B such as
those issued by the Asian-Pacific Association for the Study of the
Liver,48 the European Association for the Study of the Liver
International Consensus Conference49 and the American
Association for the Study of Liver Disease50 should ideally consider
both of these elements, and will need to be refined as more is
learned about ADAP-VEMs. More effective novel agents are clearly
needed that target other parts of the virus.
It is still essential to prevent the spread of wild, vaccine-sensitive
strains of HBV. Well-tested measures such as safe sex and
avoiding the risks associated with injection drug use will also help
Hospital and Healthcare Innovation Book 2009/2010 37
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replication phenotype of lamivudine resistant hepatitis B virus mutants by compensatory
changes in the fingers sub-domain of the viral polymerase selected as a consequence of
mutations in the overlapping S gene. Virology 2002;299:88-99. PMID:12167344
PMID:12167344 doi:10.1006/viro.2002.1448
34.
Torresi J, Earnest-Silveira L, Deliyannis G, Edgtton K, Zhuang H, Locarnini SA, et al. Reduced
antigenicity of the hepatitis B virus HBsAg protein arising as a consequence of sequence
changes in the overlapping polymerase gene that are selected by lamivudine therapy.
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M0736_2008_TAKEYOU_new.pdf
09-03-2010
15:42:38
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Recent events clearly illustrate a continued vulnerability of large populations to infectious diseases, which is related
to our changing human-constructed and natural environments. A single person with multidrug-resistant tuberculosis
in 2007 provided a wake-up call to the United States and global public health infrastructure, as the health
professionals and the public realized that todays ease of airline travel can potentially expose hundreds of persons to
an untreatable disease associated with an infectious agent. Ease of travel, population increase, population
displacement, pollution, agricultural activity, changing socioeconomic structures, and international conflicts
worldwide have each contributed to infectious disease events. Today, however, nothing is larger in scale, has more
potential for long-term effects, and is more uncertain than the effects of climate change on infectious disease
outbreaks, epidemics, and pandemics. We discuss advances in our ability to predict these events and, in particular,
the critical role that satellite imaging could play in mounting an effective response.
Waterborne disease
Water and climate go hand in hand, with precipitation and extreme
events known to be associated with waterborne outbreaks4.
Flooding is the most frequent natural weather disaster (30%46%
of natural disasters in 20042005), affecting >70 million persons
worldwide each year (data for 20055).
The most common illnesses associated with floods described in
the literature are diarrhea, cholera, typhoid, hepatitis (jaundice),
and leptospirosis. Unusual illnesses such as tetanus have also
been reported. The etiologic agents identified include
Cryptosporidium spp., hepatitis A virus, hepatitis E virus,
Hospital and Healthcare Innovation Book 2009/2010 41
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Vectorborne disease
Other emerging and reemerging infectious diseases also are
environmentally driven. Many are zoonotic, vector- 1342 Emerging
borne, or both, and have complex life histories that make
predicting disease emergence or reemergence particularly difficult.
An insect or rodent vector can make it almost inevitable that a
pathogen will be globally transported by plane or boat. With
environmental change, disease range, prevalence, and seasonality
may change in direct relationship to the vector or animal host.
Therefore, to understand the life cycle of a pathogen and the risks
of disease emergence, all stages of that life cycle and the life
cycles of its intermediate hosts must be considered.
To date, predicting vectorborne diseases has proved to be
complex. Although climate change and other environmental
stressors are major components, separation from human factors
is difficult. Climate change undoubtedly affects the distribution of
disease, but changes in human behaviour that increase exposure
risk are also critical factors. umilo et al.11 reported that climatic
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References continued
10.1073/ pnas.0237386100
umilo D, Bormane A, Asokliene L, Lucenko I, Vasilenko V, Randolph S. Tick-borne
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season in sub-Saharan Africa. Lancet. 1984;1:133942. DOI: 10.1016/S01406736(84)91830-0
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10.1017/S0950268898008905
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Broutin H, Philippon S, Constantin de Magny G, Courel M-F, Sultan B, Gugan JF.
Comparative study of meningitis dynamics across nine African countries: a global
perspective. Int J Health Geographics. 2007;6:29 [cited 2009 Mar 20]. Available from
http://www. ij-healthgeographics.com/content/6/1/29
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Xiao X, Boles S, Frolking SE, Li C, Babu JY, Salas W, et al. Mapping paddy rice agriculture in
south and Southeast Asia using multi-temporal MODros Inf Serv. images. Remote Sens
Environ. 2006;100:95113. DOI: 10.1016/j.rse.2005.10.004
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Kilpatrick AM. Chmura AA, Gibbons DW, Fleischer RC, Marra PP, Daszak P. Predicting the
global spread of H5N1 avian influenza. Proc Natl Assoc Sci. 2006;103:1936873. DOI:
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Sims D. UNH Research uses satellite observation to track avian flu. Durham (NH): University
of New Hampshire Media Relations; November 20, 2006 [cited 2008 Apr 19]. Available from
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Brennan RJ, Rimba K. Rapid health assessment in Aceh Jaya District, Indonesia, following
the December 26 tsunami. Emerg Med Australas. 2005;17:34150. DOI: 10.1111/j.17426723.2005.00755.
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Jamieson C. Preventing the second wave. Operation Sumatra Assist, Australian Government,
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Vibrio cholerae. Microbiol Mol Biol Rev. 1998;62:130114.
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Chakraborty S, Mukhopadhyay AK, Bhadra RK, Ghosh AN, Mitra R, Shimada T, et al. Virulence
genes in environmental strains of Vibrio cholerae. Appl Environ Microbiol. 2000;66:40228.
DOI: 10.1128/AEM.66.9.4022-4028.2000
31.
Hamner S, Broadaway SC, Mishra VB, Tripathi A, Mishra RK, Pulcini E, et al. Isolation of
potentially pathogenic Escherichia coli O157:H7 from the Ganges River. Appl Environ
Microbiol. 2007;73:236972. DOI: 10.1128/AEM.00141-07
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Martinez RJ, Wang Y, Raimondo MA, Coombs JM, Barkay T, Sobecky PA. Horizontal gene
transfer of PIB-type ATPases among bacteria isolated from radionuclide- and metalcontaminated subsurface soils. Appl Environ Microbiol. 2006;72:31118. DOI: 10.1128/
AEM.72.5.3111-3118.2006
11.
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Free or low-cost sources of unstructured information, such as Internet news and online discussion sites, provide detailed local
and near real-time data on disease outbreaks, even in countries that lack traditional public health surveillance. To improve
public health surveillance and, ultimately, interventions, we examined three primary systems that process event-based
outbreak information: Global Public Health Intelligence Network, HealthMap, and EpiSPIDER. Despite similarities among
them, these systems are highly complementary because they monitor different data types, rely on varying levels of
automation and human analysis, and distribute distinct information. Future development should focus on linking these
systems more closely to public health practitioners in the field and establishing collaborative networks for alert verification
and dissemination. Such development would further establish event-based monitoring as an invaluable public health
resource that provides critical context and an alternative to traditional indicator-based outbreak reporting.
26/3/10
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Epidemic curve
SMS messaging
Microblogging
Emailing
Internet searching
Social networking
Internet chatting
Time
Blogging
Online news reporting
Video/radio news reporting
Health expert reporting
Figure 1: Hypothetical timing of informal electronic sources available during an outbreak. SMS, short message service
26/3/10
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Data Acquisition
Automated process
The GPHIN software application retrieves relevant articles every 15
minutes (24 hours/day, 7 days/week) from news-feed aggregators
(Al Bawaba [www.albawaba.com] and Factiva [www. factiva.com])
according to established search queries that are updated regularly.
The matching articles are automatically categorized into >1 GPHIN
taxonomy categories, which cover the following topics: animal,
human, or plant diseases; biologics; natural disasters; chemical
incidents; radiologic incidents; and unsafe products. Articles with
a high relevancy score are automatically published on the GPHIN
database. The GPHIN database is also augmented with articles
obtained manually from openaccess web sites. Each day, GPHIN
handles 4,000 articles. This number drastically increases when
events with serious public health implications, such as the fi nding
of melamine in various foods worldwide, are reported.
Human analysis process
Although the GPHIN computerized processes are essential for the
management of information about health threats worldwide, the
linguistic, interpretive, and analytical expertise of the GPHIN
analysts makes the system successful. Articles with relevancy
below the publish threshold are presented to a GPHIN analyst,
who reviews the article and decides whether to publish it, issue an
alert, or dismiss it. Additionally, the GPHIN analyst team conducts
more in-depth tasks, including linking events in different regions,
identifying trends, and assessing the health risks to populations
around the world.
Data Dissemination
Machine translation
English articles are machine-translated into Arabic, Chinese
(simplifi ed and traditional), Farsi, French, Russian, Portuguese,
and Spanish. Non-English articles are machine-translated into
English. GPHIN has adopted a best-of-breed approach in
selecting engines for machine translation. The lexicons associated
with the engines are constantly being improved to enhance the
quality of the output. As such, the machine-translated outputs are
Table 1: Characteristics of three primary systems that process event-based informal data sources*
DATA SOURCES
(LANGUAGES)
DATA
CHARACTERIZATION
INFORMATION FORMATTING
ACCESS
GPHIN
Factiva, Al Bawaba
(9 languages)
Automatic and
human
Categorization, machine
translation, geocoded
Subscription
only
Boolean and
metadata query
system (native)
Email alert
HealthMap
Google News,
Automatic
Moreover, ProMED,
WHO, EuroSurveillance
(4 languages)
Categorization,geocoded,
time coded, extra
information
Open
Mapping, faceted
browsing (native)
RSS feed
EpiSPIDER
Categorization,
geocoded, time coded,
extra information
Open
Web exhibits,
faceted browsing
(imported)
RSS, JSON
KML feeds
SYSTEM
DATA DISSEMINATION
USER INTERFACE
*GPHIN, Global Public Health Intelligence Network; WHO, World Health Organization; RSS, Really Simple Syndication; EpiSPIDER, Semantic
Processing and Integration of Distributed Electronic Resources for Epidemics (and disasters); GDACS, Global Disaster Alert Coordinating System; CIA,
Central Intelligence Agency; JSON, JavaScript object notation; KML, keyhole markup language.
FORMAT
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Background
The EpiSPIDER project was designed in January 2006 to serve as
a visualization supplement to the ProMED-mail reports. Through
use of publicly available software, EpiSPIDER was able to display
topic intensity of ProMED-mail reports on a map. Additonally,
EpiSPIDER automatically converted the topic and location
information of the reports into RSS feeds. Usage tracking showed,
initially, that the RSS feeds were more popular than the maps.
Transforming reports to a semantic online format (W3C Semantic
Web) makes it possible to combine emerging infectious disease
content with similarly transformed information from other Internet
sites such as the Global Disaster Alert Coordinating System
(GDACS) website (www.gdacs.org). The broad effects of disasters
often increase illness and death from communicable diseases,
particularly where resources for healthcare infrastructure have
been lacking28,29. By merging these 2 online media sources
(ProMED-mail and GDACS), EpiSPIDER demonstrates how
distributed, event-based, unstructured media sources can be
integrated to complement situational awareness for disease
surveillance.
Data acquisition and dissemination
EpiSPIDER connects to news sites and uses natural language
Hospital and Healthcare Innovation Book 2009/2010 49
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Discussion
Despite their similarities, the 3 described event-based public
health surveillance systems are highly complementary; they
monitor different data types, rely on varying levels of automation
and human analysis, and distribute distinct information. GPHIN,
being the longest in use, is probably the most mature in terms of
information extraction. In contrast, HealthMap and EpiSPIDER,
being comparatively recent programs, focus on providing extra
structure and automation to the information extracted. Their
differences and similarities, summarized in the Table, can be
analyzed according to multiple characteristics: What data sources
do they consider? How do they extract information from those
sources? And in what format is the information redistributed and
how?
For completeness, the broadest range of sources is critical.
GPHINs data comes from Factiva and Al Bawaba, which are
subscription-only news aggregators. Their strategy is to rely on
companies that sell the service of collecting event information from
every pertinent news stream.
In contrast, HealthMaps strategy is to rely on open-access
news aggregators (e.g., GoogleNews and Moreover) and curated
sources (e.g., ProMED and EuroSurveillance). EpiSPIDER, until
recently, has concentrated on curated sources only (e.g., ProMED,
GDACS, and CIA Factbook). This distinction between free and
paid sources raises the question of whether the systems have
access to the same event information.
After the data sources have been chosen, the next step is to
extract useful information among the incoming reports. First, at the
level of the report stream, the system must fi lter out reports that
are not disease related and categorize the remaining (diseaserelated) reports into predefi ned sets. Then, at a second level of
triage, the information within each retrieved alert (e.g., an events
location or reported disease) is assessed. GPHIN does this data
characterization through automatic processing and human
analysis, whereas HealthMap and EpiSPIDER rely mainly on
automated techniques (although a person performs a daily scan of
all HealthMap alerts and a sample of EpiSpider alerts).
After a report in the data stream is determined to be relevant, it
is processed for dissemination. GPHIN automatically translates
the reports into different languages and grants its clients access to
the database through a custom search engine. GPHIN also
decides which reports should be raised to the status of alerts and
sent to its clients by email. HealthMap provides a geographic and
temporal panorama of ongoing epidemics through an openaccess user interface. It automatically filters out the reports that do
not correspond to breaking alerts. The remaining alerts are
prepared for display (time codes and geocodes as well as disease
category and data source) to allow faceted browsing and are
linked to other information sources (e.g., the Wikipedia definition of
the disease). These data are also provided as daily email digests
to users interested in specific diseases and locations. Although
GPHIN and HealthMap provide their own user interface,
EpiSPIDER explores conventional formats for reports, adding
26/3/10
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M0736_2008_TAKEYOU_new.pdf
09-03-2010
15:42:38
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54
Burn management
M Davey, B Ayeni, Y Ying and MJ Duncan
68
76
81
88
90
109
112
118
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Burn management
ARTICLE BY M DAVEY AND B AYENI (PICTURED)
McMaster University, Hamilton, Ontario, Canada
Y YING AND MJ DUNCAN
Department of Plastic Surgery, Childrens Hospital of Eastern Ontario, Ottawa, Ontario, Canada
Pepita, 6 years old, was thrown into a fire by another child two years earlier and sustained an 8% burn of her
lower back. The burn was initially thought to be superficial, but, months later, the wound is still open and has
never been grafted. Pepita cannot stand upright because she has flexion contractures of both hips and one
knee. Instead, she has to crawl. Her groin was not burned, and the burn on her knee was only a minor one.
Her contractures are the result of failing to ensure that she used her unburnt and minimally burnt limbs
during the acute stage of her injury. She has now been abandoned by her family1.
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Prevention
At a population health level, the true magnitude of the problem is
not well defined with few standardized comprehensive statistical
collection systems in many low-income countries. Some authors
suggest that the global estimated death rate is a gross
underestimation14. It is widely accepted that the social and
economic costs of burn injuries to low-income populations are
great and efforts to develop, evaluate, and implement prevention
strategies specific to the local cultural and economic settings are
urgently needed. Successful examples have been shown to work
in developed countries such as Norway, where with a communitybased prevention program, the rate of burn-related hospital
admissions was reduced by 52%.5
With over 2 billion people worldwide preparing meals using
rudimentary traditional stoves or open fires5, much interest has
been directed toward developing safer domestic appliances and
energy sources.14 An example of such a strategy is the inexpensive
redesigned flat kerosene lamp, designed by burn surgeon Dr.
Wijaya Godakumbura of Sri Lankas Safe Bottle Lamp Project.16
Although outcome studies have not formally been performed, with
over 600 000 lamps distributed and accompanying community
based education addressing basic fire-safety, this project is
anticipated to have a major impact on the incidence of lamprelated accidents.
Recognizing the complexity of the issue and its regional
challenges, the WHO, in collaboration with international partner
agencies, developed in 2008 an evidence-based global strategy
for burn prevention and care.5
Pathophysiology of burns
There are several processes involved in the local tissue responses
after a burn. An increase in vascular permeability leads to the loss
of water, electrolytes, proteins and heat.11 The complement and
coagulation cascades are activated and this results in thrombosis
and the release of histamine and bradykinin. These mediators
cause an increase in capillary leak and interstitial edema in distant
organs and soft tissue. In addition, the activation of the
inflammatory cascade can lead to immune dysfunction. All of
these responses increase the patients susceptibility to sepsis and
multiple organ failure.17 These systemic responses are significant
once a burn exceeds 20 percent of the patients body surface.
Hypovolemia, immunosuppression, bacterial translocation from
Initial management
Primary survey
The rapid implementation of the ABCs of trauma management
(airway, breathing, circulation) also applies to burns. The initial
physical examination of the burn victim should focus on assessing
the airway and the patients hemodynamic status, as well as
estimating the size and depth of the burn. Airway edema can
result in airway obstruction and death. One hundred percent
oxygen should be administered from the outset. If there are any
concerns about the adequacy of the airway, prompt endotracheal
intubation is mandated.18 In addition, signs of inhalational injuries
should be quickly recognized.
If there are concerns of cervical spine injuries, nasotracheal
intubation can be performed because it has the advantages of
decreased cervical spine manipulation and the tube can be easily
secured by suturing it to the nasal septum. The disadvantage of
nasotracheal tubes is that they tend to be of smaller caliber, which
are not as good for suctioning, and may increase the risk of
sinusitis. In difficult cases, fiber-optic bronchoscopy (if available)
can prove to be an invaluable tool in securing the airway. Vocal
cords, directly injured from smoke, may be resistant to usual
topical anesthesia and care must be exercised to avoid
laryngospasm. Consideration should be given to securing the
tube to the teeth with wires (or heavy sutures), rather than risking
further damage to burned facial skin with tie-tapes.
Once the airway has been addressed, the next step is to place
two large-bore (at least 14 gauge) peripheral intravenous catheters
through non-burned viable tissue. If necessary, these catheters
can be placed through burned skin because the eschar is still
sterile in the acute phase and more importantly, death can result
from delays in fluid resuscitation. A Foley catheter should be
placed to monitor urine output because this is the most
straightforward and reliable indicator of intravascular volume
status in the majority of these patients. Associated life-threatening
injuries such as cardiac tamponade, pneumothorax, hemothorax,
and flail chest must be identified and treated quickly18 Tetanus
toxoid should also be administered routinely to all burn patients,
depending on immune status.
Assessment of injury
Quantifying the extent (Figures 1 & 2) of the burn is crucial in
determining subsequent management. Burns are dynamic injuries,
and damage to the skin can continue for 24 to 48 hours after the
initial injury due to edema, coagulation of small vessels, pressure,
desiccation, and infection. Thus daily evaluation is of paramount
importance in reassessing burn depth and success of excision17.
Superficial burns (1st degree) are generally red, painful, and
involve the most superficial aspect of the skin; as such, they are
not included in the calculation of total body surface area (TBSA).
These blanch to the touch19 and have an intact epidermal barrier. Examples include sunburn or a minor scald from a kitchen
accident. These burns will heal spontaneously, will not require
operative treatment, and will not result in scarring. Treatment is
aimed at comfort with the use of soothing topical salves with or
without aloe and oral non-steroidal anti-inflammatory agents.
Surgery is not required for these patients.20
Hospital and Healthcare Innovation Book 2009/2010 55
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Partial-thickness (2nd
degree) burns involve
the
dermis
and
the epidermis. Partialthickness
injuries
classified into two types:
superficial and deep. All
second-degree injuries
involve some amount of
dermal damage, and
the division is based on
the depth of injury into
this structure.
Figure 1: Burn Depth Burns are usually
Superficial
dermal
classified into superficial, superficial
burns are erythematous,
partial thickness, deep partial thickness
painful, may blanch to
and full thickness. Here we have given
then letters A, B, C, D and E 1
touch, and often blister.
Examples
include
scald injuries from overheated
bathtub water and flash flame
burns from open carburetors.
These wounds will spontaneously
re-epithelialize from retained
epidermal structures in the rete
ridges, hair follicles, and sweat
glands in 714 days. The injury
will cause some slight skin
discoloration.
Figure 2: Adult compared to
Deep dermal burns into the
child burn surface areas
reticular dermis will appear more
pale and mottled, will not blanch to touch, but will remain painful to
pinprick. These burns will usually heal in 1428 days by reepithelialization from hair follicles and sweat gland keratinocytes,
often with severe scarring. Some of these will require surgical
treatment20.
A full-thickness (3rd degree) burn generally is identified by a dry
and leathery appearance, although a plastic-like texture and a
hemorrhagic or purpuric pattern may also be seen. Classically, fullthickness burn wounds have been described as insensate,
although there is often mixed distribution patterns which make
sensation determination less reliable as a defining characteristic.19
Deep dermal and full-thickness burns require excision and
grafting with autograft skin to heal the wounds in a timely fashion19,
thus minimizing morbidity from protein loss, sepsis, and
contracture. Since all the elements of the epidermis have been
obliterated in full-thickness wounds, healing can occur only
through wound contraction and/or spreading epithelialization from
the wound edges. In a sizable wound, this process will take weeks
to months to years to complete.21
Fourth-degree burns involve other organs beneath the skin,
such as fat, muscle, bone, and the brain.
In adults, the rule of nines can be used to quickly estimate the
size of a burn. The anterior and posterior trunk is each l8%, each
of the lower extremities is 18%, each upper extremity is 9%, and
the head is 9%. This is depicted clearly in Figure 2. Unfortunately,
the rule of nines is somewhat inaccurate in children and may
overestimate burn size because the head accounts for a greater
portion of the body surface area (BSA). In a 2-year-old child, this is
19% of the TBSA Diagrams such as the Lund and Browder charts
56 Hospital and Healthcare Innovation Book 2009/2010
(Figure 3) are more accurate and should be used for calculating the
burn size in children.18 In small burns, the surface of the patients
hand can be used to estimate the extent of the burn; it represents
approximately 1% of the TBSA (from fingertips to wrist).
Patient selection
Patient selection is the key to improving the outcomes of burn
injury within the resource constraints of a given environment. The
mortality of a given size of burn injury increases in infants and the
elderly. It is difficult to cite what size of burn constitutes a lethal
injury as mortality varies so much around the world, but local
experience will suggest what magnitude of injury is likely to be
survivable given the treatments available. For patients with clearly
lethal burn/inhalation injury it is humane to withhold fluid
resuscitation and airway intervention and provide palliation with
dressings and generous amounts of intravenous morphine.
Depending on circumstances it may be prudent to ask a
colleague to examine the patient and note their concurrence with
the lethality of the prognosis. Patients with severe, but not clearly
lethal burn injuries pose a difficult problem: they can consume an
inordinate amount of scarce hospital resources (ICU days, total
length of stay, dressing supplies, nursing and operating room
time), and still die or have dreadful outcomes. Consultation and
possible referral to a burn centre is helpful. Treatment with pain
control, dressings, prevention of infection, nutritional support,
good splinting and early mobilization of affected joints, and careful
selection of patients for surgical intervention is a sound
policy. Small but potentially disabling burns, especially in children,
should be the main focus of surgical attention. It is in this group
of patients that early surgery, meticulous graft care, splinting,
pressure garments and aggressive physiotherapy will produce the
most gratifying (and cost effective) outcomes.
Fluid resuscitation
The most commonly used formula for adults, for fluid resuscitation
after a burn, is the Parkland formula. To calculate daily fluid
requirements, a crystalloid solution at the rate of 4 mL/kg/%TBSA
burn is given intravenously. The first half of the calculated amount
of fluid is administered within the first 8 hours after the burn, and
the remaining is given over the next 16 hours. In the first 24 hours
post-burn, the initial resuscitation fluid is Lactated Ringers, which
is isotonic to plasma.
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paralyzed or sedated.
The absence of a pulse
is similarly too late
of a finding. Delayed
escharotomies can lead
to
muscle
necrosis
and limb loss. Sufficient
release can usually be
noted as soon as the
dermis
is
released,
as the wound opens
and
subcutaneous
tissue
bulges
out.
Escharotomies may need
to be done on any limb.
(Figure 4) Escharotomy
may be done with a
scalpel or diathermy
blade. While it is true that Figure 4: Escharotomy lines
full thickness burns are
usually insensate, it is not true that escharotomy can routinely be
performed without some kind of pain control. Ketamine or
fentanyl and versed are safe and effective. The incision should go
through skin but not into fascia or muscle. The mid-medial and
mid-lateral lines of each limb are incised. A small T where the
incision meets normal skin will ease constriction at the end of the
incision.
Thoracic escharotomies are also occasionally required for
improving chest-wall compliance and facilitate ventilation. This
may require multiple incisions across the chest, both longitudinally
and transversely to allow full chest expansion. Figure 4 shows
possible thoracic escharotomy lines, but more lines may be
required for very deep constricting burns.
In electrical injury, the final extent of tissue injury can be difficult
to predict. Frequent assessments and surgical debridements are
required often in the face of progressive myonecrosis. With any
high voltage electrical injury, the index of suspicion for a deep
injury should be high. The skin wound is not a reliable indicator of
the underlying damage. These injuries will require a fasciotomy,
with release of all muscle compartments to minimize muscle
damage. Patients should also be monitored for myoglobinuria
which will require treatment with increasing urine output,
alkalinization of the urine, and sometimes with very cautious use of
diuretics. Untreated myoglobinuria can lead to deposition in the
glomerular tubules and renal failure.
Inhalation injury
Inhalation injuries are associated with severe burns and poor
outcomes. A retrospective review in Cape Town, South Africa
found that inhalation injury was present in 63% of severe burn
patients (>30% TBSA), which resulted in a mortality rate of 76%.21
However, it is believed that inhalation injuries are more frequently
seen in high income countries due to the high prevalence of house
burns, where victims are confined to enclosed spaces. Alcohol
and smoking account for over half the deaths in developing
countries, so prolonged exposure to smoke may occur as a result
of intoxication. The prevalence of inhalational injury in low to
middle income countries is unknown, but suspected to be lower.
The reason for differences in prevalence is unclear, whether due to
Hospital and Healthcare Innovation Book 2009/2010 57
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Antimicrobial Salves
Silver sulfadiazine (Flamazine, Silvadene)
Mafenide acetate (Sulfamylon)
Bacitracin
Neomycin
Polymyxin B
Nystatin (Mycostatin)
Mupirocin (Bactroban)
Antimicrobial Soaks
0.5% Silver nitrate
5% Mafenide acetate
0.025% Sodium hypochlorite (Dakin solution)
0.25% Acetic acid
Synthetic Coverings
OpSite
Biobrane
Transcyte
Integra
Biologic Coverings
Xenograft (pig skin)
Allograft (homograft, cadaver skin)
Broad-spectrum antimicrobial; painless and easy to use; does not penetrate eschar; deeply may leave black tattoos
from silver ion; mild inhibition of epithelialization
Broad-spectrum antimicrobial; penetrates eschar well; may cause pain in sensate skin; wide application causes metabolic
acidosis, therefore only suitable for small areas; mild inhibition of epithelialization.
Ease of application; painless; antimicrobial spectrum not as wide as above agents
Ease of application; painless; antimicrobial spectrum not as wide
Ease of application; painless; antimicrobial spectrum not as wide
Effective in inhibiting most fungal growth; cannot be used in combination with mafenide acetate
More effective staphylococcal coverage; does not inhibit epithelialization; expensive
Effective against all microorganisms; stains contacted areas; leaches sodium from wounds; may cause methemoglobinemia
Wide antibacterial coverage; no fungal coverage; painful on application to sensate wound; wide application associated with
metabolic acidosis, and therefore generally used for small high-risk areas such as cartilage coverage in nose and ears.
Effective against almost all microbes, particularly gram-positive organisms; mildly inhibits epithelialization
Effective against most organisms, particularly gram-negative ones; mildly inhibits epithelialization
Provides a moisture barrier; inexpensive; decreased wound pain; use complicated by accumulation of transudate and exudate
requiring removal; no antimicrobial properties
Provides a wound barrier; associated with decreased pain; use complicated by accumulation of exudate risking invasive
wound infection; no antimicrobial properties
Provides a wound barrier; decreased pain; accelerated wound healing; use complicated by accumulation of exudate;
no antimicrobial properties
Provides complete wound closure and leaves a dermal equivalent; sporadic take rates; no antimicrobial properties.
Allows for coverage with a very thin skin graft with no dermis. Very expensive product
Completely closes the wound; provides some immunologic benefits; must be removed or allowed to slough
Provides all the normal functions of skin; can leave a dermal equivalent; epithelium must be removed or allowed to slough
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Wound care
Wound care is a fundamental pillar in the care of the burn patient,
and an area of evolution partially responsible for improved survival
seen since the 1960s. As a result of loss of dermal integrity, the
burn wound loses its protective barrier against invasion by microorganisms and against evaporative losses. Therefore, until
complete re-epitheliazation occurs, the burn dressing serves a
number of functions: protection against micro-organism invasion,
minimizing metabolic losses, limiting the pain of exposed burn
surfaces, containing messy wound secretions, and hiding the burn
to help prevent adverse psychological responses.30 Most of the
practices used in modern burn units are based on anecdotal or
uncontrolled clinical observations. However, with the introduction
of topical antimicrobial prophylaxis, occlusive dressing, and
improved sterility as well as a goal of early wound closure, the
incidence of burn wound infections have steadily declinedV.
Burn wound care requires an experienced eye and knowledge
of the dressing options available. Surgeons often lack the time to
examine wounds as often as they should so developing expertise
in the nursing staff is important. If dressings are changed each day
by a nurse experienced in burns many problems will be averted
and if staff understand well the importance of both splinting and
early mobilization to prevent contracture functional results will
improve. The routine inspection of wounds by a knowledgeable
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Medical management
Severe burn wounds are known to induce systemic inflammatory
response syndrome (SIRS) through the release of a series of proinflammatory endotoxins, exotoxins from infectious sources or
from the wound itself. Although the exact mechanism is not well
understood, it is clear that there is a systemic response which can
lead to progressive infection, immuno-suppression, sepsis and
eventually multi-organ failure. Supportive measures are needed
early in the care of the severely burned patient to minimize the
progression and attenuate the hypermetabolic response to burn
injury.
Nutritional support
Early nutritional support is essential in burn patients, even more so
in low-middle income countries where many patients present
malnourished. Burn patients demonstrate levels of metabolism
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Surgical management
After hemodynamic stabilization, a burned patients priority of
treatment shifts to burn-wound-management46. Preoperatively,
several factors can pose a challenge to surgical patient care. In
the developing world, many of the burns present late, already
infected, or the poor general health of the patients makes them
unfit for anesthesia. In addition, blood loss can be significant in
burn wound excision, especially since inflamed and infected
wounds tend to bleed more during tangential excision. Thus, burn
surgery can be dangerous in high risk patients where blood
transfusion facilities are not readily available.
The options for the surgical management of burns includes early
tangential excision and grafting for deep dermal burns and
delayed escharectomy skin grafting for full thickness skin loss47.
Tangential excision describes the sequential and layered excisions
of devitalized tissues to a vital bed, generally recognized by
punctuate bleeding. An inadequately excised wound is more likely
to become infected and is unsuitable for graft take, necessitating
further surgery.19 The use of tumescence (discussed below) is
good for decreasing blood loss from the burn site; however it
makes judgment of adequacy of excision and of hemostasis more
difficult. It can decrease blood loss to a minimal amount. Adequate
debridement must instead be determined by tissue quality, and
not by punctuate bleeding.
The exact timing for wound excision is debatable. It is often
suggested that burn wounds should be excised and grafted if they
are not expected to heal within 21 days of injury. This is especially
true for key functional and esthetic locations such as the hands
and face.19 The decision to perform extensive excisions in a single
setting versus staged procedures is dependent upon the
hemodynamic stability of the patient, the availability of resources,
and the coordination of all parties involved in the care of the
patient.19 Conservative treatment of burn wounds, with silver
sulfadiazine, followed by serial excision of the burn wound is
currently the standard of care in many burn centres throughout the
world. Burns are excised in areas of as much as 20% TBSA in one
operative setting, and performing the entire excision of the burn
wound in 10 days post-injury is the goal. All full-thickness burns
can be excised first, so that deep dermal and indeterminate depth
wounds are addressed later, preventing excision of potentially
viable tissue. Early excision and grafting is the treatment of choice
to potentially reduce scar contractures and hypopigmentation47.
The disadvantages to serial excision are that the patient needs to
return many times to the operative room, so that episodes of
bacterial translocation, bacteremia, and cardiovascular instability
are repeated. Other disadvantages include exaggerated blood
losses, prolongation of the hypermetabolic response, and
increased risk of infection and sepsis from remaining eschar in
which bacteria proliferate.
Near-total wound excision has been advocated as an alternative
to serial debridement in massive burns. In near-total excision, all
full-thickness and partial-thickness burns are excised within 24
hours of admission, and the excised wounds are covered with
autografts and skin substitutes are used if the burn exceeds the
donor-site supply. Areas of the face are normally not excised in the
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a scalpel and the burned dead skin is sliced away with a grafting
knife. Tangential excision is continued to the point where the
dermis looks healthy, clean and pearly white, fat appears shiny and
yellow with no haem staining and small visible vessels have
patency and flow. If the fat does not look healthy consider excision
down to the fascia which is possessed of a better blood supply
than the fat. Bleeding vessels are coagulated and the wound is
wrapped in adrenaline saline soaked gauze while natural
haemostasis takes place. Attention is the turned to the donor site
and a template of gauze from the excised wound is used to
measure the area of skin to be harvested. Adrenaline saline is
injected beneath the donor site till the skin is taught and blanched
then it is harvested with the humby knife or power dermatome.
The donor wound is wrapped in adrenaline saline gauze while
attention returns to the burn site. When hemostasis is satisfactory
the grafts are applied and secured in place. Local anesthetic can
also be added for small wounds, with 20ml of 1% xylocaine added
to 1 L of solution. The addition of local anesthetic to the solution
can decrease pain, reducing anesthetic agents and narcotics
during surgery but the toxicity of xylocaine exceeds that of the
adrenaline. A number of recent papers have addressed the safety
of high dose adrenaline tumescence during burn excision and are
cited here to placate anesthetic concerns. Atropine and ketamine
are poor choices for tumescent burn excision as the patient will be
tachycardic and hypertensive even before adrenaline infiltration is
begun. Excision of burns from the extremities under tourniquet
control can minimize bleeding significantly
If possible, donor sites should be chosen that are inconspicuous
and will have a good color match for the wound bed. Donor sites
may develop hypertrophic scars and should not cross joints.
Potential donor sites include the upper thigh or the buttock, which
remain hidden with normal clothing and the back, which heals well
but is technically difficult to harvest with a hand held grafting knife.
Selection of the donor site should also consider the color match of
the wounded area, which is most significant on the head and
neck. A number of types of donor site dressings are available. The
first type is a fine-mesh cotton gauze that may or may not be
impregnated. Dressings of this type include Scarlet Red and
Xeroform, which have the advantage of low cost and familiarity.
These may need to be reinforced with more gauze initially that can
be removed in 24-48 hours, and the inner layer left intact. The
adherent gauze will start lifting in 1-2 weeks as the wound reepithelializes. The edges can be trimmed off as they
spontaneously lift. An occlusive dressing such as
OpSite/tegaderm can also be used, but may require a few holes
to drain seromas.47
Loss of dermis leads to significant scarring and wound
contracture. There are a number of dermis substitutes that can be
used such as Integra and AlloDerm. These products allow the use
of a very thin partial thickness skin graft on top of the dermis.
These products require a very clean wound bed, and meticulous
cleanliness post-operatively to prevent infection. These two
options are very expensive, though, and are not mainstays of the
armamentarium of burn surgeons in the developing world.
Grafts must be held in place by sutures or staples. Some form
of dressing is required to hold grafts in place. In more mobile
locations, a bolster dressing may be placed on top of the graft. An
inner layer that can maintain moisture (petroleum jelly or mineral oil
product) should be placed before gauze. Grafts over joints will
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Rehabilitation
The goals of the rehabilitation process are to maximize function
and appearance of the scars. This is done by trying to counteract
two main physiologic processes, scar hypertrophy and
contracture.
Hypertrophic Scarring
Hypertrophic scarring generally does not develop in burns that
require less than 2 weeks to heal. Hypertrophic scarring develops
in 33% of wounds that take less than 3 weeks to heal, but 78% of
wounds that take more than 3 weeks. It also affects skin grafts.
Hypertrophic scars are thickened, red, and raised scars which can
often be very itchy. Unlike keloids, hypertrophic scars do not
outgrow their boundaries. They will also generally remodel and
regress over time, but this may take a number of years, and
contractures may develop in the interim. Although children
generally heal quickly, they are at higher risk of hypertrophic
scarring if there is delayed healing. In addition, individuals with
darker skin pigmentation are also at greater risk of hypertrophic
scarring and keloids. Tangential excision and grafting of burns that
require greater than 3 weeks to heal can help prevent or reduce
hypertrophic scarring.
Scar compression is the mainstay of non-surgical hypertrophic
scarring prevention and management. This can be achieved with
customized compression garments, or with elastic tensor
bandages. The goal is to have pressures of approximately
25mmHg. If using tensor bandages, they must be wrapped from
distal to proximal, taking care not to cause ischemia or venous
stasis. Using tensors for compression over grafts should be
initiated after grafts are well healed, approximately 2-3 weeks after
grafting. This should continue until scar maturation, which can
take up to 1-2 years, and is gauged by when the scar is softened
and stabilized.
Scar massage can also help with breaking down of excess scar
tissue. This is often done in combination with stretching exercises
to prevent scar contractures. Scar massage should be done 2-3
times per day with a hypo-allergenic lotion or cream, or petroleum
jelly (Vaseline). Moisturizing and massaging the scars, which can
be dry due to the lack of glands in the scar tissue, may be sore at
first, but usually becomes soothing, and can help with the
itchiness of the scars. Massaging must press hard enough to
blanch the pink scars. Maturation and flattening of the scars can
take 1-2 years, particularly in children where the hypertrophic
phase may be longer. Most scars will eventually fade and lose
their pink colour over time, but the 1-2 year time frame may be
longer.
Silicone gel sheets can also be beneficial. The exact mechanism
is unknown, but they appear to help soften the scar. To reap the
benefits, they must be worn for long periods (over 20 hours a day)
to be beneficial. They can be placed under compression
garments, or simply taped on for areas not amenable to
compression. These can be washed daily and reused.
Contractures
Joint contractures are one of the most challenging aspects of burn
management, and are the main source of disability from thermal
burns. Scar contracture is due to activity of the myofibroblasts
which act to contract scars. When the scars are across joints,
particularly flexion joints, these can lead to permanent flexion
deformities. In addition, flexed positions are often positions of
comfort during the acute phase of burn management,
exacerbating the problem. To combat joint contractures,
stretching and splinting is necessary. Stretching and range of
motion exercises should be initiated from the beginning. With initial
edema, movement may be a bit difficult but should be encouraged
with daily exercises.
To combat joint contractures, stretching, careful positioning and
splinting are necessary. Necks should be hyperextended with a roll
under the shoulders. Axillae should be carefully positioned. Upper
thigh/lower abdominal burns require positioning to prevent flexion
of the hips. Stretching and range of motion exercises should be
initiated from the beginning. With initial edema, movement may be
a bit difficult, but should be encouraged with daily exercises.
Splinting
Contractures are the most debilitating residual stigma of burns,
and high-risk patients (deeper burns over flexion joint surfaces)
can easily be identified. Contractures are much easier to prevent
than to fix. Once developed, can be very difficult to manage and
correct. Elevation of the burned limb reduces edema and
facilitates early joint mobilization. Where surgical treatment is
limited by resource issues; hyperalimentation, good dressings,
splinting and aggressive stretching can still make a big difference
to patient outcomes. Equally, surgical results will improve
dramatically with good post-operative splinting and early
mobilization as soon as the grafts are solid.
Splinting should be considered when any loss of extension is
noted across elbows and knees. Hands should be splinted from
the onset.51Simple plaster slabs covered in elastic tube bandage
or stockinet make excellent volar hand splints, can be wrapped
on with tensor bandages and are re-usable till soiled. Splints are
often applied overnight, allowing for mobilization and function in
the daytime.
There are numerous splinting techniques suggested. Both static
and dynamic splints can be used. Dynamic splints may be better
for reversing any contractures, as they may gain extension, not
only maintain the gains during therapy. However, they are
significantly more costly to produce, and long-term gains have not
consistently been shown. Many local materials have been used to
produce inexpensive splints, including easily malleable aluminum
sheets.
Neck collar braces, or custom thermoplastic splints may be
used to prevent flexion contractures, and stretches should include
both extension and lateral flexion. The splint should be properly
padded to prevent pressure points. There are also alternative
splinting techniques for the neck52. Axilla contractures can be
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Surgical release
Surgical release of burn contractures can involve local flaps for
reorientation of the scar, but often also include a skin deficit which
must be filled with a graft or flap. Skin grafts are also more prone
to contractures, and aggressive post-operative therapy much be
implemented. Repeat surgeries may be necessary. Thick (full
thickness if the area is small enough) unmeshed grafts offer less
contracture. Alternatives include artificial dermal substitutes that
will allow decreased contracture with thinner split-thickness grafts.
However, dermal substitutes such as Integra, a bovine collagen
product, are commercial produced and extremely expensive. If
skin or myocutaneous flaps are possible, they offer the advantage
of coverage with minimal contracture and need for repeat surgery.
These include both local flaps such as z-plasties and transposition
flaps, but also pedicled or free vascularized flaps. The surgeons
will require an armamentarium of possible flaps and grafts to apply
to the situation. Figure 7 gives a possible algorithm for selective
various surgical options.55 Other general principles include the
release of more proximal contractures before distal ones in limbs
with multiple levels involved, such as elbow release followed by
wrist, then fingers. Certain anatomic areas are more prone to
contractures and have specific complications.
Neck contractures
Neck flexion is often associated with webbing of the neck. There
is often a severe shortage of skin, and a significant size skin graft
may be necessary for coverage of the defect after release. Unless
very minor, or featuring a narrow band of scar, these are usually
not amenable to z-plasties. Another challenge for severe neck
contractures is difficulty with intubation. The release of the neck
may need to be done under local anesthetic to allow for neck
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times be treated with a large 4-flap z-plasty, similar to for the first
webspace, or multiple z-plasties or V-Y plasties.58 Alternatively,
they can sometimes also be managed with release and skin grafts.
The use of skin grafts requires post-operative splinting, often in
airplane splints to prevent recurrence. An alternative may be a
Figure-of-8 splint which also helps to hold the graft in place.59
Recurrent or very tight contractures may be amenable to local
flaps if the burn is localized to the axilla with sparing of chest or
back tissue. These include latissimus dorsi, or pectoralis
major/minor myocutaneous flaps.60
Face
Eyelid contractures can be released with
skin grafts. Patients with eyelid burns must
be followed to watch for ectropion, which
can lead to corneal abrasions. These can be
release with preferably full thickness skin
graft placement. Thin full-thickness skin can be harvested from the
pre or post-auricular region if available. Microstomia and
commissure burns can be treated initially with splinting and
stretching exercises. Customized splints can be made, preferably
with the ability to slowly expand the mouth. With severe
microstomia, a commissureplasty using mucosa to recreate
vermillion may be necessary.54 Esselman et al. has a literature
review of rehabilitation evidence in burn management.61
Conclusions
Deep structures
Release of the scar may be insufficient for chronic contractures.
Contractures may be limited by deep structures, such as joint
capsules, tendons, or nerves. Some of these may be released or
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Recommendations
The following recommendations capture the key elements of a
simple, but effective approach to better burn management tailored
to developing countries:
Community leaders and burn surgeons must collaborate in
developing local prevention strategies as well as community
education strategies on immediate first aid steps for burn
victims and the critical importance of early transportation to the
nearest source of appropriate medical services.
Medical personnel must be trained in resuscitation; including
aggressive fluid resuscitation, monitoring for airway
compromise, and high flow oxygen, all of which to be initiated
within the first hours in the case of a major burn. The burns
must be assessed for depth, size, need for escharotomy and
risk of inhalation injury on presentation
Both physiotherapy, including early active and passive
movements and splinting for high risk joints and high protein,
high caloric frequent feeds should be in place as of the first
day.
Wound care must be performed daily, with careful attention for
signs of invasive infection. Appropriate analgesia, sterile
conditions and topical antibiotics (SSD) should be used.
Whenever possible, deep second degree burns and third
degree burns should be grafted within 10 days of the injury.
Techniques to minimize blood loss such as tumescence and
tourniquets should be standard practice.
Systemic antibiotics should be reserved for single-dose
immediate pre-operative prophylaxis and treatment of invasive
wound sepsis, tailored if possible to wound culture results and
institutional resistance patterns.
All practicing physicians and surgeons working in areas
without a regional burn center should receive training in skin
grafting.
Blood transfusion should be limited to when physiologic need
exists.
Life-long seizure prophylaxis and patient education regarding
the importance of compliance must be part of burn care
prevention in all epileptic patients. J
Acknowledgement
Reprinted with kind permission from Surgery in Africa Monthly
Review October 2008
Bimpe Ayeni, MD MPH is a fourth year Plastic Surgery resident at
McMaster University in Hamilton, Ontario. He holds a Bachelor of
Arts Degree from Yale University, a Masters in Public Health from
Columbia University, and a Doctorate in Medicine from the
University of Ottawa.
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1998. 24: p. 58-63.
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Whitelock-Jones, L., et al., Inhalation burns in children. Pediatric Surgery International,
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27.
Masanes, M., C. Legendre, and N.e.a. Lionet, Using bronchoscopy and biopsy to diagnose
early inhalation injury. Chest, 1995. 107: p. 1365.
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Mandel, J. and C. Hales. Smoke Inhalation. 2008 [cited; Available from: www.uptodate.com.
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35.
MacMillan, B., Burn Wound Sepsis a 10 year experience. Burns, 1975. 2(1).
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Gallagher, J., S. Wolf, and D. Herndon, Burns, in Sabiston Textbook of General Surgery, C.e.a.
Townsted, Editor. 2008.
37.
Molan, P., The role of honey in the management of wounds. J Wound Care, 1999. 8: p. 4158.
38.
Halkes, S., J. du Pont, and M.e.a. Hoekstra, The use of tannic acid in the local treatment of
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39.
Chokoto, L. and E. van Hasselt, The use of tannins in the local treatment of burn wounds. .
Malawi Medical Journal, 2005. 17(1): p. 19-20.
40.
Ghalambor, A., M. Pipelzadeh, and A. Khodadadi, The Amniotic Membrane: A Suitable
Biological Dressing to Prevent Infection in Thermal Burns. Medical Journal of Islamic
Academy of Science, 2000. 13(3): p. 115-8.
41.
Ramakrishnan, K. and V. Jayaraman, Management of partial thickness burn wounds by
amniotic membrane; a cost effective treatment in developing countries. Burns, 1997. 23
(Suppl 1): p. 533-6.
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42.
Gore, M. and D. Akolekar, Evaluation of banana leaf dressing for partial thickness burn
wounds. Burns, 2003. 29: p. 487-92.
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43.
Ozumba, U. and B. Jiburum, Bacteriology of burn wounds in Enugu. Nigeria Burns, 2000. 26:
p. 178-80.
44.
Ugburo, An evaluation of the role of systematic antibiotic prophylaxis in the control of burn
wound infection at the Lagos University Teaching hospital. Burns, 2004. 30: p. 43-8.
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45.
Herndon, D.N. and R. Tompkins, Support of the metabolic response to burn injury. The
Lancet, 2004. 363.
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Manktelow, A., Burn injury and management in Liberia. Burns, 1990. 16: p. 432-6.
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Corwin, H., A. Gettinger, and R. Pearl, The CRIT Study: Anemia and blood transfusion in the
critically ill. Current clinical practicie in the United States. Crit Care Med, 2004. 32: p. 3952. http://simplelink.library.utoronto.ca.myaccess.library.utoronto.ca/url.cfm/55211
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Palmieri, T., D. Caruso, and K.e.a. Foster, Effect of blood transfusion on outcome after major
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James, J.e.a., The prevalence of HIV infection among burn patients in a burns unit in Malawi
and its influence on outcome. Burns, 2003. 29: p. 55-60.
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Edge, J., et al., Clinical Outcome of HIV positive patients with moderate to severe burns.
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Countries. Tropical Doctor, 2000. 30(3): p. 149-51.
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34.
25/3/10
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Page 68
One of the objectives of the Healthy People 2010 initiative in the United States of America (USA) is achievement of a 20% reduction
in age-adjusted coronary heart disease (CHD) mortality rates. We examined the potential for changes in cardiovascular risk factors
to achieve that target using a previously validated, comprehensive CHD mortality model. This model integrates information on
trends in all the major cardiovascular risk factors, stratified by age and sex. The potential reductions in CHD mortality within the
projected population of the USA aged 25 to 84 years in 2010 (198 million) from base year 2000 were calculated for three
contrasting scenarios. In the first scenario, if age-adjusted CHD mortality rates observed in 2000 remained unchanged, some 388
470 CHD deaths would occur in 2010. Continuation of recent risk factor trends should result in approximately 19 000 fewer coronary
deaths (some 51 000 fewer deaths attributable to improvements in total cholesterol and mens blood pressure, decreased smoking
and increased physical activity, minus approximately 32 000 additional deaths attributable to adverse trends in obesity, diabetes
and womens blood pressure). In the second scenario, success in reaching all the Healthy People 2010 risk factor targets would
achieve approximately 188 000 fewer deaths. In the third, additional reductions in risk factors to the levels already seen in the lowrisk stratum could potentially prevent approximately 372 000 deaths. Achievement of the Healthy People 2010 targets could almost
halve predicted CHD deaths. Additional reductions in major risk factors could prevent or postpone substantially more CHD deaths.
rates (from 203 per 100 000 population in 1998 to 162 per 100
000 in 2010).3 They also include specific targets for reducing
cholesterol (to 199 mg/dl), smoking (to 12%), hypertension (to
16%), diabetes (to 6%), obesity (to 15%) and inactivity (to 20%).3
Inactivity was measured in the Behavioral Risk Factor Surveillance
System of the United States Centers for Disease Control and
Prevention as the proportion of adults engaging in no physical
activity.5 If those targets are achieved, what reduction in CHD
mortality might actually result?
Large meta-analyses and cohort studies have consistently
demonstrated substantial reductions in CHD deaths related to
decreases in each of the major cardiovascular risk factors among
individuals covered by the studies.68 However, it is difficult to
attribute a decline in the mortality rate for an entire population
either to specific risk factor changes or to more effective medical
interventions because favourable trends in both often have
occurred simultaneously.9,10 Furthermore, risk factor improvements
such as lower blood pressure or cholesterol may be achieved
through medications, lifestyle changes or a combination.1,2,810
25/3/10
19:51
Page 69
Risk factor
2544
7584
-0.036
-0.046
-0.035
-0.046
-0.032
-0.035
-0.027
-0.032
-0.021
-0.026
0.900
-1.2942
0.650
-0.8238
0.450
-0.5245
0.333
-0.3719
0.317
-0.3512
1.04
0.0363
1.03
0.0297
1.02
0.0165
1.01
0.0132
1.01
0.0099
Used as input for the IMPACT model for the United States of America
25/3/10
19:51
Page 70
Table3:3.Risk
Risk
factorlevels
levelsinin2000
2000base
baseyear
yearand
andprojections
projectionsto
to 2010
2010under
underthree
three scenarios
scenarios of
of cardiovascular
change,
Table
factor
cardiovascularrisk
riskfactor
factor
change,
United
UnitedStates
Statesof
of America
America
Scenario
Smoking prevalence
(%)
Total cholesterol
a
(mg/dl) (mmol/l)
Systolic blood
pressure (mmHg)
Diabetes
prevalence (%)
Prevalence of
physical
b
activity (%)
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
Men
Women
31.6
24.7
206 (5.32)
210 (5.42)
123.5
119.6
26.87
26.73
9.0
8.9
70.4
68.0
207 (5.35)
124.4
123.9
27.86
28.51
11.7
9.5
75.1
70.5
22.6
18.7
204 (5.28)
204 (5.28)
125.3
128.5
29.18
30.16
15.2
10.1
80.8
74.1
12.0
12.0
199 (5.15)
199 (5.15)
119.4
118.9c
25.00d
26.00d
6.0e
6.0e
80
80
176 (4.54)
179
(4.64)
115.7
114.7
25.50
23.60
0.0
0.0
100
100
d
e
Table 4: Observeda and projected coronary heart disease mortality rates and deaths in the United States of America in 2000 and 2010
Population
in 2010
(thousands)
Men
2534
years
3544
years
4554
years
5564
years
6574
years
7584
years
Total
men
Women
2534
years
3544
years
4554
years
5564
years
6574
years
7584
years
Total
women
Total
men &
women
a
CHD
mortality
rates per
100 000
observed
in 2000
Annual
change in
CHD
mortality
rates
19972002
(%)
CHD
mortality
rates per
100 000
expected in
2010 if
trends
continue
21 105
3.50
- 0.52%
3.32
20 552
25.78
- 0.52%
24.43
22 064
103.52
- 2.70%
17 438
290.20
9 797
Number of
CHD
deaths in
2010 if
recent
trends
continue
Number of
CHD deaths
in 2010 if
2000 rates
unchanged
Expected
decrease in
number of
CHD deaths
in 2010
compared
with 2000
Decrease in
CHD deaths
in 2010
compared
with 2000
(%)
739
- 39
-5.2%
5 022
5 298
- 277
-5.2%
75.59
16 679
22 841
- 6 163
-27.0%
- 4.14%
170.10
29 663
50 607
- 20 944
-41.4%
705.19
- 4.03%
420.76
41 222
69 088
- 27 866
-40.3%
5 272
1736.85
3.20%
1180.98
62 265
91 573
- 29 307
-32.0%
96 229
236.00
-1.97%
161.65
240 145
-84 595
-35.2%
20 541
1.17
+2.16%
1.42
292
240
+52
+21.6%
20 568
7.63
+2.16%
9.28
1 909
1 569
+339
+21.6%
22 763
29.93
- 1.56%
- 4.15%
25.25
5 749
6 813
- 1 065
- 8 591
-15.6%
-41.5%
18 747
110.39
64.57
12 104
20 696
11 473
340.32
- 3.69%
214.61
24 621
39 044
- 14 423
-36.9%
7 578
1055.16
- 3.14%
723.60
54 838
79 964
- 25 127
-31.4%
10 1670
146.90
-1.12%
97.88
99 515
148 325
-48 815
-32.9%
19 7900
190.00
-1.5%
142.15
25 5060
388 470
-133 410
-34.3%
700
155 550
25/3/10
19:51
Page 71
Results
Trends and estimates
Approximately 388 000 CHD deaths among people aged 2584
years would be expected in 2010 if the same age-specific death
rates recorded in 2000 (the base year) were also observed in
2010. This number would represent 15% more than the 338 000
deaths observed in 2000, reflecting population aging
compounded by an increase in population size (Table 4).
Between 1997 and 2002, the overall annual declines observed
in CHD mortality rates were 2% for men and 1% for women.
base-year
following
changes
in specificheart
risk factors
Table
5: Estimated
reduction
in coronary
disease mortality in the United States of America in 2010 compared with the 2000
base-year following changes in specific risk factors
Risk factor changes
Absolute values
MenBest
estimate
Men
27.3%
22.6%
12.0%
0%
205.0
204.2
199.0
175.6
124.4
125.3
119.4
115.7
27.86
29.18
25.00
25.50
11.7%
15.2%
6.0%
0%
75.1%
80.8%
80%
100%
n/a
Women
21.9%
18.7%
12.0%
0%
206.9
204.3
199.0
179.6
123.9
128.5
118.9
114.7
28.51
30.16
26.00
23.60
9.5%
10.1%
6.0%
0%
70.5%
74.1%
80%
100%
n/a
Best estimate
n/a
n/a
n/a
n/a
n/a
n/a
WomenBest
estimate
Minimum
Maximum
-10 000
-26 000
-60 000
-8 000
-21 000
-48 000
-12 000
-32 000
-72 000
- 7 000
- 18 000
- 42 000
-3 000
-8 000
-18000
-28 000
-40 000
-103 000
-17 000
-24 000
-70 000
-41 000
-59 000
-160 000
- 15 000
- 17 000
- 68 000
-14 000
-24 000
-35 000
(+2 000)
-48 000
-83 000
(+1 000)
-39 000
-75 000
(+4 000)
-58 000
-108 000
- 6 000
- 28 000
- 54 000
(+8 000)
-20 000
-29 000
(+8 000)
-17 000
-21 000
(+5 000)
-10 000
-12 000
(+11 000)
-24 000
-27 000
(+5 000)
- 12 000
- 10 000
(+3 000)
-5 000
-10 000
(+16 000)
-44 000
-72 000
(+5 000)
-26 000
-49 000
(+22 000)
-66 000
-100 000
(+11 000)
- 24 000
- 38 000
(+5 000)
-20 000
-34 000
-7 000
-12 000
-34 000
-51 000
-6 000
-10 000
-27 000
-29 000
-9 000
-14 000
-40 000
-57 000
- 4 000
- 6 000
- 18 000
- 32 000
-2 000
-6 000
-16 000
19 000
n/a
(+32 000)
(+10 000)
(+32 000)
(+16 000)
(+16 000)
n/a
n/a
n/a
n/a
-19 000
-188 000
-372 000
-246 000
-10 000
-129 000
-281 000
-194 000
-25 000
-252 000
-507 000
-339 000
- 16 000
-105 000
- 230 000
- 164 000
-3 000
-83 000
-142 000
-82 000
n/a
-126 000
-87 000
-167 000
- 66 000
-60 000
25/3/10
19:51
Page 72
Table
6: 6.
Reductions
in coronary
heart
disease
mortality
achievable
in in
thethe
United
States
of of
America
in 2010
compared
withwith
20002000
Table
Reductions
in coronary
heart
disease
mortality
achievable
United
States
America
in 2010
compared
Age groups(years)
2534
3544
4554
5564
6574
7584
Totals
Scenario
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum values
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum values
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum values
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum values
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum values
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum values
If recent trends continue
If HP2010 targets are achieved
If all achieved low-risk stratum
values
Total
(+355a)
300
2 000b
(+2 000)
4 000
12 000
(+2 000)
20 000
46 000
1 000
44 000
89 000
9 000
52 000
106 000
12 000
62 000
120 000
19 000
188 000
Men
Women
(+55)
(+305)
225
75
1 000
1 000
(+380)
(+1 000)
3 000
2 000
4 000
8 000
(+2 000)
(+115)
16 000
5 000
35 000
11 005
2 000
-1 000
27 000
16 000
31 000
57 000
10 000
(+1 000)
25 000
28 000
62 000
44 000
5 000
7 000
37 000
25 000
67 000
53 000
16 000
3 000
105 000
83 000
372 000
230 000
142 000
25/3/10
19:51
Page 73
lA
ct
iv
ab
Di
BM
ys
Ph
ete
ic a
in
ok
Sm
Sy
Ch
ol
s to
es
lic
te
ro
BP
ity
1525
355-300
-5000
-1525
75
-84
65
-74
55
-64
45
-54
35
-44
25
-34
2235
-1450
-4190
-12 175
-8775
-11 840
-20815
-45 000
-45 770
-43 615
-52 300
-61 790
-85 000
-88 500
-125 000
-106 295
-119 705
25/3/10
19:51
Page 74
25/3/10
19:51
Page 75
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Bots ML, Grobbee DE. Decline of coronary heart disease mortality in the Netherlands from
1978 to 1985: contribution of medical care and changes over time in presence of major
cardiovascular risk factors. J Cardiovasc Risk 1996;3:271-6. PMID:8863098
doi:10.1097/00043798-199606000-00002
21.
Vartiainen E, Puska P, Pekkanen J, Tuomilehto J, Jousilahti P. Changes in risk factors explain
changes in mortality from ischaemic heart disease in Finland. BMJ 1994;309:23-7.
PMID:8044063
22.
Critchley JA, Capewell S. Substantial potential for reductions in coronary heart disease
mortality in the UK through changes in risk factor levels. J Epidemiol Community Health
2003;57:243-7. PMID:12646537 doi:10.1136/jech.57.4.243
23.
Unal B, Critchley JA, Capewell S. Small changes in UK cardiovascular risk factors could
halve coronary heart disease mortality. J Clin Epidemiol 2005;58:733-40. PMID:15939226
doi:10.1016/j.jclinepi.2004.09.015
24.
Stamler J, Stamler R, Neaton JD, Wentworth D, Daviglus ML, Garside D, et al. Low riskfactor
profile and long-term cardiovascular and noncardiovascular mortality and life expectancy:
findings for 5 large cohorts of young adult and middle-aged men and women. JAMA
1999;282:2012-8. PMID:10591383 doi:10.1001/jama.282.21.2012
25.
Daviglus ML, Stamler J, Pirzada A, Yan LL, Garside DB, Liu K, et al. Favorable cardiovascular
risk profile in young women and long-term risk of cardiovascular and all-cause mortality.
JAMA 2004;292:1588-92. PMID:15467061 doi:10.1001/jama.292.13.1588
26.
Unal B, Critchley J, Capewell S. IMPACT, a validated comprehensive coronary heart disease
model: overview & technical appendices. Liverpool: Liverpool University; 2007. Available
from: http://www.liv.ac.uk/PublicHealth/sc/bua/impact.html [accessed on 5 October 2009].
27.
Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially
modifiable risk factors associated with myocardial infarction in 52 countries (the
INTERHEART study): case-control study. Lancet 2004;364:937-52. PMID:15364185
doi:10.1016/S0140-6736(04)17018-9 Publication: Bulletin of the World Health Organization;
Type: Policy and Practice Article DOI: 10.2471/BLT.08.057885
28.
Briggs A, Sculpher M, Buxton M. Uncertainty in the economic evaluation of health care
technologies: the role of sensitivity analysis. Health Econ 1994;3:95-104. PMID:8044216
doi:10.1002/hec.4730030206
29.
Naidoo B, Thorogood M, McPherson K, Gunning-Schepers LJ. Modelling the effects of
increased physical activity on coronary heart disease in England and Wales. J Epidemiol
76-80 The Breast Service Psychosocial Model of Care Project:2009 IHF ref 5
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Objective: It has been consistently demonstrated that many women with breast disease will experience psychosocial
distress at some stage along the patient journey. Psychosocial care has recently gained more prominence and is
increasingly recognised as an important aspect of care offered to patients with breast cancer. The purpose of this project
was to develop a model that improved the way psychosocial services were provided to patients. The aim of this paper is to
describe the process in developing this psychosocial model of care for patients with breast disease.
Methods: Using in-depth semi-structured interviews with a sample of patients and staff, we examined psychosocial
concerns experienced by breast patients and the factors associated with the effective assessment and delivery of
psychosocial care. The project was approved by the Royal Womens hospital ethics secretariat as a quality assurance
project.
Results: An inductive analysis of staff responses indicated that a standardised screening and referral pathway was needed
in a context of well defined staff roles and a multidisciplinary team environment. An inductive analysis of patient responses
indicated that psychosocial concerns were common, but varied, and a tailored approach to the provision of psychosocial
care was warranted.
Discussion: In line with these findings, a standardised assessment and referral pathway was developed for The Breast
Service that may be extended for use in other clinical settings and tumour streams.
Setting
Recently, the Royal Womens Hospital and Royal Melbourne
Hospital breast services merged to form The Breast Service in an
attempt to connect existing resources and provide a more
comprehensive breast cancer service. Strategies to detect and
respond to patients psychosocial needs were identified as a key
priority area for The Breast Service. Before the merging of
services, psychosocial care coordination differed between sites
76-80 The Breast Service Psychosocial Model of Care Project:2009 IHF ref 5
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Box 1: Issues with the psychological screening tool identified by staff and patients
Objectives
The aim of the psychosocial model of care project was to develop
a standardised way of screening for psychosocial distress and
referring patients to the most appropriate clinician(s) and supports.
The first objective of the project was to provide a reflection of the
strengths and weaknesses of the current model of psychosocial
care from relevant clinicians and to generate ideas on the most
effective way to merge and coordinate existing services. The
second objective was to provide a reflection from consumers
regarding their psychosocial needs, the level of psychosocial
support they received and their perceptions and opinions on the
structure and delivery of the current psychosocial model of care
76-80 The Breast Service Psychosocial Model of Care Project:2009 IHF ref 5
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Conclusion
In summary, the psychosocial model of care project has
transformed the way psychosocial care is provided to patients
attending The Breast Service. We have implemented a
standardised screening, assessment and referral process and a
multidisciplinary team to provide a service of psychosocial care to
all patients. Decisions about assessment, referrals and treatment
no longer rely solely on the breast care nurse. Instead,
collaborative recommendations are made for the patient in a forum
National Breast and Ovarian Cancer Centre and National Health and Medical
Research Council guidelines for the psychosocial care of patients with cancer
recommends assessing these risk factors to alert practitioners about certain subgroups of potentially at-risk patients.
76-80 The Breast Service Psychosocial Model of Care Project:2009 IHF ref 5
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Patient is not
considered high risk
and is not distressed
Patient is
considered high
risk and is
distressed and
requires action
(not immediate)
A referral is made
and the patient is
discussed at the
next Psychosocial
Multidisciplinary
meeting (PMDM)
Step 5 PMDM
Go to step 2
76-80 The Breast Service Psychosocial Model of Care Project:2009 IHF ref 5
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References
1.
Australian Institute of Health and Welfare and National Breast Cancer Centre. Breast cancer
in Australia: an overview, 2006. Canberra: AIHW, 2006. (AIHW Cat. No. CAN 29.)
Institute of Medicine. Meeting psychosocial needs of women with breast cancer [report
brief]. Washington, DC: National Academies Press, 2004: 1-8.
3.
National Breast Cancer Centre and National Cancer Control Initiative. Clinical practice
guidelines for the psychosocial care of adults with cancer. Sydney: National Breast Cancer
Centre, 2003.
4.
Schou I, Ekeberg O, Sandvik L, et al. Multiple predictors of health-related quality of life in
early stage breast cancer. Data from a year follow-up study compared with the general
population. Qual Life Res 2005; 14: 1813-23.
5.
Badger T, Segrin C, Dorros SM, et al. Depression and anxiety in women with breast cancer
and their partners. Nurs Res 2007; 56: 44-53.
6.
McArdle JMC, George WD, McArdle CS, et al. Psychological support for patients undergoing
breast cancer surgery: a randomised study. BMJ 1996; 312: 813-6.
7.
Shaw BR, McTavish F, Hawkins R, et al. Experiences of women with breast cancer:
exchanging social support over the CHESS computer network. J Health Commun 2000; 5:
135-59.
2.
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As in other developed countries, the Australian population is ageing, and cancer rates increase with age. Despite their
substantially lower life expectancy, Indigenous Australians are also experiencing concerning cancer statistics, characterised by
increasing rates, later diagnosis, higher mortality, and lower participation in screening than the non-Indigenous population.
Eighteen months after the first national Indigenous Cancer Control Forum, this environmental scan within the statebased Cancer
Councils was undertaken to map activities in service provision in Indigenous cancer control with a view to sharing the lessons
learned. The findings show that although most of the organizations had tried to work with Indigenous communities on cancer
issues, there have been difficulties in building and sustaining relationships with Indigenous organizations. Lack of having
Indigenous staff internally, few Indigenous-specific resources, and few planned, long-term commitments were some of the
major impediments. Some of these limitations can easily be overcome by building and improving regional or local partnerships,
providing cultural awareness training to internal staff, and by building the capacity of Indigenous organizations. Health
promotion projects of the Cancer Councils directed at Indigenous people could be more effectively implemented with such
considerations.
What is known about the topic? For many years cancer was not considered a high priority issue for Indigenous Australians as a
consequence of social and other health issues. Cancer incidence and death rates of Indigenous Australians have been unclear
as there has been limited epidemiological information and misclassification of Indigenous status. It is now evident that the
pattern of cancer differs for Indigenous Australians, and Indigenous people tend to be diagnosed later, have poorer
participation in treatment and a higher mortality rate for any equivalent stage of diagnosis.
What does this paper add? This paper presents a snapshot of the staffing, projects, programmes and activities of the state
Cancer Councils in early 2006 in terms of efforts to progress cancer control issues focussing on Indigenous Australians. Most
successful initiatives began by establishing a relationship and working over the longer term to sustain programme activity.
What are the implications for practitioners? Insights from the analysis of progress in the cancer field are relevant and
applicable to practitioners in other areas of health where mainstream services have a role to improve the health of Indigenous
communities.
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Methods
Environmental scanning was agreed to be a suitable method for
learning about how a range of organizations across the sector had
approached supporting Indigenous cancer control approaches
and gathering information about successful initiatives and efforts
that had been less productive, and this approach was accepted
by a Steering Committee and approved by the Curtin Health
Research Ethics Committee.
An initial approach letter was mailed to the Chief Executive
Officers/Directors (CEOs) of all the Cancer Councils, outlining the
background to the survey. They were also requested to nominate
appropriate staff members who could be interviewed about their
organizations past or present initiatives to improve Indigenous
engagement with cancer issues and to pass the background
information about the study on to those they nominated. When the
individuals were contacted and nominated others, these additional
nominees were also interviewed if available and willing. A copy of
the letter sent to their CEO was provided to the participants
beforehand.
Semi-structured interviews, either face-to-face or by telephone,
were undertaken with the key nominated staff (Indigenous and
non-Indigenous). The interview was based upon a theme list
developed following a review of relevant literature and discussion
within the research team. The list was also discussed with
Indigenous colleagues and forwarded to a Steering Committee
established to oversee the project of which this scan was a
component. Key areas focusing on Indigenous Australians that
were considered during the interviews, included: cancer
prevention and education; cancer support services for Indigenous
health organizations; healthcare delivery (workforce/access to
healthcare services); research; advocacy/policy and human
resources and any cross-organisational initiatives. Interviews were
taped with the permission of participants, and the responses were
coded following the key themes of the interview schedule.
Thematic analysis was undertaken manually, in which the efforts
and experiences of each Cancer Council were recorded against
the major service areas.
Staff from The Cancer Councils of the Australian Capital
Territory, Tasmania, Victoria, New South Wales and the Cancer
Foundation of Queensland participated in telephone interviews.
Information was collected from staff at the Cancer Councils of
Western Australia and South Australia through face-to-face
interviews. Before submission of this article for publication, it was
circulated to the CEOs of all participating Cancer Councils, giving
them the opportunity to make additions or corrections, and
appropriately represent their organisation, and suggested
amendments were incorporated.
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Jurisdiction
Organisational
Indigenous person employed
Position with specific Indigenous
focus
Cultural awareness training
Specific Indigenous action plan
ACT
NSW
Qld
SA
Tas
Vic
WA
No
Not
current
No
No
No
Yes
No
No
No
No
No
Yes
No
No
No
Yes
No
Yes
Recent
No
No
No
No
Voluntary
Tobacco
Cervical
screening
No
No
No
No
No
No
No
No
No
No
Strong
Yes
No
Beginning No
No
Yes
No
No
Yes
Yes
No
Ad hoc
Yes
Yes
Yes
Yes
Limited
Yes
Yes
Sustained
Funds
VAHS +
Yes
Sustained Yes
Yes
No
Limited
No
Limited
Yes
Ad hoc
Yes
Yes
For women
Yes
Yes
Limited
Beginning Yes
Ad hoc
Yes
Limited Yes
No
Yes
No
Beginning
Yes
* A non-Indigenous person spends 1 day a week on Indigenous cancer issue. ACCHOs =Aboriginal controlled community health
organisations.
Figure 1: Summary of progress in organisational and programme initiatives for indigenous cancer control by participating jurisdictional
Cancer Councils, March 2006
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their first and usual language. There were also issues with some
Indigenous clients not wanting to be alone in private rooms,
preferring being at floor level rather than bed height, having
different dietary preferences and their preferred foods being
unavailable. Despite challenges in communication, staff often
understood the desire of rural patients to return home to die, but
it generally had required dedicated effort and substantial cost to
achieve this. A number of informants spoke of the importance of
improving the quality of data around Indigenous cancer and
needs. Good information serves as the impetus for setting
priorities and directing resources, giving individuals a rationale for
further work with a minority population. Baseline data for
monitoring progress was seen as vital for people in the field.
Discussion
Cancer Councils in Australia have been highly effective nongovernment organizations with considerable expertise on all
aspects of cancer control. As a result of their strategic approach,
they are effective advocates around cancer screening, treatment
and support services. As key players in cancer control, they
contribute through education, training, research, advocacy and
cancer support service functions, all of which are necessary
components of achieving improved cancerrelated outcomes for
Indigenous Australians. Cancer Council staff acknowledged the
limitations of their organizations in addressing Indigenous cancer
issues and their own deficiencies in understanding Indigenous
culture and hence the right way to do things. But their
willingness and enthusiasm to work with these communities was
apparent in the organisation and participation at the 2004
Indigenous Cancer Control Forum in Darwin, and this was
followed by new initiatives within many of the Cancer Councils.
These initiatives include planning for a state-based Indigenous
Cancer Forum in South Australia (held in September 2006),
training of AHWs, cultural safety training for non-Indigenous
cancer support staff, and working in collaboration with local and
regional Indigenous health organizations.
Limitations identified in the environmental scan which impeded
progress on Indigenous cancer issues were the lack of dedicated
staff time for Indigenous issues, lack of Indigenous staff, limited
commitment of significant resources on a sustained basis, and
lack of Indigenous input into policy and programmes. There were
no Indigenous Board members, and where an Indigenous person
had been appointed as a staff member, often many demands were
made upon them. Some were uncomfortable working in a
mainstream organisation without Indigenous colleagues providing
peer-support. While it was recognised as desirable to have
Indigenous staff members working within the organizations,
respondents appreciated the practical challenges of this, and that
an Indigenous person per se was not a panacea. Most
organizations therefore opted to develop linkages with Indigenous
health organizations, and in some instances such projects had
been sustained over a number of years, with resources committed
over that time period. The linkage approach sometimes proved
frustrating as it often relied upon individual relationships and
required that the Indigenous organisation have both capacity and
commitment to the partnership. Informants recognised the
necessity to build capacity around cancer within the Indigenous
health sector. Considerable activity, not all of which had yet come
to fruition, had been initiated at planning and service levels
Hospital and Healthcare Innovation Book 2009/2010 85
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References
1.
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As a pioneer in medical technology since 1896 after recording the first X-ray images in Japan, Shimadzu
develops, manufactures and distributes a broad range of diagnostic systems in almost all areas of clinical
applications Digital Subtraction Angiography (DSA), cardiovascular systems, digital radiography &
fluoroscopy systems and general radiography equipment.
Under the BRANSIST name Shimadzu offers floor- or ceilingmounted as well as biplane C-arm systems with integrated safire
FPDs (22 x 22 cm or 43 x 43 cm). In addition to the brilliant image
quality, the BRANSIST system enables real-time operation at a
rotation speed of up to 60 per second.
The SONIALVISION safire X-ray multifunctional instrument can
be used, for instance, to create three-dimensional images of
patients standing upright during prostheses check-ups.
SONIALVISION safire has a low access of 47 cm and a capacity
of up to 318 kg for use in bariatrics.
RADspeed safire, the digital high-end product of the RADspeed
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Breast Cancer constitutes a major public health issue globally. In Africa, it is the commonest malignancy affecting women
and the incidence rates appear to be rising. While mortality rates are declining in the developed world as a result of early
diagnosis, screening, and improved cancer treatment programmes, the converse is true in the developing world.
Breast cancer and its treatment constitute a great physical, psychosocial and economic challenge in resource limited
societies as found in Africa. The hallmarks of the disease in Africa are clinically advanced disease, lack of adequate
infrastructure for diagnosis, screening and treatment, preponderance of younger pre-menopausal patients.
This Review is meant to provide practical guidance for the surgeon working in the developing world.
History
Breast cancer is one of the oldest known forms of malignancies.
90 Hospital and Healthcare Innovation Book 2009/2010
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LEVEL OF RESOURCE
Basic
EVALUATION GOAL
Baseline assessment and repeated survey
Limited
Enhanced
Diagnostic mammography
Opportunitic mamographic screening
Maximal
several risk factors have been identified. Table 1 lists the known
risk factors.14
The risk factors include:
Age: The incidence of breast cancer increases with age and is
rare before the age of 20 years. The breast cancer incidence in
Caucasians is highest at age 50-59, after menopause,
dropping after age 70. In Africa and African-Americans the
peak age incidence is about one decade less, so that the
majority of the patients are pre- menopausal. While numerous
theories have been proposed to explain this difference,
including age at menarche, time of first delivery, parity, sociodemographic factors, body mass index, and underlying genetic
difference, none are completely satisfactory and more research
is needed in this area.3-5;15-17
Sex: Breast Cancer is 100 times more common in women
than in men with male breast cancer accounting for <1% of all
breast cancer cases in the United States and 0.1% of cancer
mortality in men18-20. However in Africa this situation may be
different as from 5-15% of breast cancer in Uganda and
Zambia may occur in males.18;21-24
Geographic variation: A wide difference in age adjusted
incidence and mortality for breast cancer exists between
different countries (up to five fold). Figure 1 shows the
difference which may be explained by environmental and
genetic factors.25-28
Hormone/pregnancy related factors: The role of estrogen
in the causation of breast cancer has been extensively studied
and the general opinion is that estrogen is the primary
stimulant for breast epithelial proliferation. Factors that increase
exposure to high or prolonged level of estrogen are therefore
associated with an increased risk of developing breast
cancer29-33. These include early menarche, late menopause, use
of contraceptives and exogenous estrogen, nulliparity and
increased age at first term pregnancy. Induced abortion and
spontaneous abortion do not increase the risk. Prolonged
lactation and breast feeding reduce the risk. As the living
standard and healthcare facilities in Africa improve, it is
probable that age at menarche will decrease while that of
menopause increases. The demands for education and a
career may increase the number of women who delay
childbearing, have fewer children, use contraceptives and
breast feed for a shorter time. These will likely impact on the
increase in the incidence of breast cancer as African countries
meet the minimum development goals.
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Lifestyle risks
Anthropometric indices and physical activity: Height, obesity and
high body mass index are risk factors especially in post
menopausal women. In pre-menopausal women, obesity and high
body mass index has an insignificant but inverse relationship to
breast cancer risk that is reduced by physical activity.37-39
Diet, alcohol and smoking: alcohol and diets rich in fat especially
saturated fat raises the risk while smoking does not appear to
affect the risk.40-42
70% of women with inherited early-onset breast cancer.9 Up to 5087% of women carrying a mutated BRCA1 gene develop breast
cancer during their lifetime. Risks for ovarian and prostate cancers
are also increased in carriers of this mutation. BRCA2 mutations
are identified in 10-20% of families at high risk for breast and
ovarian cancers and in only 2.7% of women with early-onset
breast cancer. The lifetime risk of developing breast cancer in
female carriers is 25-30%. BRCA2 is also a risk factor for male
breast cancer; male carriers have a lifetime risk of 6% for
developing the cancer. BRCA2 mutations are associated with
other types of cancers, such as prostate, pancreatic, fallopian
tube, bladder, non-Hodgkin lymphoma, and basal cell carcinoma.
Risk management strategies for BRCA-1 and BRCA-2 carriers
include:
prophylactic mastectomy and reconstruction;
prophylactic oophorectomy and hormone replacement
therapy;
intensive surveillance for breast and ovarian cancer; and
chemoprevention using Tamoxifen or raloxifene (postmenopausal women)
In contrast, less is known about genetic mutations as a cause of
breast cancer in the non-Caucasian population. Studies that have
been done of African-Americans, whose genetic history includes
Caucasians, have identified BRCA-1 and -2 mutations but of a
different pattern.17,45,46 In native Africans, a wide range of BRCA-1
and BRCA-2 mutations and sequence variations have been found
which are unique. This suggests that there may be significant
differences in the genetics of hereditary breast cancer in Africa.
A screening of 206 black South African women with breast
cancer revealed 3 common BRCA1 mutations: 185delAG in exon
2, 4184del4 in exon 11, and 5382insC in exon 2022. A second
study of the coding regions of BRCA1 and BRCA2 genes from 70
Nigerian patients diagnosed with breast cancer before the age of
40 years revealed 2 novel BRCA1 truncating mutations, Q1090X
and 1742insG; four BRCA1 missense variations; one BRCA2
truncating mutation, 3034del4, previously unreported in anyone of
African descent; and 20 nontruncating variants were detected in
BRCA2.45 BRCA1 and BRCA2 mutations and sequence
variations are potentially significant in cases of early-onset breast
cancer within Africa. However, only a small portion of the
mutations were protein truncating, fewer than those observed
among white women47
Other rare genetic changes that account for predisposition to
breast cancer include Li Fraumeni syndrome (TP53 gene mutation),
Cowdens syndrome, Peutz-Jeghers and Muir-Torre syndromes,
Ataxia Telangiectasia syndrome (caused by the ATM gene).48-51 New
breast cancer susceptibility genes are being reported and they
include the CHEK2 or CHK2 gene, cytochrome P450 genes
(CYP1A1, CYP2D6, CYP19), glutathione S-transferase family
(GSTM1, GSTP1), alcohol and one-carbon metabolism genes
(ADH1C and MTHFR), DNA repair genes (XRCC1, XRCC3,
ERCC4/XPF) and genes encoding cell signaling molecules (PR, ER,
TNFalpha or HSP70). All these factors contribute to a better
understanding of breast cancer risk but the degree of penetrance
of these genes are far less than the BRCA1 and BRCA2 genes43,51
Risk assessment
Several statistical models are currently in use in North America to
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predict the risk of breast cancer, based on the above risk factors
identified in the American Caucasian population. The universal
applicability of these models can not, however be taken for
granted as the data on which they rely on were generated from
predominantly American Caucasian population and have not been
tested for African women43,52,53
The most prominent statistical models are the Gail and the
Claus models. Gail and colleagues developed the most frequently
used model, which incorporates age at menarche, the number of
breast biopsies, age at first live birth, and the number of firstdegree relatives with breast cancer. It predicts the cumulative risk
of breast cancer according to decade of life. To calculate breast
cancer risk with the Gail model, a woman's risk factors are
translated into an overall risk score by multiplying her relative risks
from several categories. This risk score is then compared to an
adjusted population risk of breast cancer to determine a womans
individual risk. A software programme incorporating the Gail
model is available from the National Cancer Institute at
http://bcra.nci.nih.gov/brc.
Claus and colleagues, using data from the Cancer and Steroid
Hormone Study, a case-control study of breast cancer, developed
the other frequently used risk-assessment model, which is based
on assumptions about the prevalence of high-penetrance breast
cancer susceptibility genes. Compared with the Gail model, the
Claus model incorporates more information about family history,
but excludes other risk factors. The Claus model provides
individual estimates of breast cancer risk according to decade of
life based on knowledge of first- and second-degree relatives with
breast cancer and their age at diagnosis. Risk factors that are
less-consistently associated with breast cancer (diet, use of oral
contraceptives, lactation), or are rare in the general population
(radiation exposure), are not included in either the Gail or Claus
risk-assessment models.54
Pathology
Breast cancers are derived from the epithelial cells that line the
terminal duct lobular unit. Cancer cells that remain within the
basement membrane of the elements of the terminal duct lobular
unit and the draining duct are classified as in situ or non-invasive.
An invasive breast cancer is one in which there is dissemination of
cancer cells outside the basement membrane of the ducts and
lobules into the surrounding adjacent normal tissue.
Classification of Primary Breast Cancer
Noninvasive Epithelial Cancers
Lobular Carcinoma in situ (LCIS).
Ductal Carcinoma in situ (DCIS) or intraductal carcinoma:
Papillary, cribriform, solid and comedo types
Invasive Epithelial Cancers (percentage of total)
Invasive lobular carcinoma (10-15).
Invasive ductal carcinoma.
Invasive ductal carcinoma, (NOS) Not Otherwise Specified
(50-70).
Tubular carcinoma (2-3).
Mucinous or colloid carcinoma (2-3).
Medullary carcinoma (5).
Invasive cribriform (1-3).
Invasive papillary (1-2).
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Diagnosis
Examination
Early breast cancer causes no symptoms and is usually painless.
The commonest symptom is a painless lump in the breast.
Examination of the breast should be done in such a way to show
respect for the privacy and comfort of the patient. A systematic
approach to breast examination is important. Initial examination
should start with the patient in an upright position with careful
visual inspection of masses, skin and nipple changes, and
asymmetries. Palpation should be done to include all the breast
quadrants, the nipple-areola complex, the axillary tail and the
axilla. Simple maneuvers like stretching the arms high above the
head, tensing the pectoralis muscles may help accentuate
asymmetries and dimpling.
Other less frequent presenting signs and symptoms of breast
cancer include (1) breast enlargement or asymmetry; (2) nipple
changes, retraction, or discharge, including Pagets disease; (3)
ulceration or erythema of the skin of the breast including
inflammatory carcinoma; (4) an axillary mass; and (5) systemic
symptoms such as fatigue, cough, ascites or new musculoskeletal
discomfort.
Imaging
Mammography, Ductography, Ultrasonography, MRI are imaging
Limited
PATHOLOGY
Interpretation of biopsies
Enhanced
On-site cytopathologist
Diagnostic mammography
Bone scan
Maximal
Stereotactic biopsy
Sentinal node biopsy
HER2/new statue
IHC ataining of aentinel nodes
for cytokeratin to detect
micrometastaes
CT scanning, PET
MIBI scan, breast MRI
CBC, coomplete bloodcount; CT, computed tomography; ER, estrogen recaptor; IHC, immunohistochemistry; MIBI, 99mto-sastamibi; MRI, magnetic resonance imaging;
PET, positron emission tomography; PR, progerterone receptor
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Level of resource
Basic
LOCAL-REGIONAL TREATMENT
Surgery
Modified radical mastectomy
Limited
Breast-conserving theraphy*
Radiation therphy
Breast-conserving whole-breast
irradiation as part of breast-conserving
therapy
Classical CMF**
AC, EC or FAC**
Enhanced
Maximal
Taxanes
Aromatase inhibitors
LH-RH agonists
Growth factors
Dose-dense chemotherapy
Level of resource
Basic
LOCAL-REGIONAL TREATMENT
Surgery
Modified radical mastectomy
Limited
Breast-conserving theraphy***
Radiation therphy
*
Breast-conserving whole-breast
irradiation as part of breast-conserving
therapy
Postmasectomy irradiation of the chest
wall and regional nodes for high-risk cases
Enhanced
Maximal
AC, EC or FAC**
Taxanes
Aromatase inhibitors
LH-RH agonists
Growth factors
Dose-dense chemotherapy
* Chest wall and regional lymph node irradiation substantially decrease the risk of postmastectomy local recurrance, if available it should be used as a basic level resource
** Requires blood chemistry profile and complete blodd count (CBC) testing
*** Breast-conserving therapy requires mamography and reporting of margin status.
AC, doxonubian and cyclosphamida; CMF, cyclophamide, methotrexate, and 5- fluorourcil; EC, epirubicin and cyclophosphamide; FAC, 5 - fluorourcil doxonubicin, and cyclophosphamide;
LH+RG, lutelnizing hormone-releasing hormone
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Biopsy
Pathologic diagnosis of a breast lesion can be achieved using a
number of biopsy techniques. With a larger biopsy sample, greater
accuracy and more information are obtained, but this is at the
expense of increased invasiveness. Ideally, needle biopsies should
be performed after imaging to help prevent distortions of imaging
due to hematoma. The various needle biopsy techniques can be
divided into two groups:
1. Fine needle aspiration will provide cytology which will allow
a diagnosis of malignant cells but will not differentiate between
in situ or invasive disease.
2. Tissue biopsy for histology which include Tru cut biopsy,
Biopty cut, Mammotome. These relatively larger tissue samples
will allow the diagnosis of invasive versus in situ cancer.
Table 4 compares the accuracy of needle biopsy techniques.
Open Biopsy (Excision or Incision biopsy) The ultimate diagnostic
biopsy is open biopsy of a lesion, normally performed under
general or local anesthetic. Open excisional biopsy should be
reserved for lesions for which some doubt remains regarding
diagnosis after less invasive assessment or for benign lesions that
the patient wants removed. A wide clearance of the lesion is usually
not the goal in diagnostic biopsies, thus avoiding unnecessary
distortion of the breast. It is also useful for excision of
mammographic lesions when percutaneous biopsy has failed or is
equivocal. Where frozen section is available, open excisional biopsy
may be performed at the same time the as definitive breast cancer
surgery. Incisional biopsy is used only in cases where the lesion is
very large and a percutaneous biopsy has been unsuccessful.
Screening
Annual screening mammography has been demonstrated to
reduce breast cancer mortality among women older than 50 years
by 20 39%. The benefit in younger women is not yet established.
For Caucasian women aged 4049, the results of RCTs are
consistent in showing no benefits at 57 years after entry, a
marginal benefit at 1012 years, and unknown benefit thereafter.
This is primarily because when used as a screening tool, the
detection rate per screened individual is lower because of denser
breasts and an overall lower incidence. The controversy over the
effectiveness of screening mammography among younger women
(i.e., 4049 years) has led to varying recommendations about its
use for this age group. In patients with high risk factors a yearly
mammography assessment from the age of 40 years is
advisable.65-67 Considering the younger demographic pattern of
Breast Cancer in Africa, it is not clear what role screening
mammography should have in Africa.
Other methods of early breast cancer screening like Self Breast
Examination and Clinical Breast Examination have not been
demonstrated to improve mortality in patients; rather SBE has
resulted in more breast biopsies due to false positive results, more
physician visits and apprehension in patients68. It is pertinent to
state that most of the studies that evaluated the role of SBE and
CBE have been done in developed societies where cancers are
small at diagnosis and this may not be relevant in Africa where the
majority of patients present late. Incorporation of Breast
Awareness programmes and health education into the Primary
Health Care of African countries may very well be a useful option
to allow for a diagnosis at an earlier stage. Cultural attitudes play
96 Hospital and Healthcare Innovation Book 2009/2010
Treatment
Treatment strategy will depend on the stage of the disease.
In situ breast cancer (DCIS and LCIS)
LCIS: Observation alone with or without tamoxifen is the preferred
option for women diagnosed with LCIS because their risk of
developing invasive carcinoma is relatively low (approximately 21%
over 15 years) and is equal in both breast..70 Follow-up of patients
with LCIS includes physical examinations every 6 to 12 months for
5 years and then annually. Annual diagnostic mammography is
recommended in patients being followed with clinical observation.
DCIS: Treatment options for DCIS are mastectomy, breastconserving surgery (BCS) plus radiotherapy or BCS alone. The
goal of treatment for DCIS is to reduce local recurrence, because
50% of the time that DCIS recurs it recurs as an invasive cancer.
Factors that may modify treatment are:
the grade of the lesion, with higher-grade lesions more likely to
recur in a short time;
the youth of the patient, with many more years at risk for
recurrence and
the size of the lesion.
For years the traditional surgical management of DCIS was
mastectomy, with or without axillary dissection. Breast
conservation technique and irradiation is now a preferred
alternative where local breast radiation is available. Only small, low
grade DCIS that has been excised with a large margin may be
considered for BCS alone. Axillary lymph node staging is
discouraged in women with apparent pure DCIS. However, a small
proportion of patients with apparent pure DCIS will be found to
have invasive cancer at the time of their definitive surgical
procedure which will require a further axillary dissection.71 Addition
of Tamoxifen reduces the risk of developing contralateral breast
cancer.72,73. Follow-up of women with DCIS includes a physical
examination every 6 months for 5 years and then annually, as well
as yearly diagnostic mammography.
Early breast cancer (stages I and II or T1-3N0-1 M0):
Staging for metastatic disease is standard for most patients
diagnosed with early breast cancer and include a chest X-ray,
bone scan and ultrasound of the abdomen. If negative, treatment
intent is curative, and involve modalities that fight the cancer
locally (surgery and radiation) and systemically (chemotherapy and
endocrine therapy).
Loco-regional treatment:
Local treatment requires the treatment of the entire breast and the
axillary lymph nodes with surgery, radiation, or a combination of
both. Surgery can be breast conservation therapy (BCT) and
axillary staging (SLNB or axillary dissection) or simple or total
mastectomy with axillary staging (modified radical mastectomy).
The surgical procedure for the excision of the breast in BCT
goes by several names (Partial mastectomy, tylectomy, segmental
resection, quadrantectomy or lumpectomy).
The goal of breast-conserving surgery is to minimize the risk of
local recurrence while leaving the patient with a cosmetically
acceptable breast. The selection of BCT versus mastectomy
depends on the size of the tumor relative to the rest of the breast
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treatment while for a woman at low risk the benefit will be small yet
she will be exposed to the same toxicity. For example, a 20%
reduction with chemotherapy for a patient with a baseline 50% risk
of recurrence will result in an absolute reduction to 10% (from 50%
to 40%) where as a woman with a 10% recurrence risk reduces
her risk of recurrence to 8%, only a 2 % absolute reduction. Some
women would not choose chemotherapy for a 2% risk reduction
and others might. The decision to take systemic therapy therefore
is therefore very much dependent on the woman and her
understanding of these risks.99
Adjuvant endocrine therapy is effective in ER and/ or PR positive
tumors. The most commonly used endocrine therapy is the
Selective Estrogen Receptor Modulator (SERM) Tamoxifen, used
in premenopausal women. Other SERM agents like Toremifene
and Raloxifene are equally effective. There is strong evidence to
support the superiority of a 5 year Tamoxifen therapy over shorter
durations. Tamoxifen in addition helps to maintain bone mineral
density in post menopausal women and reduces the risk of
developing cancer in the contralateral breast. The side effects of
Tamoxifen include hot flashes, risk of thrombo-embolic disease,
endometrial carcinoma and cataracts.
For post-menopausal women, third generation selective
aromatase inhibitors have been shown in recent trials to be more
effective than Tamoxifen and have become the standard of care.
Examples include non steroidal type (anastrozole and letrozole)
and the steroidal type exemestane. Patients using aromatase
inhibitors have less gynecological symptoms such as endometrial
cancer, vaginal bleeding, and vaginal discharges. Fewer
cerebrovascular events and venous thromboembolic events were
also observed with patients receiving aromatase inhibitors.
However, musculoskeletal effects (arthritis, arthralgia, and/or
myalgia) and bone toxicity (bone fractures) are associated with
aromatase inhibitors.
The combination of endocrine therapy and cytotoxic
chemotherapy provides benefits greater than the benefits from
either therapy alone. They are therefore usually offered sequentially,
with chemotherapy given right after surgery, local radiation therapy
is then given, and endocrine therapy commenced. Premenopausal
women are given Tamoxifen for five years. The optimal duration of
the aromatase inhibitors has not yet been determined and
postmenopausal women remain on them indefinitely.
Ovarian ablation (e.g., surgical oophorectomy or radiation
ablation) or suppression (e.g., use of the gonadotropin- releasing
hormone or luteinizing hormone-releasing hormone analogues) is
another effective way to reduce estrogen in premenopausal
women. It can be used as an adjuvant treatment alone or to
induce menopause in very high risk premenopausal women to
allow the use of adjuvant aromatase inhibitors.
Chemotherapy
Chemotherapy has been shown to substantially improve the long-
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Prognosis
Natural history
The natural history of breast cancer in 250 untreated women
revealed the following statistics; Median survival of untreated breast
cancer was 2.7 years after initial diagnosis. The 5- and 10-year
survival rates were 18.0 and 3.6%, respectively. Only 0.8% survived
for 15 years or longer. Autopsy data confirmed that 95% of these
women died of breast cancer, while the remaining 5% died of other
causes. Almost 75% of the women developed ulceration of the
breast during the course of the disease. The longest surviving
patient died in the nineteenth year after diagnosis.121
With modern treatment, the 5-year survival rate for stage I
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Level of resource
Basic
LOCAL-REGIONAL TREATMENT
Surgery
Modified radical mastectomy
Limited
Radiation therphy
Enhanced
Breast-conserving theraphy**
Maximal
Reconstructive surgery
Tamoxifen
Aromatese inhibitors
LH-RH agonists
Growth factors
Dose-dense chemotherapy
*Requires blood chemistry profile and complete blodd count (CBC) testing
** Breast-conserving therapy requires mamography and reporting of margin status.
AC, doxonubian and cyclosphamida; CMF, cyclophamide, methotrexate, and 5- fluorourcil; EC, epirubicin and cyclophosphamide; FAC, 5 - fluorourcil doxonubicin, and cyclophosphamide;
LH+RG, lutelnizing hormone-releasing hormone
patients is 94%; for stage IIa patients, 85%; and for stage IIb
patients, 70%, while for stage IIIa patients the 5-year survival rate
is 52%; for stage IIIb patients, 48%; and for stage IV patients, 18%.
Prognostic Iindicators:
Tumor size
Prognosis deteriorates with increasing tumor size, which is an
independent predictor of survival in node-negative patients and
correlates with the incidence of nodal metastases.
Staging
The status of the axillary lymph nodes is one of the most useful
prognostic indicators for breast cancer, with average 10-year
survival rates of 60-70% for node-negative patients, dropping to
20-30% in node-positive patients.
Histopathology
Histologic type
Carcinoma in situ, because it is a preinvasive condition, is
curable if completely removed, although 16% of patients with
carcinoma in situ develop invasive recurrence after local
excision of ductal carcinoma in situ, usually high grade.
Similarly, 18% of patients develop invasive recurrence after
lobular carcinoma in situ excision.
Well-differentiated invasive cancers have a relatively good
prognosis if they are tubular, mucinous, cribriform, or
secretory.
Medullary carcinoma is probably of intermediate prognosis, but
different studies have used different criteria for its definition.
Invasive ductal and invasive lobular carcinomas have a less
favorable prognosis but are influenced heavily by other factors.
Cytologic grade
Cytologic grade is the best predictor of disease prognosis in
carcinoma in situ but is dependent on the grading system
used, such as the Van Nuys classification (high-grade, lowgrade comedo, low-grade noncomedo).
The grading of invasive carcinoma is also important as a
prognostic indicator, with higher grades indicating a worse
prognosis. Microscopic criteria for grading are shown in
Table 5.
102 Hospital and Healthcare Innovation Book 2009/2010
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Table 6: Treatment and allocation of resources: Metastatic (stage IV) and recurrent breast Cancer
Level of resource
Basic
LOCAL-REGIONAL TREATMENT
Surgery
Radiation therphy
Total mastectomy for
ipeilateral breast tumor recurrance*
Limited
Enhanced
Maximal
Reconstructive surgery
Chemotherphy
Classical CMF**
Anthracycline montherapy
or in combination**
Taxanes
Capecitabine
Trastzumab
Aromatese inhibitors
Growth factors
Vinorebine
Gemcitabine
Carboplatin
Fulvestrant
Biophosphonates
Cyclin D1
Nm23
Proteases
uPA
Cathepsin D
Tenascin C
Markers of proliferation - Ki-67
HER-2/neu identifies patients with a poor prognosis. These
patients are likely to respond to treatment with trastuzumab
(Herceptin).
Tumors positive for Ki-67 have a high metastatic potential and
warrant the possible use of early aggressive therapy.
uPA and cathepsin D identify poor prognosis node-negative
tumors. In these cases, chemotherapy can be offered.
The use of gene expression profiling to detect breast carcinoma
has already shown that the differential expression of specific genes
is a more powerful prognostic indicator than traditional
determinants such as tumor size and lymph node status. These
molecular assays are awaiting clinical validation.
Prevention
Screening as currently practiced can reduce mortality but not
incidence, and then only in a particular age group. Advances in
treatment have produced significant but modest survival benefits.
A better appreciation of factors important in the etiology of breast
cancer would raise the possibility of disease prevention. Currently,
prevention strategies fall into two groups: chemoprevention and
surgical prophylaxis.
Chemoprevention is defined as the systemic use of natural or
synthetic chemical agents to reverse or suppress the progression
of a premalignant lesion to an invasive carcinoma129. Tamoxifen is
currently the only agent that has been approved clinically for use
in women with high risk of developing cancer. Raloxifene,
selenium, retinoids, aromatase inhibitors and cyclo-oxygenase 2
inhibitors require further clinical investigation before adoption in
this context.
Surgical prophylaxis: by either a bilateral mastectomy or
oophorectomy, is another avenue of prevention. Some studies
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FACILITIES
Health facility
Operating facility
Pathology laboratory
Pharmcay
Outpatient care facility
RECORD KEEPING
Individual medical records and servvice-based patient registartion
Linked
Imaging facility
Radiation theraphy
Clinical information systems
Health system network
Imaging services
Radiation oncology services
Peer support services
Early detection programme
Enhanced
Opportunistic screening programme Centralized referal cancer centre(s) Facility-based follow-up registry
Cancer follow-up
Rehabilitation services
Population based cancer registry Regional Cancer registry
Maximal
Population based
screening programme
Individual psychological care
Sarellite (non-centralized
or regional) Cancer centre
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Conclusion
Management of breast cancer is a major challenge in resource
limited countries.
Efforts should be geared towards early diagnosis, prompt and
standardized treatment to reduce the burden of advanced disease
in African women, majority of who are worse hit in the most
productive part of their life time.
Our knowledge about breast cancer is evolving, but is still
limited with respect to its etiology and biology, and with respect to
its features in individual countries and cultures.
Further research is needed to understand the role of genetics
and environment in the etiology of breast cancer in Africa.
Recommnedations
In high-resource countries, evidence-based guidelines outlining
optimal approaches to early detection, diagnosis, and treatment of
breast cancer have been defined and disseminated. These
guidelines unfortunately are not applicable in countries with
resource constraints as they are not economically feasible or
culturally appropriate.
The following recommendations might be considered appropriate
in the resource-poor countries of Africa. Following the Breast Health
Global Initiative we have stratified the recommendations into Basic,
Limited, Enhanced and Maximal.10-12,138
Definition of stratification terms
Basic level Core resources or fundamental services
absolutely necessary for any breast healthcare system to
function. By definition, a healthcare system lacking any basiclevel resource would be unable to provide breast cancer care
to its patient population. Basic-level services are typically
applied in a single clinical interaction.
Limited level Second-tier resources or services that
produce major improvements in outcome, such as increased
survival, but which are attainable with limited financial means
and modest infrastructure. Limited-level services may involve
single or multiple clinical interactions.
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1.
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Responding to challenges
in physical therapy
ARTICLE BY CATHERINE SYKES PT, MSC
professional policy consultant, World Confederation for Physical Therapy
BRENDA MYERS BScPT, MHSA
Secretary General, World Confederation for Physical Therapy
MARILYN MOFFAT PT, DPT, PhD, FAPTA, CSCS
President, World Confederation for Physical Therapy
TRACY BURY MSc Grad Dip Phys MCSP
professional policy consultant, World Confederation for Physical Therapy
This paper describes a range of contemporary challenges affecting the physical therapy profession and its
practice around the world, and the way the profession is responding to them.
Professional challenges
Physical therapy now faces a number of new challenges around
the world, which are being addressed by the World Confederation
for Physical Therapy (WCPT).
These include the growth of lifestyle-related diseases, such as
arthritis, cardiovascular disease, diabetes and asthma; new
technologies such as robotics; increasingly complex service
delivery systems; the supply of physical therapists to meet service
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New technologies
Technology has been developing apace in recent years and,
physical therapists with their educational background in the
physical, biological, biomechanical, and kinesiological sciences
can engage readily with these new technologies.
Technology for delivering services
Physical therapists have been using electronic channels, such as
the telephone and the internet, to augment their service provision
to patients and clients and to help to reduce the costs of service
delivery. For example, a 12-week home-based tele-rehabilitation
programme delivered to people with multiple sclerosis resulted in
improved functional outcomes. The individualised exercise
programmes devised during a face-to-face consultation with a
physical therapist were monitored by online video conferencing.
Advantages of this form of delivery included the ability to monitor
performance, make progressions and address questions and
complications promptly. Tele-rehabilitation was well accepted by
the programme recipients and cost effective for providers
(Finkelstein et al 2008).
110 Hospital and Healthcare Innovation Book 2009/2010
Education
WCPT recognises that there is diversity in the social, economic,
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Conclusion
Many of the contemporary issues for physical therapy are
interdependent. Where there is high quality professional education
in accredited education programmes and a regulatory
environment that supports autonomous practice, direct access to
physical therapy services and respectful and collaborative
relationships amongst health care providers, there are excellent
opportunities for enhancing the delivery of physical therapy
services to all that need them. J
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127
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STERILIZATION PACKS
A well-designed and correctly used sterilization pack provides for
effective sterilization and safe handling and storage of all items
until the moment they are used. A pack must remain sealed
against bacteria and facilitate aseptic presentation of the
packaged product. The Steriking sterilization packaging are
developed and designed to ensure optimal reliability of use in
hospitals and other health care institutions. The sterile state of
medical device, which is achieved through sterilization, is
maintained with the help of an appropriate packaging. The design,
materials and manufacture of the packaging materials have to be
compatible with the medical device to be packed, the handling
processes of the medical device, the sterilization method to be
used, the labelling systems and distribution and storage
conditions as well.
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SSIs represent a major cause of morbidity in surgical patients, affecting only around 2% of patients with
clean cases, but upwards of 15-20% of patients undergoing contaminated cases. This article sets out to
show the best ways of dealing with surgical site infections and makes specific recommendations for the
best ways of treating SSIs.
Aetiology of SSIs
SSIs are caused by the deposition and multiplication of
microorganisms in the surgical site of a susceptible host. There are
a number of ways microorganisms colonize and cause infection,
including: a) direct contact either from another patient, transfer
from surgical equipment or the hands of the hospital staff; b)
airborne dispersal surrounding air contaminated with microorganisms that deposit onto the wound; and c) self-contamination
(also known as endogenous infection) physical migration of the
patients own normal flora which are present on the skin, mucous
membranes or gastrointestinal tract to the surgical site. Most
surgical infection is due to bacterial and, more rarely, fungal
infection. Viruses, such as human immunodeficiency virus (HIV)
and the hepatitis B and C viruses are important to surgeons
because they may contract these diseases from their patients.
Due care has to be taken when managing such patients and
infection significantly alters the host response to other diseases.
The commonest organism causing SSI is Staphylococcus
aureus. Other common causative organisms include other Gramnegative aerobes, Streptococcus spp. and anaerobes. A study by
Erickson et al. in Tanzania showed that S. aureus was the most
common isolate (n=22), followed by E. coli (n=12) and Klebsiella
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Wound status
Wound characteristics which increase the risk of SSI include:
presence of foreign bodies, nonviable tissue in wound, tissue
ischemia and haematoma formation. All of these characteristics
provide a fruitful bacterial growing environment. Other factors
known to promote SSIs are a prolonged
Table 1: Classification of the risk of SSI13
preoperative hospital stay (since there is a growing
opportunity for the skin to be colonized by
WOUND CLASSIFICATION
DESCRIPTION
INFECTIVE RISK (%)
pathogens), a long operation time (as it probably
increases the extent of both tissue trauma and
Clean
Uninfected operative wound, no acute
<2
inflammation, no entry to internal organs,
contamination), and poor surgical techniques (see
and no break in aseptic technique. Hernia
below).
repair is an example.
The risk of SSI varies with the type of surgery.
Certain
types of surgery carry a higher risk of
Clean Opening to internal organ but minimal or no
<10
contamination than others and have led to the
contaminated
spillage of contents. No evidence of infection
or major break in aseptic technique.
classification of surgical wounds as clean, cleanCholecystectomy and lysis of adhesions are examples.
contaminated, contaminated, or dirty (Table 1).
Contaminated
Dirty
15-20
~40
Surgeon-related factors
Factors directly related to surgeon technique
include minimizing devitalisation of tissues (avoiding
factors such as tissue tension, crushing, and
parallel or tram track scars), adherence to sterile
technique, haemostasis to prevent accumulation of
Hospital and Healthcare Innovation Book 2009/2010 121
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Prevention of SSIs
Prevention is always better than a cure, and thus a careful
assessment of risks related to SSIs is paramount. The goal of SSI
management is to prevent or minimise the risk through careful
planning.
The following factors or methods external to the patient are
critical to preventing SSIs: a) Theatre environment and care of
instruments; maintenance of positive pressure ventilation of
operating theatre, laminar airflow in high risk areas, and
sterilisation of surgical instruments, sutures etc. according to
guidelines, and b) Surgical team members educated in aseptic
technique; staff with infections excluded from duty and scrubbing
up followed by appropriate sterile attire.
The following section outlines the evidence regarding hair
removal, preparation of the sterile field, and wound closure
technique. Prophylactic antibiotic use is discussed in section 6.
Decisions regarding hair removal
Hair removal is commonly performed prior to surgery, yet both the
Centers for Disease Control and Prevention (CDC) and the
Norwegian Centre for Health Technology Assessment recommend
against hair removal14. The CDC recommends that, if performed,
hair removal should be done by clipping or use of a depilatory
cream, rather than by razor. A recent Cochrane Database of
Systematic Reviews identified 11 studies that met criteria for
inclusion in a meta-analysis of hair removal and infections; 3 of
these studies compared shaving with clipping and found that
shaving increased surgical site infections (relative risk 2.02, 95%
confidence interval 1.21 to 3.36). Furthermore, shaving versus
clipping leads to more skin trauma even under ideal conditions,
providing further evidence that shaving should be avoided15.
There were no studies meeting inclusion criteria that compared
clipping of hair to no hair removal. Two studies compared shaving
with no hair removal, and found that shaving increased infection
(relative risk 1.59). However there were relatively few subjects in
these two studies and hence the conclusion did not reach
statistical significance.
Evidence from within Africa supports the CDC recommendation
against hair removal. Adeleye et al. recently reported their
experience with 17 cranial procedures on black Africans, in which
all of the fields were non-shaved, and reported no serious
complications over a 2 to 6 month follow-up16.
In conclusion, if hair is to be removed at all, it should be done by
clipping and not by shaving. Furthermore, hair should not routinely
be removed except in cases where the presence of hair interferes
with the technical aspects of the surgery, which is a judgment that
is best left to the operating surgeon within the context of these
recommendations.
Preparation of the surgical field
Two factors relate to the surgical field the choice of skin
preparation, and the method of draping. In developing countries,
the choice of drapes has been limited due to cost constraints,
whereas in developed countries, sterile, adhesive iodineimpregnated drapes (commonly known as Ioban) are available.
These adhesive drapes are placed over the skin after preparation
122 Hospital and Healthcare Innovation Book 2009/2010
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DRUG CLASS
EXAMPLES
AND
One protease inhibitor (PI)
lopinavir
saquinavir
fosamprenavir
ritonavir
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Summary of recommendations
In conclusion, SSIs represent a major cause of morbidity in
surgical patients, affecting only around 2% of patients with clean
cases, but upwards of 15-20% of patients undergoing
contaminated cases.
1. To limit the chance of SSIs, one should treat any endocrine or
metabolic disorders in the patient, and optimize nutritional
status.
2. Preoperative antibiotics should be given for clean-contaminated
and contaminated cases (second or third generation
cephalosporin). For clean cases, the evidence is mixed, and if
given the best choice is a first generation cephalosporin. The
antibiotic should be given before incision, but no longer than 60
minutes before, and should not be continued for more than 24
hours postoperatively. Antibiotics for dirty cases represent
treatment of infection and thus are not considered prophylaxis.
3. Body hair need not be removed, and if the surgeon chooses to
remove hair, it should be done by use of clippers or a depilatory
agent; shaving causes an increased chance of wound infections
and must be avoided.
4. Chlorhexidine is the best skin preparation agent. Soap followed
by iodine, or 70% alcohol followed by iodone are the next best
alternatives.
5. Intraoperatively, patients should retain normothermia,
normoglycemia, and adequate perfusion and oxygenation. The
surgeon should minimize tissue devitalisation, adhere to sterile
technique, avoid hematoma formation, and close potential
spaces.
6. Evidence supports closing primarily all wounds, and avoiding
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Many hospitals employ systems and personnel to reduce the effects of patient handling activities. Research has
found limited evidence for the benefits of patient handling interventions and poor levels of evidence for the
reduction of work-related MSDs in the healthcare setting. Historically the reduction of MSDs has been the primary
purpose of patient handling interventions but other benefits have been identified. This paper describes the range
of outcomes that have been identified in published research. Describes the type of intervention strategy that gives
best results and suggests that hospitals and healthcare providers need to consider appropriate audit systems to
collect suitable data to prove the success of their management systems.
Literature analysis
Patient handling
A series of systematic reviews have failed to identify
musculoskeletal disorder (MSD) reduction from patient handling
interventions (Van Poppel, 2004, Bos et al, 2006, Amick et al
2006, Haslam et al, 2006, Dawson et al, 2007, Martimo et al,
2008). More inclusive reviews identify that other outcomes could
be used to show success (Hignett et al 2003, Fray and Hignett
2006, Fray and Hignett 2009). The volume of evidence for the
reduction of known risk factors is growing and the development of
multi-faceted ergonomics, equipment and education packages
are showing improvements in practice (Nelson et al 2006, Collins
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Discussion
Larger people or bariatric care
Randall et al (2009) suggest that the handling of people with BMI
over 35kg/m2 may raise the injury potential. The increased
awareness and development of bariatric handling systems
(Gallagher 2004, VISN8 2006) would agree with the increased risk.
An unpublished study in a UK hospital (OHS 2009) showed that
the perception of significant risk when moving very large patients
changed behaviour in a positive way. This creates a possible
subgroup of high risk patients that fit the description of large but
not noted as bariatric. The evidence of the growing population
indicates that this specific group will continue to be more prevalent
in the future. As familiarity with bariatric patients widens, the level
at which the highly protective behaviour is triggered may also
increase thus increasing the number of people in the larger but not
bariatric category.
Hoists as a handling solution?
Early biomechanical studies recorded high levels of spinal
compression due to lifting tasks. Hoisting or mechanical lifting has
been proven to allow these lifting risks to be avoided (Hignett
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Van Poppel M, Hooftman W, Koes B, 2005. An update of a systematic review of controlled
clinical trials on the primary prevention of back pain at the workplace. Occup Med, 2004
Aug; 54 (5) : 345-352
Zhuang Z, Stobbe T, Collins J, Hsiao H, Hobbs G, (2000). Psychophysical assessment of
assistive devices for transferring patients/rsidents. Appl Ergon 31 :35-44
Zhuang Z, Stobbe T, Hsiao H, Collins J, Hobbs G, (1999). Biomechanical valuation of assistive
devices for transferring residents. Appl Ergon 30: 285-294
Web References
Baros Automatic Patient Hoist. www.smartlift.eu (Accessed 30/08/09)
BBC News 2009. Japan looks to robots to fill jobs. http://news.bbc.co.uk/1/hi/world/
asia-pacific/8234463.stm. Published 2009/09/03. Accessed Sept 2009.
Hill-Rom Intelligent Bed Products. http://www.hill-rom.com/usa/PatientSafety/Flash/
PatientSafetyDemo.htm (Accessed 15/09/09)
NHS Employees 2009, Pay Circular (AforC) 1/2009.
http://www.nhsemployers.org/Aboutus/Publications/PayCirculars/Documents/
pay_circular%20_AfC_%20%201_2009.pdf (Accessed Sept 2009)
Nursing Times 2009. Care staff would welcome robot helpers.
www.nursintimes.net/5004704.article.
Published 1 Aug 2009. Accessed 8 Sept 2009.
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The International
Hospital Federation
The IHF is driven by its founding ethos that it is the right of every
human being irrespective of geographical, economic, ethnic or
social condition to enjoy the best standard in quantity and quality
of health and access to hospital and health care services. By
promoting this value, IHF supports the improvement of the health of
society. The provision of health and health care to all people,
recognizes and accepts current best practice in medical standards
and patient care as well as the ethical behaviour and standards of
integrity required to govern, lead and manage health-care
organizations.
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Publications
These include:
World Hospitals and Health Services
(WH&HS) Journal. First launched in 1929 as Nosokomeion,
and renamed World Hospitals and Health Service, is published
four times a year, featuring articles from leading international
figures, in the field of hospital and healthcare management. It
includes features such as surveys, country profiles, case
studies and advertising. The paper and electronic journal, is
Events
available to all IHF members, free of charge, or by annual
These are organized and located to enable us to be present in all
subscription to non-members.
regions of the world. Our regional events are supported by the
International Hospital Federation Reference Book, our
Biennial World Hospital Congress. The subject focus of each of
resource for sharing ideas and information about hospital
these events is tailored to address the needs of the host region,
thereby ensuring our contribution to regional health services
management strategies, care regimens and the evaluation of
management and development. Our events also provide both a
medical equipment and treatments, among other topics. This
publication forms an integral part of our
communications strategy featuring annual
assessments of the worldwide evolution in
hospital care and facilities development.
Building Quality in Health Care
(BQHC) journal, launched in October 2007,
is published in collaboration with The
Methodist Hospital (Texas, USA). It is
intended to fill a gap in the publishing
market on quality of health service, in that
its aim is to bridge the gap between
scientific evidence and actual practice in
healthcare. It seeks to play a critical role in
establishing global benchmarks in
organizations whose primary focus is
patient care and safety. Its mission also
IHF Full Members
IHF Associate Members
includes identification and dissemination of
practical knowledge regarding sustainable
IHF Affiliated hospital organizations in 2009
applications that would contribute to
Hospital and Healthcare Innovation Book 2009/2010 133
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IHF reference
FINAL.ai
Quality 4
20/10/09
09:00:58
Vol. 3 No. 1 |
lity
Building Qua
dist
rnal of Metho
The Official Jou
2009
in Health Care
l Federation
tional Hospita
and the Interna
International
Proceedings Report
CM
MY
CY
CMY
tal Federation
International Hospi le des Hpitaux
ationa
Fdration Intern acional de Hospitales
Federacin Intern
Training Man
ual
on
Tuberculosis
& Multidr
Control, Treatme ug-resistant TB
nt & Prevention
for
Hospital/Clinic
/Health Facility
Managers
with support
from Lilly
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IHF reference
Activities
The diverse and various initiatives include:
IHF Leadership Summit:
The Leadership Summit is an invitation-only event, organised by
the International Hospital Federation (IHF), for top level decision
makers on hospital issues from National Hospital Associations,
Ministries of Health and IHF Governing Council members.
Industry representatives are also invited, with whom discussions
are held on the needs and motivations of both suppliers and
consumers in a non-commercial environment.
The Summit marks the beginning of a new direction for the IHF
and for its members, as it provides an initial opportunity for the
leaders of IHFs constituent organizations to reflect together on
their individual and common goals and on the problems they
collectively confront. The inaugural event was held in Paris,
France, in May 2009. The next meeting is to be held in USA, in
June 2010.
Development of a Training Manual for Tuberculosis (TB) and
MultiDrug Resistant-Tuberculosis (MDRTB) Control for
Hospital/ Clinic/Health Facility Managers. The target audience
of this manual are managers of hospitals, clinics and health
service facilities, to prepare them to make informed decisions
to support therapies and drugs used in the treatment of TB
and MDRTB; and to train them to implement infection control
programmes so as to protect both staff and uninfected
patients from TB transmission within healthcare facilities. This
project, which remains ongoing, is part of the Lilly MDR TB
Partnership (www.lillymdr tb.com) in which we became a
partner in 2004.
MDR-TB Workshops:
TB Hospital Managers Training SeminarPretoria, South
Africa (2006); Beijing, China (2008); Mumbai, India (2009)
Inter-professional MDR-TB Infection Control Training
Seminars Cape Town, South Africa (2007); Rio de Janeiro,
Brazil (2009); Durban, South Africa (2009).
First Global Forum on Human Resources for HealthGHWA,
Kampala, Uganda (2008).
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President-Designate
Mr THOMAS C DOLAN
Chief Executive Officer
AMERICAN COLLEGE OF
HEALTHCARE EXECUTIVES
One North Franklin Street
Suite 1700
Chicago, Illinois 60606-3491
UNITED STATES OF AMERICA
Tel: +1 312 424 9365
Fax: +1 312 424 0023
E-mail: tdolan@ache.org
Mr GERARD VINCENT
Dlgu Gnral
FEDERATION HOSPITALIERE DE
FRANCE
1 bis Rue Cabanis
75014 Paris
FRANCE
Tel: +33 1 44 06 84 42 / 44
Fax: +331 44 06 84 45
E-mail: g.vincent@fhf.fr /
l.maute@fhf.fr
Dr MUKI REKSOPRODJO
President Director & CEO
RUMAH SAKIT METROPOLITAN MEDICAL CENTRE (MMCH)
JlHR Rasuna Said Kav C-21
Kuningan Jakarta Selatan 12940
INDONESIA
Tel: +6221 72791383, 72791404;
Fax: +6221 7252026
Email: mukirekso7@gmail.com
Dr TAI-CHUN YOO
President
KOREAN HOSPITAL ASSOCIATION
35-1, Mapo-Dong, Mapo-Gu, Seoul
KOREA
Tel: +822 718 754 Ext 183
Fax: +822 718 7522
Email: intlaffairs@kha.org.kr
Dr ERIK KREYBERG NORMANN
President
NORWEGIAN HOSPITAL & HEALTH SERVICE ASSOCIATION
Nedre Slottsgt. 7, 0157 Oslo
NORWAY
Tel: +47 22 40 25 50
Fax: +47 22 40 55 51
Email: erik.normann@helse-sorost.no
Prof CARLOS PEREIRA ALVES
Vice Chair
ASSOCIACAO PORTUGUESA PARA O DESENVOLVIMENTO
HOSPITALAR
Av. Antnio Augusto de Aguiar, 32-4
1050-016 Lisboa
PORTUGAL
Tel: +351 21 37 83 / 66
Fax: +351 21 37 73
Email: ihf@ihf.min-saude.pt
Dr LEKE PITAN
Former Commissioner for Health
Lagos State
House G40C, Road 2
Victoria Garden City, Lagos
NIGERIA
Tel: +234 1 775 4544 /
+234 803 7787834 /
+44 7785 764 692
Email: drlekepitan@yahoo.com
Dr THABO LEKALAKALA
Director Hospital Management
and Planning
DEPARTMENT OF HEALTH
Street Hallmark Building
231 Proes Street
001 Pretoria
SOUTH AFRICA
Tel: +27 12 312 0930
Fax: +27 12 312 3388
Email: lekala@health.gov.za
Dr DELON WU
President
TAIWAN HOSPITAL ASSOCIATION
25F, No29-5
Sec. 2, Jung jeng E. Road
Danshuei Township, Taipei County
TAIWAN
Tel: +886 22 808 3300
Fax: +886 22 808 3304
Email: hatw@hatw.org.tw
Mrs ALISON KANTARAMA
President
UGANDA NATIONAL ASSOCIATION OF HOSPITAL
ADMINISTRATORS (UNAHA)
Mulago Hospital
PO Box 7051, Kampala
UGANDA
Tel: +256 414 554 748
Fax: +256 414 532 591
Email: alisonkantarama@yahoo.com
Mr ABDUL SALAM AL-MADANI
President
INDEX HOLDING
Dubai Healthcare City
Block B, Offices 203 303
P.O.Box 13636, Dubai
UNITED ARAB EMIRATES
Tel: +97 14 362 4717
Fax: +97 14 362 4718
Email: index@emirates.net.ae
Prof STEPHEN BARNETT
Chief Executive
NHS CONFEDERATION
29, Bressenden Place
London SW1E 5DD
UNITED KINGDOM
Tel: +44 (0) 20 7074 3281
Fax: +44 (0) 844 774 4319
Email: Steve.Barnett@nhsconfed.org;
natasha.mal@nhsconfed.org
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Eric de Roodenbeke
Director General
Eric de Roodenbeke assumed the position of
Director General of the International Hospital
Federation in June 2008. Between July 2007 and May 2008 he was
Senior Health Specialist at the World Health Organization (WHO) for
the Global Health Workforce Alliance (GHWA) during which time he
was involved in support country action programmes to develop a
response to the HRH crisis; development of strategies for regional
networks in support of HRH development and was the focal point
for follow-up actions in Francophone countries. He was Senior
Health Specialist at the World Bank (AFTH2 & WBI) from 2004 to
2006 in which time he was Team leader (TL) for various health
intervention, educational, management and capacity building
programmes mostly in Africa. He was Director of the 700-bed
University Hospital of Tours, and Senior Officer responsible for
hospital and health financing interventions at the French Ministry of
Foreign Affairs from 2001 to 2003 and 1999 to 2001, respectively.
Between 1996 and 1998, he was Senior Officer on hospital policy
expertise at the French Ministry of Cooperation. From 1994 to 1996,
he was Deputy Director of the 870-bed University Hospital of
NANTES. 1989 to 1994, Dr de Roodenbeke was the Expert, task
team leader for a project involving construction, equipment ,
management of a 500- bed hospital in, Burkina Faso. He was
Deputy Director of Epinal- Vosges (France) General Hospital from
1984 to 1989. Dr de Roodenbeke has published widely on hospital
organisation, health systems reforms human resources and health
facility management, health policy, insurance and financing in
developed and developing countries. Dr de Roodenbeke holds a
Ph.D. in health economics - University of Paris 1, Sorbonne (France);
a Hospital Administration Diploma from ENSP Rennes (France); and
a Diploma in Public Health from the University of Nancy (France). He
speaks fluent French (native language) and English and basic Greek
and German. He is a member of various social organizations and is
affiliated to the French Health Economics Society.
Sev Lucas
Membership Manager
Sev Lucas has a Masters degree in public health in
developing countries and is a graduate of a Masters in
health economics in developing countries from the University of
Clermont Ferrand (CERDI, Center for Studies and Research on
International Development). Sev joined IHF in January 2009. She is
responsible for member liaison activities and support of designated
IHF projects. She is also in charge of development of the health
system knowledge database and in charge of the newsletter.
Sev is from Bretagne, northwestern region of France and enjoys
skiing, sailing, surfing, traveling and playing the saxophone. She
speaks fluent French, Spanish, English and she is learning
Portuguese
Dwight Moe
Dwight Moe joined the IHF in 2003 and was the
Projects and Events Manager. Born in Honolulu,
Hawaii, he lived in North America, Asia and Europe.
Dwight did his studies at the University of Minnesota
in International Relations and Chinese. He has over ten years of
experience in event planning and operations. His career has led him
around the world organising and managing travel events for major
clients in the automotive, financial and pharmaceutical industries. He
and his wife enjoy cooking, skiing and travel.
Dwight left the IHF in December 2009 to pursue further career
goals.
Sheila Anazonwu
Ccile Reynes
French Translator
oined the IHF in 2000 as French Translator, on a parttime basis. Since 2004 began working on a free-lance
basis.
Loly Vaswani
Spanish Translator
joined the IHF as part-time Spanish translator in 1988.
In 1990 she moved to Malaga, Spain, but continued
to work for the IHF. Since 2004 she began working on
a free-lance basis.
Hospital and Healthcare Innovation Book 2009/2010 137
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IHF Consultants
Audit & Conseil de Leman
13 Chemin du Levant, 01210 Ferney Voltaire, France
Tel: +33 (0) 450 40 75 76 +33 (0) 450 40 75 76;
Fax: +33 (0) 450 40 98 85
email: info@ac-leman.com / Contact: M. Laurent Forstmann
Haysmacintyre, Fairfax House,
15 Fulwood Place, London WC1V 6A, UK
Tel: +44 (0)20 7969 5500; F +44 (0)20 7969 5600
Email: rpierce@haysmacintyre.com / Contact: Mr. Ray Pierce
NBM-Europe.Com
373 Route du Nant, ZA de Magny, 01280 Prevessin-Mons, France
Tel: +33 (0) 450 28 07 29 +33 (0) 450 28 07 29;
Fax: +33 (0) 450 28 08 04
email: infor@nbm-europe.com / Contact: M. Olivier Bail
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ARGENTINA
CONFEDERACION ARGENTINA DE CLINICAS
Tucuman 1668 2do - 4 piso
1050 Buenos Aires, ARGENTINA
Tel: +54 11 4373 2315;
Fax: +54 11 4372 3229
Internet: www.caes.com.ar
CAMARA ARGENTINA DE
EMPRESAS DE SALUD
Tucuman 1668 2ndo-4 piso
1050 Buenos Aires, ARGENTINA
Tel : +54 11 4372 5915/5762
Fax: +54 11 4372 3229
Internet: www.caes.com.ar
AUSTRALIA
AUSTRALIAN HEALTHCARE ASSOCIATION
Suite 4 Level 1 99 Northbourne Avenue
2600 Turner, AUSTRALIA
Tel : +61 2 6162 0780;
Fax: +61 2 6162 0779
Internet: www.aushealthcare.com.au
AUSTRIA
Abteilung VII/3
BUNDESMINISTERIUM FR GESUNDHEIT, FAMILIE UND JUGEND
Radetzkystrae 2, A-1030 Wien
AUSTRIA
Tel: +43 1 711 00-0;
Fax +43-1 711 00-14300
Internet: www.bmgfj.gv.at
BAHRAIN
MINISTRY OF HEALTH
PO Box 12
Manama, BAHRAIN
Tel: +973 17 252755
Fax: +973 17 27 0044
Internet: www.moh.gov.bh
BELGIUM
ASSOCIATION BELGE DES HOPITAUX - ASBL
Place A. Van Gehuchten 4
1020 Brussels, BELGIUM
Tel: +322 477 3910
Fax: +322 477 3920
Internet: www.hospitals.be
SANTHEA
9 Quai au Bois de Construction
1000 Brussels, BELGIUM
Tel : +322 210 4270
Fax: +322 511 0454
Internet: www.santhea.be
GERMANY
DEUTSCHE KRANKENHAUSGESELLSCHAFT
Bereich Politik Wegelystrasse 3
10623 Berlin, GERMANY
Tel: +49 30398011014
Fax: +49 30398013011
Internet: www.dkgev.de
GREECE
MINISTRY OF HEALTH AND SOCIAL SOLIDARITY
17 Aristotelous Street
10187 Athens, GREECE
Tel: +30 210 5248225
Fax: +30 210 5236023
Internet: www.mohaw.gr
HONG KONG (SPECIAL ADMINIST. REGION: CHINA)
HOSPITAL AUTHORITY
5/F Hospital Authority Building
147B Argyle Street
Kowloon, HONG KONG
(Special administ. Region: China)
Tel: +852 2805 6769
Fax: +852 2881 8058
Internet: www.ha.org.hk
HUNGARY
MAGYAR KORHAZSZO VETSEG
(Hungarian Hospital Associaton)
Ibrahim u. 19, 1125 Budapest, HUNGARY
Tel: +361 12145118 /+36 30 9967185
Fax: +361 12145159
Internet: www.korhazszovetseg.hu
INDONESIA
INDONESIAN HOSPITAL ASSOCIATION
Jl. Boulevard Artha Gading A-7A
No 28 Kelapa Gading
14350 Jakarta Utara, INDONESIA
Tel: +62214585783
Fax: +62214585783
Internet: www.pdpersi.co.id
ITALY
FEDERAZIONE ITALIANA AZIENDE SANITARIE ED OSPEDALIERE
Corso Vittorio Emanuele II 24, 186 Roma, ITALY
Tel: +39 06 6992 4145
Fax: +39 06 6780907
Internet: www.fiaso.it
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JAPAN
JAPAN HOSPITAL ASSOCIATION
13-3 Ichiban-cho Chiyoda-ku
1028414 Tokyo, JAPAN
Tel: +813 3265 0077
Fax: +813 32302898
Internet: www.hospital.or.jp
KOREA
KOREAN HOSPITAL ASSOCIATION
Mapo Hyun Dai Bldg
35-1 Mapo-dong, Mapo-gu
121-737 Seoul, KOREA
Tel: +822 718 7503
Fax: +822 7187522
Internet: www.kha.or.kr
KUWAIT
MINISTRY OF PUBLIC HEALTH
P O Box 5, 13001 Safat, KUWAIT
Tel/Fax: +965 486 3703
LEBANON
SYNDICAT DES HOPITAUX DU LIBAN
Ghazal Bldg - 7th Floor, PO Box 662-165 Adlieh
662 Beirut, LEBANON
Tel: +961 1 611011
Fax: +961 1 616772/3/4
Internet: www.syndicateofhospitals.org.lb
LUXEMBOURG
ENTENTE DES HOPITAUX LUXEMBOURGEOIS
13-15 rue Jean-Pierre Sauvage
2514 Luxembourg, LUXEMBOURG
Tel: +352 424 142
Fax: +352 425 550
Internet: www.ehl.lu
MEXICO
ASOCIACION NACIONAL DE HOSPITALES PRIVADOS
Pablo Casals 640
44670 Guadalajara Jalisco, MEXICO
Tel: +52 333 669 881
Fax: +52 333 669 882
NETHERLANDS
NVZ vereniging van ziekenhuizen
Postbus 9696, 3506 Utrecht, NETHERLANDS
Tel: +31 30 273 9451
Fax: +31 30 273 9780
Internet: www.nvz-ziekenhuizen.nl
NIGERIA
IHF NIGERIA CHAPTER: Nigerian Hospital Association
First Foundation Place
36 Opebi Road, Ikeja, Lagos, NIGERIA
Tel: +234 803 3547371
Internet: www.ihfnigeria.org
NORWAY
NORSK SYKEHUS-OG HELSETJENESTEN
Nedre Slottsgt 7, 1570 Oslo, NORWAY
Tel: +47 22 402 555;
Fax: +47 22 414 871
Internet: www.nsh.no
PERU
FEDERACIN PERUANA DE ADMINISTRADORES
DE SALUD (F.E.P.A.S)
(Peruvian Federation of Health Administrators)
PSJE, Jorge Buckley 340, DPTO 203
San Antonio Miraflores, Lima 18, PERU
Tel: +51 1 999 100 628 / 971 56406 / 910 83575
Internet: www.fepas.org.pe
PHILIPPINES
PHILIPPINE HOSPITAL ASSOCIATION
14 Kamias Road, Quezon City, PHILIPPINES
Tel: +63 2 922 7674/75
Fax: +63 2 929 2219
Internet: www.philhospitals.org
PORTUGAL
ACSS-ADMINISTRACAO CENTRAL DOS
SERVICOS DE SAUDE
Av.Antonio Augusto de Aguiar 32-4
1050-016 Lisbon, PORTUGAL
Tel: +351 21 317 974
Fax: +351 21 317 976
Internet: www.apdh.pt
PUERTO RICO
ASOCIACION DE HOSPITALES
DE PUERTO RICO
Villa Nevarez Professional Center
Suite 101- Villa Nevarez
927 San Juan PR, PUERTO RICO
Tel: +1 787 764 0290
Fax: +1 787 753 9748
Internet: www.asociacionhosppr.org
SAUDI ARABIA
MINISTRY OF HEALTH
International Health Department
11176 Riyadh, SAUDI ARABIA
Tel: +966 1 408 1233
Internet: www.moh.gov.sa/en/ (Include)
SOUTH AFRICA
DEPARTMENT OF HEALTH
231 Proes Street Hallmark Building
001 Pretoria, SOUTH AFRICA
Tel: +27 12 312 0930
Fax: +27 12 312 3388
Internet: www.doh.gov.za
SWEDEN
THE SWEDISH ASSOCIATION OF LOCAL
AUTHORITIES AND REGIONS (SALAR)
SE-118 82 Stockholm, SWEDEN
Tel: +468 452 7200
Fax: +46 8 452 7210
Internet: www.skl.se
SWITZERLAND
H+ LES HOPITAUX DE SUISSE
Lorrainestrasse 4a, 3013 Bern, SWITZERLAND
Tel: +41 31 335 1111 / 335 11 14
Fax: +41 31 335 1170
Internet: www.hplus.ch
TAIWAN
HOSPITAL ASSOCIATION OF TAIWAN
25F n 29-5 section 2 Chung Cheng East Road Damshui
Township, Taipei Hsien, TAIWAN
Tel: +886 2 2833 8829; +886 2 2808 3300 ext. 24;
Fax: +886 2 2832 3571
Internet: www.hatw.org.tw
TUNISIA
MINISTERE DE LA SANTE PUBLIQUE
Tunis 1030 TUNISIA
Tl : (216) 71 56 06 85
Fax : (216) 71 26 04 74
Internet: www.ministeres.tn/html/ministeres/sante/html
UK ENGLAND
NHS CONFEDERATION
29 Bressenden Place
London SW1E 5ER, UK ENGLAND
Tel: +44 207 074 3280/1
Fax: +44 207 074 3201
Internet: www.nhsconfed.org
USA
AMERICAN HOSPITAL ASSOCIATION
325 Seventh Street NW
Washington DC 20004-2802, USA
Tel: +1 312 626 2363/ +1 202 638 1100
Fax: +1 202 626 2345
Internet: www.aha.org
UGANDA
UGANDA NATIONAL ASSOCIATION OF HOSPITAL
ADMINISTRATORS (UNAHA)
c/o Mulago Hospital, PO Box 7051
Kampala, UGANDA
Tel: +256 414 554 748
Fax: +256 414 532 591
UNITED ARAB EMIRATES
DEPARTMENT OF HEALTH AND
MEDICAL SERVICES
P O Box 4545, Dubai,
UNITED ARAB EMIRATES
Tel: +971 4 370 031
Fax: +971 4 374 563
Internet: www.dohms.gov.ae
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HILLERD HOSPITAL
Helsevej 2, 3400 Hillerd,
DENMARK
Tel: +45 48 29 48 29
Internet: www.hillerodhospital.dk
FINLAND
HOSPITAL DISTRICT OF HELSINKI AND UUSIMAN
PO Box 100, FI 000 HUS, FINLAND
Tel: +358 9 471 71200
Fax : +358 9 471 71206
Internet: www.hus.fi
GERMANY
LIPPISCHE NERVENKLINIK DR. SPERNAU GmbH & CO.KG
Waldstrae 2, 32105 Bad Salzuflen, GERMANY
Tel: +49 (0) 5222 188-103/ +49 (0)5222 188-0
Fax: +49 (0) 5222 188-199
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KENYA
THE NAIROBI HOSPITAL
PO Box 30026, Nairobi, KENYA
Tel: +254(0) 20 284 5000 / 20 284 6000 /
+254 (0) 722 204 114
Fax: +254(0) 20 272 8003 / 20 272 5237
Internet: www.nairobihospital.org
MEXICO
HOSPITAL SAN JAVIER
Av. Pablo Casals 640,
Col. Prados Providencia Esq. con Eulogio Parra
Guadalajara, 44670 Jalisco. MEXICO
Tel: +52 (33) 3640 1128 / 3669 0222
Internet: www.sanjavier.com.mx
MONGOLIA
TEGS KHUSEL HOSPITAL
49 Peace Avenue, Ulaanbaatar, MONGOLIA
Tel/Fax: +976 11 458 191
MOROCCO
ASSOCIATION MAROCAINE DES
GESTIONNAIRES HOSPITALIERS (A.M.G.H.)
7 Rue Kharoub Hay Riad, Rabat, MOROCCO
Tel: +212 53 37 71 63 96/ 661 14 40 52;
Internet: www.amgh.ma
NETHERLANDS
AMC Academisch Medisch Centrum
Meibergdreef 9, 1105 Amsterdam, NETHERLANDS
Tel: +31 20 566 2106; Fax: +31 20 691 2796
Internet: www.amc.uva.nl
ACADEMISCH ZIEKENHUIS MAASTRICHT
Postbus 5800, 6202 AZ Maastricht, NETHERLANDS
Tel: +31 43 387 65 43
Fax: +31 43 387 78 78
Internet: www.azm.nl
REVALIDATIECENTRUM RIJNDAM ADRIAANST
Postbus 23181, 3001 KD Rotterdam
NETHERLANDS
Tel: +31 181 658 571; Fax: +31 181 626 848
NIGERIA
TOTAL HEALTH TRUST
2 Marconi Road, Palmgrove Estate,
Lagos State, NIGERIA
Tel: +234 (0)1 774 7150 / +234 (0)1 804 5263
Fax: +234 (0)1 555 0508
Internet: www.totalhealthtrust.com
PAKISTAN
AGA KHAN UNIVERSITY HOSPITAL
Stadium Road, P.O. Box 3500,
Karachi 74800, PAKISTAN
Tel: +92 21 3493 0051
Fax: +92 21 3493 4294 / 3493 2095
Internet: www.aku.edu
SPAIN
HOSPITAL PLATO FUNDACIO PRIVADA
C/ Plato 21, 08006 Barcelona
SPAIN
Tel: +34 933 069 900
Internet: www.hospitalplato.com
SERVICIO DE SALUD DEL
PRINCIPADO DE ASTURIAS
Plaza del Carbayon 1, 33011 Oviedo
SPAIN
Tel: +34 98 510 6601 / +34 98 510 8500
Fax: +34 98 506 633 / +34 98 510 8511
Internet: www.asturias.es
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IHF reference
Honorary Members
Members elected by the General Assembly for special services rendered to the IHF or to the healthcare field in general
AUSTRALIA
R H Kronborg MBE
6 Pentland Road
3225 Point Londsdale
Victoria, AUSTRALIA
Dr Errol Pickering
13 Firestone Court
Robina Woods
The Gold Coast
4226 Queensland, AUSTRALIA
CANADA
Jean-Claude Martin
710-500 Rue de la Montagne
Montreal H3C 4T6
CANADA
FINLAND
Arvo Relander
Luuvaniementie 3 A 5
Helsinki
FINLAND
FRANCE
L Peyssard
12 Avenue Maurice Barres
13008 Marseille
FRANCE
GERMANY
Dr Klaus Proessdorf
Theodor Schwannstr. 10
50735 Koln-Riehl
GERMANY
HONG-KONG
(SPECIAL ADMINISTRATIVE REGION
CHINA)
Dr Een Kiong Yeoh
Flat 18A, Tower II, Ruby Court
55 South Bay Road
Hong-Kong
(SPECIAL ADMINISTRATIVE REGION CHINA)
MEXICO
Dr G Fajardo Ortiz
Juarez 14 Casa 11
Tlacopac San Angel
1040 Deleg Alvaro Obregon CP
MEXICO
THE NETHERLANDS
Dr Ton Krol
Postbus 2621
2002 RC Haarlem
THE NETHERLANDS
Dr Rene Peters
Weerdsingel O.Z.82 Bis
3514 Utrecht
THE NETHERLANDS
POLAND
Prof T Tolloczko
Wiejska 9/9
480 Warsaw, POLAND
PORTUGAL
Prof J M Caldeira Da Silva
Av Antonio Augusto de Aguiar 144 - 2 D
1050-021 Lisbon, PORTUGAL
SWEDEN
Prof Per-Gunnar Svensson
Fockgrand 1
260 93 TOREKOV
SWEDEN
T Thor
Koltrastvagen 39
183 51 Taby, Sweden
SWITZERLAND
Dr Franois Kohler
Talgut Zentrum 22-602
3063 Ittigen, SWITZERLAND
Ferdinand Siem TJam, MD MPH
Chemin du Ruisseau 2C
1291 Commugny VD, SWITZERLAND
Dr Andrei Issakov
4b chemin Edouard Sarasin
1218 Grand Saconnex
SWITZERLAND
UNITED KINGDOM
D Maitland
128 Osidge Lane
London N14 5DN
England - UK
Acknowledgements
The International Hospital Federation and Pro-Brook Publishing
would like to thank all the contributors to the publication and those
involved in the production process.
Pro-Brook Publishing
Tim Probart, Publisher; Trevor Brooker, Publisher; Stephen King, Business
development; Susan Pulman, Business development; Simon Marriott, Art direction
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GE Healthcare
The burden of surgical diseases is large and is increasing, and there are enormous gaps in access to surgery between high and
low income countries. Surgical services may be cost effective at the district level in LMICs, and providing access to essential
surgery should be viewed as primary prevention of death and disability. The integration of essential surgical services into
health systems, within the context of primary healthcare reforms, will surely improve population health.
Johnson Controls
JOHNSON CONTROLS uses its 125 years of experience to help healthcare organizations create comfortable, safe and sustainable
healing environments while providing measurable results. By utilizing our expertise in energy and sustainability, facilities,
building and technology infrastructure, healthcare organizations can improve their financial results, the environment of care and
their standing in the community. Johnson Controls provides design assist and construction management, funding solutions,
network integration solutions for clinical and non-clinical systems, energy management and central utility plants, operations
support and best practices, systems maintenance and facility management services. http://www.johnsoncontrols.com
Aramark
ARAMARK is a global leader in professional services, providing award-winning food services, management of facilities, assets, and
clinical technology, and uniform/career apparel to healthcare institutions and other businesses. In FORTUNE magazines 2009 list
of Worlds Most Admired Companies, ARAMARK ranks number one in its industry, consistently ranking since 1998 as one of the
top three most admired companies in its industry. ARAMARK seeks to responsibly address key issues by focusing on employee
advocacy, environmental stewardship, health and wellness, and community involvement. Headquartered in Philadelphia,
Pennsylvania (USA), ARAMARKs 255,000 employees serve clients in 22 countries. Visit www.aramark.com to learn more.
HCA International
HCA International owns six leading private hospitals in London, each with international reputations for the highest standards of
care. They are: The Wellington, the largest private hospital in the UK, The London Bridge Hospital, The Harley Street Clinic, The
Portland Hospital for Women and Children, The Lister Hospital and The Princess Grace Hospital.
HCA hospitals treat approximately 350,000 patients annually and specialise in complex medical procedures. The HCA Cancer
Network, for example, is the largest private provider of cancer care in the UK and is the best equipped outside the NHS.
In the past five years, HCA has invested over 100 million in capital expenditure including the latest diagnostic and treatment
technology. HCA International is owned by Hospital Corporation of America, the largest for-profit hospital operator in the United
States.
Project1:Layout 1
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C
Corp
orate P
Partnership
p Program
Benefitss include:
Yeaar-long access to decision makers from around the world.
Exclusive opportunity for relationship building and shari
a ng ideas and experiences
bettween corporate leaders an
a d executives in the hospital sector.
Acccess to IHF policy and advo
ocacy communications
I
-
Advert
v ising and marketing opportunities
How Can Health Organizations Get the Most Out of Their Data?
Copyright 2009 ESRI. All rights reserved. The ESRI globe logo, ESRIThe GIS Company, ESRI, ArcMap, ArcInfo, www.esri.com, and @esri.com are trademarks, registered trademarks, or service marks of ESRI in the United States, the
European Community, or certain other jurisdictions. Other companies and products mentioned herein may be trademarks or registered trademarks of their respective trademark owners.
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