SummaryA 28-year-old male ingested 75 g of arsenic trioxide in a successful suicide attempt. The presentation, management and postmortem jndings are presented and discussed. Key wordsPoisoning, acute; arsenic. Case historyA 28-year-old self-employed analytical chemist attempted suicide by drinking a bottle of vodka and ingesting 75 g of arsenic trioxide. He fell asleep in his laboratory, awoke 4 hours later and admitted himself to hospital.On admission he was vomiting profusely and had copious watery diarrhoea. He had some abdominal discomfort, but there was no evidence of gastrointestinal bleeding. On examination he was alert and cooperative, but shocked (blood pressure 85/60 mmHg, pulse 100 beats/minute). His chest was clear, and his abdomen soft with bowel sounds; he had absent knee jerks, but good limb power and flexor plantar responses.Initial blood results showed that he was haemoconcentrated (haemoglobin 17.9 g/dlitre, haematocrit 0.57/litre) with normal urea, creatinine and electrolytes. Blood gases on air revealed a metabolic acidosis (Pao, 12.9 kPa, Paco, 3.7 kPa, base deficit 11 mmol/litre). His chest X ray showed a radiopaque substance in the stomach.Intravenous fluids were given, a urinary catheter inserted, and his stomach was washed out. Large volumes of saline were given via a nasogastric tube to purge the bowel. A suspension of activated charcoal was given to bind any unabsorbed arsenic. DMSA (2, 3-dimercaptosuccinic acid) capsules were brought by courier from the National Poisons Information Service and given orally. However, the patient vomited these and later dimercaprol was given intramuscularly.The patient was transferred to the Intensive Care Unit after initial resuscitation. Over the next 11 hours he remained alert, but continued to lose large amounts of body fluids. His central venous pressure was maintained between 0 and 9 cmH,O above the midaxillary line with 1 litre/hour of intravenous fluids (50% colloid, 50% crystalloid), with added potassium chloride (total 180 mmol). His urine output fell. A Swan Ganz catheter confirmed adequate left heart filling pressures (pulmonary artery wedge pressure 12 mmHg). Dopamine (at 2 lg/kg/minute) was given but the urine output failed to improve (27 mI/ hour), and his creatinine rose to 304 lmol/litre. He became more acidotic and was given aliquots of 8.4% sodium bicarbonate solution. His temperature rose to 38.4"C per axilla.The patient was transferred to a centre with dialysis facilities because of deteriorating renal' function. He remained alert and cooperative during the transfer, which took an hour. He had stopped vomiting and had an unquenchable thirst. His systolic blood pressure fell and was only maintained between 65 and 75 mmHg by three pressurised infusion lines. His breathing became progressively more acidotic and he was unable to move his legs, although sensation remained intact.Sixteen hours after ingestion, having had no previous arrhythmia, the patient developed a bradycardia and then asystole. He died despite attempted resuscitation....
Health-care-associated infections (HCAIs) are a major global safety concern for patients, healthcare professionals and public health particularly in developing countries where access to hand washing facilities is limited due to infrastructure. Alcohol-based hand sanitizer offers a viable alternative where water sources are unreliable or insufficient. However, in resource-limited settings, the introduction of alcohol-based hand sanitizer has been slow due to economic, manufacturing and procurement challenges compounded by the lack of evidence as to its acceptability in varying organizational cultures. This case study describes the process of producing, educating, distributing, scaling up and monitoring the impact of a quality improvement project to locally produce alcohol based hand sanitizer using the formula provided by the World Health Organization in a district hospital in Rwanda. During a 10-month implementation, hand sanitizer was made available to all departments of the hospital and all hospital staff received training on the proper use and ordering of the product. The overall hand hygiene compliance using any method significantly increased from 59% pre intervention to 67% post intervention (P < 0.001). Specifically, the use of hand sanitizer for hygiene significantly increased from 46% to 58% (P < 0.001). By producing hand sanitizer in-house, the hospital saved 71% when compared to purchasing commercial products. The use of hand sanitizer is not a replacement for running water in the hospital. However, with the lack of proper infrastructure, making hand sanitizer available is an acceptable alternative to improve the infection prevention and control standard. The production of hand sanitizer within a health care facility is cost effective and is feasible to integrate into existing opera-A. Budd et al. 151tions. The team is working with the Rwandan Ministry of Health to introduce the program to all public hospitals as a national program.
Purpose The purpose of this study is to improve the hand hygiene compliance in a hospital in Rwanda. Hand hygiene is a fundamental routine practice that can greatly reduce risk of hospital-acquired infections; however, hand hygiene compliance in the hospital was low. Design/methodology/approach A multiple-strategy intervention was implemented with a focus on ensuring stable water supply was available through installing mobile hand hygiene facilities. Findings The intervention significantly increased the overall hand hygiene compliance rate by 35 per cent. The compliance for all of the five hand hygiene moments and all professions also significantly increased. Practical implications By implementing an intervention that involved multiple strategies to address the root causes of the problem, this quality improvement project successfully created an enabling environment to increase hand hygiene compliance. The hospital should encourage using the strategic problem-solving method to conduct more quality improvement projects in other departments. Originality/value Findings from this study may be useful for hospitals in similar settings seeking to improve hand hygiene compliance.
Hospital beds are one of the most frequently used non-invasive equipment in the clinical area and have a high risk of transmitting hospital acquired infections. However, they are usually not cleaned effectively. Accordingly, we conducted this quality improvement project to improve the bed cleaning process in a rural district hospital in Rwanda. A pre-post intervention study was conducted from in April 2015 to February 2016. The beds in the maternity unit were observed after patient was discharged. We implemented an alert system included using a signage system to help inform cleaners to clean the beds. Guidelines for the new system were created and trainings were provided. The intervention significantly increased the percentage of clean beds from 44% pre-intervention to 90% post-intervention (P < 0.001). 93% of staff followed the new labelling system. By focusing on system and process change, this quality improvement project successfully increased the percentage of clean beds without additional financial investment.
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