Reported competencies of junior medical doctors in managing seriously ill and injured children in South African hospitals
| dc.contributor.advisor | Smit, Liezl | en_ZA |
| dc.contributor.advisor | Redfern, Andrew | en_ZA |
| dc.contributor.author | Erasmus, Louisa Marina | en_ZA |
| dc.contributor.other | Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Paediatrics and Child Health. | en_ZA |
| dc.date.accessioned | 2021-07-08T08:10:12Z | |
| dc.date.accessioned | 2021-12-22T14:12:37Z | |
| dc.date.available | 2021-07-08T08:10:12Z | |
| dc.date.available | 2021-12-22T14:12:37Z | |
| dc.date.issued | 2020-03 | |
| dc.description | Thesis (MMed)--Stellenbosch University, 2021. | en_ZA |
| dc.description.abstract | Background The correct management of seriously ill and injured children is a critical skill for doctors with dire consequences for the patient if interventions are not appropriate and timely. While children comprise a significant part of the burden of disease, little is known about the competencies of junior doctors in managing seriously ill and injured children in South African public hospitals. This study aimed to document the resuscitation experience, reported confidence and theoretical knowledge of South African junior doctors in managing seriously ill and injured children admitted to paediatric departments, as well as the formal and informal paediatric resuscitation training opportunities utilised by them. Methodology A quantitative cross-sectional descriptive study was done. Junior doctors (interns, medical officers and registrars) working in the Department of Paediatrics of all eight of South Africa’s Medical Schools and its direct affiliated teaching hospitals, were invited to participate in an anonymous, self-administered electronic questionnaire to assess their reported levels of confidence, experience and training in the management of seriously ill and injured children. Theoretical knowledge was assessed with a set of multiple-choice questions. These doctors were purposively sampled as a likely best-case scenario of junior doctor competencies in managing seriously ill children in South African public healthcare facilities. Descriptive statistics were used to analyse data. Either Pearson chi-squared or Fisher’s exact were used to test for associations between doctor’s training experience and categorical outcome variables. Ethics approval was obtained from the Stellenbosch University Human Research Ethics Committee (S17/09/176). Results Seven South African Medical Schools participated in the study. 118 Junior doctors completed the survey; a response rate of 24%. Sixty three (53%) registrars, 35 (30%) medical officers and 20 (17%) interns participated. Most (89%) had received their undergraduate medical training at South African universities. Participants were more likely to have attended an accredited advanced paediatric than neonatal training course; 75% a paediatric and 53% a neonatal training course. Ten percent of all respondents reported no formal training in the management of seriously ill and injured children; three paediatric registrars and seven interns. Structured in-house training and assessment events on the management of seriously ill and injured children during employment are not provided on a regular basis with 42% of all respondents reportedly never having received any such formal training nor having had exposure to simulations (mock codes). Where training was provided, it was reported as infrequent (53%). Debriefing and feedback opportunities were not standard practice. Only 8% of respondents reported consistent debriefing opportunities after resuscitations, with 29% of medical officers and 46% of registrars reportedly having never had any debriefing opportunities. Forty five percent of interns and 37% registrars had reportedly never received feedback after resuscitation events. No statistically significant difference was noted between the groups. Only 27% of respondents reported a dedicated resuscitation team in the event of a paediatric arrest at their institution. Resuscitation events were not uncommon, with 71% of respondents actively partaking in more than 10 resuscitations during the preceding 2-year period. Bag mask ventilation and intubation were the most common procedures reported by all participants, with defibrillation, intraosseous placement and pneumothorax needle decompression the least performed. As expected, the number of procedures performed increased as junior medical doctors progressed in rank (p-value <0.05). Although half of the interns (10/20; 50%) have reportedly been expected to take the lead in resuscitation, 25% have performed less than 5 bag mask ventilations, 65% have never intubated, 75% have never commenced inotropes and none had placed an intraosseous line. Most (17/20; 85%) interns experienced anxiety upon realizing the need for resuscitation of a paediatric patient and only 15% (3/20) reportedly feels confident when leading a resuscitation. Sixty percent (12/20) of interns reported their knowledge of the resuscitation of paediatric patients as lacking; with only 15% (3/20) passing the knowledge test. In the final year of training (year 4), not all registrars have had opportunities to practice some of the critical procedures/skills in the preceding 2 years. Commencement of inotropes ( 6%), placement of umbilical vein catheterization (6%), pneumothorax needle compression (33%), interosseous line placement (6%) and defibrillation (56%) have not been performed. Forty one percent (26/63) of paediatric registrars reportedly experienced anxiety upon realizing the need for resuscitation of a paediatric patient. Although participants overall regarded themselves to possess appropriate knowledge in respect to the management of seriously ill and injured children and neonates, only 56% (66/118) passed the MCQ test, of which 15% (3/20) were interns, 49% (17/35) medical officers and 74% (46/63) registrars. No positive correlation between reported confidence in managing ill children and pass rate of the MCQ questions were shown (p-value 0.18). Neither was a positive correlation found between respondents’ reported knowledge and assessed knowledge (p-value 0.18). Anxiety was less in those participants who have received formal assessment and training at commencement of their current employment (p- value < 0.05). Confidence increased with number of active participations in resuscitation events (p-value < 0.05). Conclusion Shortcomings in training, assessment, feedback and knowledge in respect to the management of seriously ill and injured paediatric patients were identified with reference to junior medical doctors; this may adversely affect the quality of health care in paediatric emergencies. It is recommended that directors of clinical programmes place more emphasis on the management of seriously ill and injured paediatric patients in their undergraduate and post-graduate training curricula. Structured feedback and debriefing opportunities should be introduced to improve junior medical practitioners’ competencies as well as patient outcomes. Structured feedback and debriefing opportunities should be introduced to allow reflection on experience, identification of learning opportunities and changed behaviour. Future larger studies are recommended to compare findings and include real-life assessments to make more valid deductions. | en_ZA |
| dc.description.abstract | Agtergrond Die toepaslike behandeling van kritiek siek- of beseerde kinders is ‘n noodsaaklike vaardigheid vir mediese dokters, wat ernstige gevolge vir pasiënte mag inhou sou toepaslike ingrepe nie tydig geïmplementeer word nie. Alhoewel kinders ‘n wesenlike gedeelte van siektegevalle behels, is beperkte inligting beskikbaar rakende die vermoeëns van junior dokters om kritiek siek- of beseerde kinders in Suid-Afrikaanse publieke hospitale te hanteer. Hierdie navorsingstudie het ten doel gehad om die vermoeëns van junior dokters rakende resussitasies, hul vlak van ervaring en selfvertroue, hul teoretiese kennis rakende die behandeling van kritiek siek- of beseerde kinders in Suid-Afrikaanse hopitale wie in pediatriese departmente opgeneem word sowel as opleidingsgeleenthede aan sodanige dokters gebied, te evalueer. Metodologie ‘n Kwantitatiewe beskrywende navorsingstudie is uitgevoer. Junior dokters (mediese interns, -gesondheidsbeamptes en pediatriese registrateurs) werksaam in die pediatriese departemente van 8 Suid-Afrikaanse mediese skole en hul geaffiliteerde opleidingshospitale is uitgenooi om ‘n anonieme, self-geadministreerde elektroniese vraelys te voltooi ten einde hul mate van ervaring, selfvertroue en opleiding rakende die hantering van kritiek siek- of beseerde kinders te evalueer. Teoretiese kennis is geëvalueer deur middel van meervoudige keuse vrae. Die steekproef verteenwoordig die beste weerspieëling van junior dokters se vermoeëns om kritiek sieke- of beseerde kinders in Suid-Afrikaanse publieke hospitale te behandel. Beskrywende statistiek is aangewend ten einde data te ontleed. Pearson chi- kwadraat- en Fisher se presisie toets is toegepas ten einde verwantskappe tussen die vermoeëns van dokters en kategoriese veranderlikes te bepaal. Etiese goedkeuring is verkry vanaf die Stellenbosch Universiteit se Menslike Hulpbronne Etiese Komitee (S17/09/176). Bevindings Respondente van sewe Suid-Afrikaanse mediese skole het aan die navorsingstudie deelgeneem. 118 junior dokters het die vraelys voltooi: Reaksiekoers van 24%. 63 (53%) pediatriese registrateurs, 35 (30%) mediese gesondheidsbeamptes en 20 (17%) -interns het aan die studie deelgeneem. Meeste respondente (89%) het hul voorgraadse mediese opleiding aan ‘n Suid-Afrikaanse universiteit verwerf. Meer respondente het gevorderde pediatriese- as neonatale opleidingskursesse bygewoon: ‘n 75% bywoningsyfer vir gevorderde pediatriese kursusse teenoor 53% bywoningsyfer vir neonatale opleidingskursusse. 10% van respondente het vermeld dat hul geen formele opleiding rakende die behandeling van kritiek siek of beseerde kinders ontvang het nie; 3 pediatriese registrateurs en 7 intern dokters. Formele interne opleidings- en assesseringsgeleenthede rakende die behandeling van kritiek siek- of beseerde kinders het nie op ‘n gereelde grondslag plaasgevind nie. 42% van respondente het vermeld dat hul nooit aan enige simulasies (oefenkodes) blootgestel is nie. Waar opleidingskursusse wel aangebied is, het sodanige kursusse nie op ‘n gereelde grondslag plaasgevind nie (53%). Ontledingsessies- en terugvoergeleenthede is nie standaard praktyk nie. Alleenlik 8% van respondente is ontledingsessies na resussitasies gebied. 29% van mediese beamptes en 46% van pediatriese registrateurs het vermeld dat hul geen ontledingsessies gebied is nie. 45% van mediese interns end 37% van pediatriese registrateurs het nog nooit enige terugvoer na resussitasies ontvang nie. Geen stasties wesenlike verskille is opgemerk tussen die groepe nie. Alleenlik 27% van respondente het aangedui dat hul mediese fasiliteite oor toegewyde aangewese resussitasiespanne beskik om behandeling toe te pas sou ‘n pediatriese hartstilstand by hul instelling plaasvind. Resussitasies is nie ongewoon nie: 71% van respondente het aktief aan meer as 10 resussitasies gedurende die voorafgaande 2-jaar tydperk deelgeneem. Masker ventilasie en intubasie is die prosedures wat mees algemeen uitgevoer is. Defibrillasie, intraosseous lynplasings en pneumothorax naald dekompressies is die minste uitgevoer. Na verwagting het die aantal prosedures uitgevoer verhoog soos junior mediese dokters in rang en ervaring gegroei het (p-waarde <0.05). Alhoewel daar van 50% van mediese interns (10/20) verwag is om die leiding te neem gedurende resussitasies, is daar vermeld dat 25% van mediese interns nog nooit pasiënte met behulp van maskers geventileer het nie. 65% van mediese interns het nooit pasiënte geïntubueer nie. 75% van mediese interns het nog nooit inotrope geïnisieer nie. Geen mediese interns het nog intraosseus lyne geplaas nie. Meeste (17/20; 85%) mediese interns het aangedui dat hul angs ervaar wanneer hul besef het dat ‘n pediatriese pasient geresussiteer moet word. Alleenlik 15% (3/20) van mediese interns het aangedui dat hul oor voldoende selfvertroue beskik het om ‘n resussitasie te lei. 60% (12/20) van mediese interns het vermeld dat hul kennis rakende die resussitasie van pediatriese pasiente beperk is. Teen hul finale jaar van opleiding (jaar 4) het nie alle pediatriese registrateurs nie die geleentheid gehad om sekere kritiese resussitasie prosedures uit te voer nie: Inisiasie van inotrope (6%), die plasing van umbiliese kateters (6%), pneumothorax naald dekompressies (33%), interosseus lyn plasings (6%) en defibrillasie (56%). 41% (26/63) van pediatriese registrateurs het angs vermeld wanneer hul besef het dat ‘n pediatriese pasient geresussiteer moet word. Alhoewel respondent hulself geag het om oor voldoende kennis te beskik ten opsigte van die behandeling van kritiek siek- of beseerde kinders, het alleenlik 56% (66/118) die meervoudige keuse vraag toets geslaag het: 15% (3/20) mediese interns, 49% (17/35) - gesondheidsbeamptes en 74% (46/63) pediatriese registrateurs. Geen positiewe verwantskap is gevind tussen die gerapporteerde vlak van selfvertroue rakende die behandeling van kritiek siek- of beseerde kinders en die slaagsyfer van sodanige toets nie (p-waarde 0.18). Geen positiewe verwantskap is gevind tussen die respondent se vermelde vlak van kennis en hul geassesseerde kennisvlak nie (p-waarde 0.18). Verminderde angs vlakke is gemerk in respondente wie formele assesserings- en opleidingsessies by hul huidige werkgewer ontvang het (p-waarder < 0.05). Respondente se vlak van selfvertroue het toegeneem soos die aantal aktiewe deelnames aan resussitasies toegeneem het (p-waarde < 0.05). Samevatting Tekortkominge ten opsigte van opleiding, assessering, terugvoer en kennis rakende die behandeling van kritiek siek- of beseerde pasiënte is geïdentifiseer ten opsigte van junior mediese dokters. Sodanige tekortkominge mag die kwaliteit van pediatriese gesondheidsorg belemmer. Die bostaande bevindinge het bygedra tot die vasstelling van kliniese sorg faktore toepaslik aan die Suid-Afrikaanse mileu en waar nodig, mitigasie strategieë en ingrepe in verband daarmee. Daar word voorgestel dat direkteure wie kliniese programme struktureer, meer klem plaas op die hantering van kritiek siek of -beseerde pediatriese pasiënte in hul voorgraadse en na-graadse opleidingsillabus. Gestruktureerde terugvoer en ontledingsessies moet geïmplementeer word ten einde junior mediese dokters se vaardighede te verbeter asook om positiewe uitkomste vir die publiek te bewerkstellig. Formele assesserings- en opleidingsgeleenthede moet voor and gedurende indiensneming met behulp van simulasies (gesimuleerde kodes) en observasie geskied ten einde kennis en vaardighede tydens resussitasies vereis, te evalueer. | af_ZA |
| dc.description.version | Masters | en_ZA |
| dc.format.extent | 75 pages | en_ZA |
| dc.identifier.uri | http://hdl.handle.net/10019.1/123621 | |
| dc.language.iso | en_ZA | en_ZA |
| dc.publisher | Stellenbosch : Stellenbosch University | en_ZA |
| dc.rights.holder | Stellenbosch University | en_ZA |
| dc.subject | Doctors -- Clinical competence | en_ZA |
| dc.subject | Injuries -- Management | en_ZA |
| dc.subject | Wounds and injuries -- Children | en_ZA |
| dc.subject | Accidents and injuries -- South Africa | en_ZA |
| dc.title | Reported competencies of junior medical doctors in managing seriously ill and injured children in South African hospitals | en_ZA |
| dc.type | Thesis | en_ZA |