Managing the epidemiological & demographic challenges facing hospitals services in Kwa-Zulu-Natal, South Africa.

CC JINABHAI, PD RamdasNelson R Mandela School of MedicineFaculty of Health Sciences, University of Natal

KEY CHALLENGESHospital managers and policy makers faced considerable challenges after the democratic elections in 1994 to :promote and protect the health of the South African population, undergoing rapid epidemiological, cultural, socio-economic and demographic transitions.

Dimensions - Health Promoting HospitalsManagement, Governance, Changes in the epidemiological and demographic profiles of patients,Re-orientating staff attitudes to protect patient rights,Provide cost-effective, high quality care

STRATEGIC & POLICY OBJECTIVESKey to this process of revitalisation of hospitals was to provide high quality, cost-effective care, to optimally promote the health of individuals, communities and health professionals.

There are 62 ProvincialHospitalsInKZN

The hospitals are distributed over an area of about 93 000 kmbut access is difficult due to poor roads.Although the KZN Province inherited a number of disadvantaged hospitals from the previous apartheid government, it is working at improving them.

HIV/AIDS & TBThis epidemics among hospital staff and communities, has made health promotion a national priority and radically influenced the form, content and governance of health service delivery.

EM Irusen, DP Naidoo, D Sebastian, C Stone*, UG Lalloo.

Dept of Medicine & Medical Registry* King Edward VIII Hospital.

THE IMPACT OF HIV AT KING EDWARD VIII HOSPITAL PROFILE OF AN ESTABLISHED EPIDEMIC

For all years: more female than male admissions. The in-hospital mortality was 21.7-24.7% per annum. Mortality in the medical wards contributed to 73.4% of this mortality.

HIV 60% of total med. mortalityRESULTS

Impact of Maternal HIV/AIDS on Paediatric HIV Infections and MortalityMTCT > 90% of all perinatal HIV infections MTCT rates = 9% (no breastfeeding) 34% (breastfeeding)*

National IMR42/1000IMR for HIV uninfected17/1000 (CHBH)#IMR for HIV infected354/1000 (KEH)*

* Bobat et al, (1999) SAMJ 89: 646-648# Gray G, et al. Petra Study

WorkloadHealth Resource Utilisation atTertiary CentreAIDS Patients

Displacement ofPatients with Other Medical Disorders or Not Develop ThemTeachingScope of Medicine

National HIV Seroprevalence Among Antenatal Attendees

HIV Seroprevalance (%)

8.7

11.1

13.2

20.2

22.9

27.9

29.3

29.7

36.2

HIV AMONG ANTENATAL WOMEN AT KING EDWARD VIII HSP OVER TEN YEARS

HIV/AIDS and MORTALITYSA POPULATION STRUCTURE for 2009

Chart1

-2402898-296865.52351927289447.2

-2561642-241588.92513526236544.6

-2676583-82373.3263001980777.8

-2551108-8082.5219237811752.1

-2087986-7838.1149782356904.1

-1673615-77368.11213306281157.7

-1417739-276164.41103429537149.3

-1185454-4113661007095591374.7

-963295.3-399515.4926496.7512154.5

-819761.5-332865.8876623.3385256.5

-712777.4-248877.1839011.6251451.2

-589897.1-158050.5773175.9128903.6

-487473.1-87755.9688981.844459.6

-393840.1-40264.9564835.65421.5

-294239.9-11651.8430241.8180.6

-181092.2-948291104.90

-91185.801750210

-38238.6092171.60

Male survivors

Male Aids deaths

Female survivors

Female Aids deaths

Sheet1

Sheet1

-2402898-296865.52351927289447.2

-2561642-241588.92513526236544.6

-2676583-82373.3263001980777.8

-2551108-8082.5219237811752.1

-2087986-7838.1149782356904.1

-1673615-77368.11213306281157.7

-1417739-276164.41103429537149.3

-1185454-4113661007095591374.7

-963295.3-399515.4926496.7512154.5

-819761.5-332865.8876623.3385256.5

-712777.4-248877.1839011.6251451.2

-589897.1-158050.5773175.9128903.6

-487473.1-87755.9688981.844459.6

-393840.1-40264.9564835.65421.5

-294239.9-11651.8430241.8180.6

-181092.2-948291104.90

-91185.801750210

-38238.6092171.60

Male survivors

Male Aids deaths

Female survivors

Female Aids deaths

Sheet2

Males

Females

Sheet3

To date, no studies have been conductedon the impact of the HIV/AIDS epidemic on South African hospitals and their staff.The following study is an early attempt to address this gap.

FINDINGS RELATING TO HOSPITAL MANAGEMENT Since mid-1990s patients clinical profile changed Managers reported major impact of epidemic on the hospital services, increases in patient volumes, crowding out of non-emergency and non-HIV-related conditions

Few policies, guidelines or criteria for admission, treatment or dischargeClinical policies Hospital management believe: - no need for an official policy - clinician opinion should be the deciding factor Factors influencing admission: availability of beds stages of the disease perceived benefits of clinical/curative interventions There is a greater integration of TB and STD services with HIV/AIDS services

Managing patient loads Screening procedures by gateway clinics which focus on HIV- positive patients Oncology treatments and certain laboratory services referred to tertiary centres Only very ill patients admitted to hospital Patients discharged as soon as conditions are stabilised Patients only rehydrated on an OPD basis Only admitted if severely ill with complications or life-threatening conditions

Impact on non-HIV/AIDS patientsThe epidemic has resulted in: the modification of care of non-HIV/AIDS patients cardiac, respiratory and endocrine patients treated on an outpatient basis, unless critically illStaff pressures have resulted in: less monitoring shorter periods of assessment greater reliance on other categories of staffHowever, because of the long distances that patients have to travel and the lack of transport, patients and their families put pressure on staff to be admitted. This causes conflict.

Pressures on staff as a result of the HIV/AIDS epidemic Staffs clinical knowledge, skills and acumen challenged by spectrum of HIV associated conditions Staff have to make life and death decisions

Limited treatment and care options available Staff have to confront their own fears, prejudices and humanity

Staff exposed to the infection Changes in the job descriptions of staff not ratified Some staff feel that additional councillors and clinicians are needed Coping mechanisms for staff have not been developed

Risks to staffRegister of staff who are HIV positiveKept by all hospitals but inaccurate because of stigma. Staff use private sector. Needle-stick injuries

National health policy stipulates that all hospital staff are eligible for ART and counselling.

SCHOOL BASED HIV/AIDS PREVENTION School children 27% KZN population / most vulnerableKey strategies: Target primary school / secondary school pupilsHealth promoting schools prevent transmission / promote healthy behaviours

Home Based Care

Managers : Hospital, Medical, Nursing, Systems & FinancesSpecific components clearly defined key performance areas (KRAs) in performance contracts. The hospital manager : required to establish the changing morbidity and mortality profile of patients and communities, to ensure that all resources were aligned to addressing these needs and priorities. A Charter of Patient Rights was disseminated at community level to establish a partnership between patients and hospitals.

The quantitative and qualitative impact of these transformations on patients and health professionals, have important lessons for other middle-income countries; which are attempting to provide cost-effective, high quality care.

The threat of HIV/AIDS is starting to emerge as a wave of illness and death among young people.

This Province has a population of around 9 million and is extremely beautiful with modern cities and charming rural areas.Of the 63 hospitals, 56 are acute care regional and district hospitals distributed throughout the province.Some of the hospitals are difficult to access however due to poor roads. Flat tyres due to pot holes are common.

Many of the hospitals are in a poor condition the legacy of the previous apartheid government. The Province is however working at improving them.

The study was carried out jointly by the Nelson Mandela Medical School in KZN, COHSASA and the KZN DOH.Since the mid-1990s there had been a rapid change in the clinical profile of patients.Managers reported that the HIV/AIDS epidemic had had a major impact on the hospital services, with significant increases in patient volumes and crowding out of non-emergency and non-HIV-related conditions.

These changes had started as early as 1989/1990, when the hospitals first begun to treat HIV patients

There are few formal, consistent, stipulated policies, guidelines or criteria for the admission,treatment or discharge of HIV/AIDS patients at the individual hospitals. Hospital managements believed that there was no need for an official policy but that all sick patients should be assessed and that the opinion of the clinician should be the deciding factor. Primary factors influencing admission were the availability of beds, stages of the disease and perceived benefits of clinical/curative interventions.There has been a greater integration of TB and STD services with HIV/AIDS services.

Patients screening procedures have been established by means of gateway clinics with a specific focus on assessing HIV-positive patients or those with clinical conditions associated with HIV/AIDS. Owing to the extra burden being placed on hospitals by AIDS patients and the limited staff and resources, only very ill patients were admitted and they were discharged as soon as their conditions were stabilised.In some case patients are only rehydrated on an OPD basis and are only admitted if they are severely ill with complications or have life-threatening conditions.

Oncology treatments and certain laboratory services (CD4 counts,phage typing and multi-drug resistance) are referred to tertiary centres.

The epidemic has resulted in the modification of care of non-HIV/AIDS patients: Symptomatic cardiac, respiratory and endocrine patients who were previously admitted to stabilise, investigate and start management are frequently treated on an outpatient basis, unless critically ill. Staff pressures have resulted in less monitoring, shorter periods of assessment and greater reliance on other categories of staff to assess and treat.Because of the long distances that patients have to travel and the lack of transport, patients and their families put pressure on staff to be admitted. This causes conflict.

Pressures on staff as a result of the HIV/AIDS epidemicStaffs clinical knowledge, skills and acumen were challenged by the diverse spectrum of HIV-associated and related illnesses and conditions.The insidious, informal changes in the job descriptions of staff as they struggle to cope with the changing clinical load are neither acknowledged nor ratified. Staff have to manage the concerns and expectations of terminally ill patients and their families, and make life and death decisions regarding the limited treatment and care options available. Staff have to confront their own fears, prejudices and humanity in providing essential psychological and social support while they themselves are being exposed to the infection.Additiona stress on staff results from:1. Inability to provide a full clinical assessment and optimum management on HIV/AIDS and non-HIV/AIDS patients. Staff feel helpless as an increasing number of young patients die in spite what they do.Demands from patients and families for admission Some staff feel they need additional resources, including councillors and additional clinicians to assess, treat and manage the acute complications and stages of AIDS. Coping mechanisms for staff have not been developed to assist them to deal with the stress; there is little psychological support.

Registers of staff who are HIV positive are kept by hospitals but these are inaccurate because staff are concerned about the stigma of having AIDS and the possible victimisation that might follow. Thus, many prefer to use services outside the hospital in in private sector. As for needle-stick injuries, there is a national health policy which stipulates that all hospital staff are eligible for ART and counselling.