In the last couple of months of completing my law thesis I found myself struggling to put things into the simplest terms. All the ideas I had been researching and writing about were coming together like the pieces of a puzzle, but I kept wanting to re-explain everything in great detail in every chapter, and sometimes even within a chapter. The word count was growing every day, but my arguments and conclusions weren’t necessarily getting any clearer….more

Selected health budget vote speeches from Gauteng, the Western Cape and North West provinces….more

MESSAGE FROM THE DIRECTORATE: OCCUPATIONAL HEALTH, SAFETY AND ENVIRONMENTAL MANAGEMENT

 WHAT TO DO IN THE EVENT OF A TREMOR/ EARTHQUAKE

 Although earthquakes/tremors do not commonly occur in most parts of South Africa, it is still considered necessary to take note of the below guidelines regarding what to do if an earthquake, severe tremor (or tremor as recently happened) should occur:

 IF INDOORS

• Stay calm and kneel or sit on the floor (before the tremors knock you down). This position protects you from falling and allows you to still move around if necessary.
• Crawl under a large sturdy object (such as a strong table or desk) to avoid being struck by falling debris from the roof/ceiling/walls/windows. Cover your head/neck with your arms/hands.
• Be prepared to move with your shelter if the shaking shifts it around.
• If there is nothing sturdy to crawl under then position yourself at an interior wall near the centre of the building. Interior walls are less likely to collapse than outer / exterior walls.
• Stay away from windows, mirrors, loose standing cupboards, shelves, light fixtures and ceiling fans (i.e. anything that could fall on you).
• Stay inside until the tremors and shaking stops and until it is considered safe to go outside.
• Use the stairs to evacuate from a building (not the elevator/lift) and only evacuate when it is considered safe to do so. Do not exit a building during the tremors/shaking.
• Be aware that the power may go out and sprinkler systems or fire alarms may be activated. 

IF OUTDOORS

• Stay calm and move away from exterior walls of buildings to avoid being struck by falling debris from collapsing walls, windows and roof tiles/sheeting.
• Move away from power cables, trees and structures that may collapse and fall on you.
• Once in the open, stay there until the tremors/shaking stops while covering your head and neck with your arms and hands. 

IF DRIVING

• Stay calm and stop the vehicle as quickly but as safely as possible.
• Do not stop next to buildings and large trees or under bridges and overhead power lines.
• If considered safe to do so, stay in the vehicle.
• Proceed cautiously after the earthquake has stopped avoiding damaged roads/bridges. 

IF TRAPPED UNDER DEBRIS

• Stay calm and do not disturb unstable structures which may cause further collapse.
• Try not to inhale dust by covering your mouth with a handkerchief or clothing.
• If possible, shout or tap on a pipe, wall or any other object so rescuers can locate you.

Jonathan De Villiers

DIRECTOR: OCCUPATIONAL HEALTH, SAFETY AND ENVIRONMENTAL MANAGEMENT

I was interested to see this paper on the limited success of implementation of clinical practice guidelines (with thanks to Irina Ibraghimova). The emphasis is on high-income countries. I would be interested to hear perspectives on implementation of clinical practice guidelines in low-income settings.

Hand Clin. 2014 Aug;30(3):361-365. doi: 10.1016/j.hcl.2014.04.007. Epub 2014 May 27. Clinical Practice Guidelines: What Are They and How Should They Be Disseminated? [restricted access] Graham B.

Abstract

Clinical practice guidelines summarize the available evidence for patient management in a format that is easy for clinicians to use. These guidelines usually use methodologically rigorous principles for retrieving and evaluating the literature and for establishing consensus among work group members, but implementation by clinicians is often incomplete. The reasons why guidelines fail to gain widespread acceptance vary with the topic and clinician group. Successful dissemination of practice guidelines requires an understanding of the barriers to implementation and the use of multiple strategies to address these. This article examines the factors affecting implementation and the approaches to overcoming these obstacles.

Key points

• Clinical practice guidelines use rigorous methods to find, evaluate, and summarize the literature into a series of points that should help guide clinicians in their management of patients.
• Clinicians are often reluctant to implement the recommendations of practice guidelines and the reasons for this vary with the topic and with the practice context.
• Multiple strategies to overcome the barriers preventing implementation should be used together and be selected from the particular characteristics of the target clinician population.

EXTRACTS (selected by Neil PW)

‘The evidence-based practice movement that started in the 1980s had at its foundation the idea that outcomes would improve if patients were managed using principles developed from medical knowledge accumulated from a body of methodologically sound clinical research. Clinical practice guidelines (CPGs) sought to summarize this medical evidence into general management pathways that clinicians could use to provide patients with the best care possible. However, despite this seemingly laudable objective, CPGs in general have had, in most instances, a modest impact on day-to-day practice. In some cases CPGs have been essentially ignored by most clinicians. The reasons for the failure of CPGs to influence practice are varied but, before examining these, it is important to understand how CPGs are developed (although these methods continue to evolve) and what they represent.’

‘Why do physicians not use CPGs?

• Implementation of CPGs by clinicians may be poorer than expected despite the methodologically rigorous process in the CPG development…
• Lack of Awareness…
• Lack of Familiarity…
• Lack of Agreement…
• Lack of Self-efficacy…
• Lack of Outcome Expectancy…
• Inertia of Previous Practice…
• External Barriers may include simple factors such as the time required to put into practice a particular recommendation. Guidelines may be perceived as difficult to implement or physicians may think that recommendations conflict with patient preferences. In addition, implementation of guidelines may also be affected by practice circumstances, such as facilities that are under the control of an institution, increased costs, decreased reimbursement, or the perception of an increased vulnerability to liability…’

How and why do physicians change their practices?

The ways that physicians change their behavior has been reviewed by Molding and colleagues.10 They identify 8 key principles that have an important impact on changing physician behavior and they conclude that these factors have to be taken into consideration in the dissemination of evidence-based CPGs:

• – Recognition that change in behavior is a process
• – Thought leaders (change agents) must identify with the concerns of clinicians who are the targets of CPGs
• – Assessment of the readiness to change and the specific barriers to these changes
• – The recognition that multiple strategies for change are more effective than any single strategy; education of clinicians must address the domains of knowledge, attitudes, and skill development; education strategies must encourage interaction and participation by clinicians
• – Social influences may play an important role
• – Environmental support (ie, support by institutions) is important to both initiating change and maintaining the new status quo

The investigators concluded that consideration of these factors should allow the development of effective dissemination strategies that address the specific barriers to change of the target clinician population… The reasons underlying the failure of physicians to adopt the recommendations contained in CPGs are varied and dictate a similarly varied and multidimensional approach to informing, reminding, and reinforcing clinician behavior.

— Let’s build a future where people are no longer dying for lack of healthcare knowledge: Join HIFA www.hifa2015.org

(With thanks to Dieter Neuvians and HESP Newsletter – highly recommended – hesp-news.org/ )

A new paper in The Lancet infectious Diseases finds that access to antibiotics has increased by 36% in 10 years, and concludes: ‘To prevent a striking rise in resistance in low-income and middle-income countries with large populations and to preserve antibiotic efficacy worldwide, programmes that promote rational use through coordinated efforts by the international community should be a priority.’ The paper refers to the WHO Factsheet on Antimicrobial Resistance, updated in April 2014:

http://www.who.int/mediacentre/factsheets/fs194/en/

CITATION: Thomas P Van Boeckel et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. The Lancet Infectious Diseases, Volume 14, Issue 8, Pages 742 – 750, August 2014. doi:10.1016/S1473-3099(14)70780-7

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(14)70780-7/fulltext?_eventId=login

SUMMARY

Background: Antibiotic drug consumption is a major driver of antibiotic resistance. Variations in antibiotic resistance across countries are attributable, in part, to different volumes and patterns for antibiotic consumption. We aimed to assess variations in consumption to assist monitoring of the rise of resistance and development of rational-use policies and to provide a baseline for future assessment.

Methods: With use of sales data for retail and hospital pharmacies from the IMS Health MIDAS database, we reviewed trends for consumption of standard units of antibiotics between 2000 and 2010 for 71 countries. We used compound annual growth rates to assess temporal differences in consumption for each country and Fourier series and regression methods to assess seasonal differences in consumption in 63 of the countries.

Findings: Between 2000 and 2010, consumption of antibiotic drugs increased by 36% (from 54 083 964 813 standard units to 73 620 748 816 standard units). Brazil, Russia, India, China, and South Africa accounted for 76% of this increase. In most countries, antibiotic consumption varied significantly with season. There was increased consumption of carbapenems (45%) and polymixins (13%), two last-resort classes of antibiotic drugs.

Interpretation: The rise of antibiotic consumption and the increase in use of last-resort antibiotic drugs raises serious concerns for public health. Appropriate use of antibiotics in developing countries should be encouraged. However, to prevent a striking rise in resistance in low-income and middle-income countries with large populations and to preserve antibiotic efficacy worldwide, programmes that promote rational use through coordinated efforts by the international community should be a priority.

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Let’s build a future where people are no longer dying for lack of healthcare knowledge: Join HIFA www.hifa2015.org