Background The South African health system functions within a resource-constraint environment. By improving the efficiency of theatre services, costs can be reduced alongside improvement in service delivery. This study aimed to assess theatre operating efficiency at a central hospital in Gauteng Province, South Africa. Objectives To assess theatre efficiency by determining the theatre utilization rate, theatre cancellation rate, and determining the causes of inefficiency. Methods An audit was conducted from 15 May 2023 to 19 May 2023, between the hours of 08h00 and 16h00, in 7 operating rooms. The 5-day audit was conducted to capture a snapshot of theatre efficiency to inform operational management decision making. Times were collected for each surgical case including the anaesthesia start and finish time, surgical start and finish time, and turnover time. Cancellations of cases were documented with reasons, additional delays observed were recorded. Results A total of 16 320 min were available for utilization for elective and emergency cases. A total of 63 elective and 6 emergency cases were performed. The theatre utilization rate accounted for 67,7 % (11 047 min) of block time. Surgical time was 40 % of the block time. Non-surgical time accounted for 60 % and included anaesthetic time (25 %), time lost due to early finish (10 %), turnover time (3 %), time lost due to late starts (4 %) and post-surgical time (3 %). The day of surgery cancellation rate was 39 %, with 40 elective cases cancelled of 103 elective cases booked. Hospital-related factors accounted for 90 % of all cases and 10 % were secondary to patient-related factors, illustrating a greater need to address hospital related factors to reduce day of surgery cancellations. Conclusions The theatre utilization rate did not meet standards reflected in literature. The day-of-surgery cancellation rates were higher than what is recommended. Causes of inefficiency need to be addressed to optimize theatre functions. Recommendations Key strategies include realistic scheduling of elective theatre cases, maximizing theatre availability, implementing staff rotations, enhancing professional communication and performing continuous theatre audits. These interventions aim to improve theatre utilization and reduce day of surgery cancellations, which will ultimately enhance patient outcomes.

Background: Length of stay (LOS) is an integral part of inpatient care in hospitals, particularly in Emergency Departments (EDs). It is an essential performance indicator for the National Indicator Data Set in South Africa. Multiple studies have indicated a correlation between an increased LOS and worse patient outcomes in a variety of acute medical conditions. The study aims to establish the key factors of LOS in the ED at a central hospital in the Gauteng Province of South Africa. Methodology: A cross-sectional study was conducted over seventeen months (Aug 2023 to Dec 2024) based on 2927 entries of patients admitted at the ED for more than 48 hours. No intervention was done as part of this study. Results: The median LOS was 2.81 days (IQR: 2-3) with a minimum of 2 days and a maximum of 12 days. A regression analysis demonstrated that the most significant determinants for prolonged LOS were gender and disease group of boarded patients awaiting ward transfer.Significant differences (p < 0.001) in the LOS between clinical disciplines were noted, with medical (45%) and surgical departments (46%) accounting for most boarding patients compared to all other clinical disciplines. Conclusions: Data demonstrated that 80% of patients in the ED wait an average of 3 days before transfer into the wards. This extended ALOS in the ED has consequences for patient outcomes and the quality of healthcare provided. Based on the findings of this study, strategies to improve patient flow are essential in facilitating timeous discharge from wards and to prioritise the forward flow of patients waiting in ED.

The term “médecine sociale” (social medicine in English) was first coined in 1848 during the French Revolution by Dr. Jules Guérin. It is a branch of medicine that focuses on the impact of social and economic conditions on health, disease, and the practice of medicine, with the intention of creating a healthier society. It is an interdisciplinary program between medicine and social sciences, expected to equip medicine with the knowledge and skills needed for analyzing the social causes of health and illness, akin to how the alliance between medicine and laboratory sciences provided insights into the biological, chemical, and physical bases of diseases. Social medicine is also interconnected with social determinants of health. While social determinants of health specifically target social and environmental conditions that affect health, social medicine has a broader scope, encompassing the entire social context of health, including societal structures and cultural factors. In the post-apartheid era, social medicine could play an important role in transforming the healthcare system to ensure equity and inclusivity, leading to improved health outcomes. This would require re-engineering the education of health professionals in South Africa at both undergraduate and postgraduate levels, as practiced in many parts of the world. This will assist South Africa in joining the global movement of social medicine for the promotion of human rights and social justice in medicine, and a better understanding of the impact of social factors on the aetiology and management of medical disorders in the 21st century.

Background. Coronavirus disease (COVID-19) has imposed unprecedented stressors on South Africa (SA)'s healthcare system. Superimposed on the country's quadruple burden of disease, pandemic-related care further exposes existing inequities. Some of these inequities are specific to hospital-based inpatient services, such as the geographical maldistribution of hospital beds, lack of oxygen supplies and assisted ventilation, and scarcity of trained healthcare workers. Certain high-risk groups, such as individuals with cardiometabolic comorbidity, are likely to develop severe COVID-19 disease requiring hospitalisation with potential for a prolonged length of stay (LoS). It may be helpful for health authorities to identify those at risk for prolonged LoS to facilitate appropriate health systems planning. Objectives. To identify hospital admission laboratory parameters associated with a hospital stay >14 days in patients with COVID-19 pneumonia. Methods. A retrospective observational study design was used. Laboratory data were obtained from an SA private laboratory for 642 inpatients with suspected or confirmed COVID-19 pneumonia, comprising 7 months of admission laboratory data from six private hospitals in Johannesburg, Gauteng Province. Results. Of 642 hospital admissions for pneumonia, 497 were confirmed to have COVID-19 infection (reverse transcription-polymerase chain reaction test positive). In the COVID-19-positive group, hospital LoS was prolonged in 35.4% of admissions. Univariate analysis demonstrated an association with the following risk factors for prolonged LoS: older age; male sex; high serum creatinine, sodium (Na), chloride, potassium and urea levels and low estimated glomerular filtration rate; raised white blood cell count, lymphopenia, neutrophilia and an elevated neutrophil-to-lymphocyte ratio (NLR); and elevated levels of D-dimers, interleukin-6 (IL-6), and procalcitonin (PCT). The strongest univariate associations (relative risk (RR) >= 2.0) with a hospital stay >14 days were high Na levels, NRL >18, high PCT levels and IL-6 >40 pg/mL. On multivariable analysis, the following factors remained significantly associated with prolonged LoS: older age (RR 1.015 per year of age; 95% confidence interval (CI) 1.005 - 1.024); hypernatraemia (RR 1.80; 95% CI 1.25 - 2.60); hyperkalaemia (RR 1.61; 95% CI 1.18 - 2.20); and neutrophilia (RR 1.47; 95% CI 1.15 - 1.88). Conclusions. COVID-19 pandemic preparedness requires hospital-based inpatient care to be prioritised in resource-limited settings, and availability of beds and prompt admissions are essential to ensure good clinical outcomes. In this study of COVID-19 patients admitted with pneumonia, multivariable analysis showed older age, hypernatraemia, hyperkalaemia and neutrophilia to be associated with LoS >14 days. This may assist with healthcare systems planning.

National Strategic Plan for the prevention and control of non-communicable diseases in South Africa

INTRODUCTION: The coronavirus disease 2019 (COVID-19) first reported in Wuhan, China in December 2019 is a global pandemic that is threatening the health and wellbeing of people worldwide. To date there have been more than 274 million reported cases and 5.3 million deaths. The Omicron variant first documented in the City of Tshwane, Gauteng Province, South Africa on 9 November 2021 led to exponential increases in cases and a sharp rise in hospital admissions. The clinical profile of patients admitted at a large hospital in Tshwane is compared with previous waves. METHODS: 466 hospital COVID-19 admissions since 14 November 2021 were compared to 3962 admissions since 4 May 2020, prior to the Omicron outbreak. Ninety-eight patient records at peak bed occupancy during the outbreak were reviewed for primary indication for admission, clinical severity, oxygen supplementation level, vaccination and prior COVID-19 infection. Provincial and city-wide daily cases and reported deaths, hospital admissions and excess deaths data were sourced from the National Institute for Communicable Diseases, the National Department of Health and the South African Medical Research Council. RESULTS: For the Omicron and previous waves, deaths and ICU admissions were 4.5% vs 21.3% (p < 0.00001), and 1% vs 4.3% (p < 0.00001) respectively; length of stay was 4.0 days vs 8.8 days; and mean age was 39 years vs 49,8 years. Admissions in the Omicron wave peaked and declined rapidly with peak bed occupancy at 51% of the highest previous peak during the Delta wave. Sixty two (63%) patients in COVID-19 wards had incidental COVID-19 following a positive SARS-CoV-2 PCR test . Only one third (36) had COVID-19 pneumonia, of which 72% had mild to moderate disease. The remaining 28% required high care or ICU admission. Fewer than half (45%) of patients in COVID-19 wards required oxygen supplementation compared to 99.5% in the first wave. The death rate in the face of an exponential increase in cases during the Omicron wave at the city and provincial levels shows a decoupling of cases and deaths compared to previous waves, corroborating the clinical findings of decreased severity of disease seen in patients admitted to the Steve Biko Academic Hospital. CONCLUSION: There was decreased severity of COVID-19 disease in the Omicron-driven fourth wave in the City of Tshwane, its first global epicentre. (C) 2021 The Author(s). Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

Background. Congestion at health facilities poses the risk of extensive spread of the severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) to patients at high risk for severe illness and death due to this infection. During the lockdown to control the spread of the virus, many patients with chronic conditions are not visiting health facilities and not collecting their chronic medication. To improve adherence to medication, home delivery of medication was instituted for patients with chronic diseases who had been receiving care at the Skinner Street Clinic in Tshwane. Objective. To support patients with chronic diseases who were unable to collect their medication, by remotely consulting (telehealth) and delivering their medication during the lockdown due to the COVID-19 pandemic. Methods. Patients were identified for potential home delivery of medication from the clinic appointment book. Their files were retrieved, and they were telephoned and offered the option of receiving medication through home delivery instead of attending a health facility. For those who qualified and accepted home delivery, files were sent to the clinic pharmacy. Medication parcels were prepared and sent to ward-based outreach teams to deliver to patients. Relevant information was captured on the Qualtrics platform. Results. A total of 1 727 files were evaluated. Of these patients, 60% were on treatment for HIV infection, and 19% for hypertension. A total of 32% ( n =547) were eligible for home delivery of medication, but only 25% of the 1727 patients accepted the home delivery of medication. Almost 25% could not be contacted. Compared with those with non-communicable diseases (NCDs) or a combination of HIV and one or more NCDs, a higher proportion of HIV-positive patients with no other diagnosis chose not to have their medication delivered at home. Patients using the service expressed their appreciation and requested that it be extended to others. Conclusion. Home delivery of medication has significant advantages for patients. It can ensure that patients continue to adhere to their chronic medication in the midst of the COVID-19 epidemic, without increasing their risk of contracting the virus. Expanding the home delivery of medication to more facilities while aligning it with the Centralised Chronic Medicine Dispensing and Distribution programme has the potential to alleviate the congestion and workload of primary care facilities while these are under severe pressure owing to the COVID-19 pandemic.

BACKGROUND On 26 March 2020, the South African (SA) government initiated a 21-day national level 5 lockdown which was subsequently eased off and downgraded to level 4 on 1 May and to level 3 on 1 June. The effect of lockdown measures on SARS-CoV-2 infectivity is currently uncertain. In this article, we analyse the effects of the lockdown measures on the SARS-CoV-2 epidemic in one of the epicentres in SA. OBJECTIVES  To measure the effects of lockdown measures introduced in SA on SARS-CoV-2 attack rates (ARs, the percentage of individuals who tested positive in a specified time period) in Gauteng Province during a 4-month period (March - June 2020). METHODS  In this retrospective cohort study, we used a comprehensive database from an independent pathology laboratory in Gauteng. We analysed trends of positivity rates of reverse transcription polymerase chain reaction tests done during the 4-month period. The ARs are reported over time (unweighted and age-weighted 14-day moving averages) by age groups, gender, and different regions/districts in Gauteng. RESULTS  A total of 162 528 tests were performed at a private laboratory between 5 March and 30 June 2020, of which 20 574 were positive (overall AR 12.7%). These positive tests constituted 44.8% of all positive cases in the province (20 574/45 944). Sixty-two percent of all tests were done in June during lockdown level 3. There was an exponential increase in the AR in June (18.3%) when lockdown was eased to level 3, in comparison with 4.2% (March), 2.2% (April) and 3.3% (May). The increase in June was seen in all the age groups, although it was more pronounced in the 21 - 60 years age groups than the younger (0 - 20 years) and older (>60 years) age groups. The AR was significantly higher in males (13.2%) compared with females (12.1%) (χ2 test, p<0.0001). CONCLUSIONS The findings of this study testify to the rapid increase in ARs resulting from easing of the lockdown regulations, especially to level 3 in June. Of concern is the upward trend in the AR across all age groups, especially <20 years (15.9%), which was not reported in other parts of the world. Population age dynamics should therefore be considered when taking future decisions about lockdown regulations.

Role of clinical informatics in the implementation of universal health coverageTo the Editor: On 23 September 2019, the United Nations General Assembly held a high-level meeting on universal health coverage (UHC).This meeting, held under the theme 'UHC: Moving together to build a healthier world' , aims to accelerate progress toward UHC, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all. [1]E-health (or health/clinical informatics) is recognised as one of the key components of successful implementation of UHC by the World Health Organization, which states that 'It has become increasingly clear that UHC cannot be achieved without the support of eHealth' , [2] which was also acknowledged by the World Health Assembly: 'eHealth is the cost-effective and secure use of ICT [information and communications technology] in support of health and health-related fields, including health-care services, health surveillance, health literature, health education, knowledge and research.' [3] In South Africa (SA), strategic issues that highlighted the 2012 -2017 e-health strategy [4] were as follows: widely differing levels of e-health maturity across and in provinces; a large number of disparate systems with little or no interoperability and communication; several past initiatives that have not reached fruition because of poor planning or lack of consistent sponsorship, management and/or funding; and a low degree of co-operation, collaboration and sharing across all sectors.Reasonable progress has since been made in certain areas, such as the developing new e-health strategy, the National Health Normative Standards Framework for interoperability, the Health Patient Registration System, and the provision of e-health infrastructure. [5]However, the massive investments associated with this progress have not been met with corresponding investments in capacity building of healthcare personnel, who are the ultimate users of the deployed systems.They not only generate data through e-health, but also use these data for effective and efficient decisionmaking -even at grass-roots level.It is in this light that newly designed training programmes in clinical informatics would be necessary, covering broad concepts in an electronic health record (EHR) system, its implementation, as well as its adoption for decision-making, especially in the clinical setting.Clinical informatics includes the study and practice of an information-based approach to healthcare delivery in which data must be structured in a certain way to be effectively retrieved and used for decision-making. [6]The EHR system forms the backbone of clinical informatics.All of this information must be collected, stored, interpreted, analysed and implemented into a treatment plan.Training in clinical informatics should integrate computer science, clinical data and application of information technology in healthcare settings.It would assist health professionals to process information and to manage patient populations routinely, thus bridging the gap between personal and population health that has existed for more than a century.It is important for SA universities to partner with public and private sector institutions to develop integrated training programmes for healthcare professionals, if SA wishes to achieve its objectives associated with UHC.In view of this, the University of Pretoria has decided to develop formal continuous professional development programmes on clinical informatics, which would be available from 2020.

Background: The National Health Laboratory Services (NHLS), Quality Assurance (QA) department’s responsibility is to ensure diagnostic supplies meet required standards. Of particular importance are in vitro diagnostic devices (IVD’s) such as: reagents, all controls including Quality Controls (QC), equipment and laboratory consumables. Applying the required standards ensures that they are ‘fit for purpose’. This process supports and enhances laboratory accreditation as well as strengthening all laboratory systems. Objectives: To assess: (i) the IVD’s acquisition processes within the NHLS; (ii) whether a health technology assessment (HTA) framework could be used and (iii) assessing the impact of implementing a health technology assessment unit in supporting accreditation and strengthening laboratory systems. Methods: The researchers planned a strategy meeting to review IVD acquisition processes within the selected organisation. The participants were multidisciplinary technical laboratory personal. The discussions at the HTA strategic workshop focused on Quality Assurance and laboratory accreditation in addressing the requirements of ISO15189:2012, which is important to ensure consistent adherence to accreditation and compliance measures across all the laboratories within the NHLS framework. Results: A workshop entitled: Health Technology Assessment Strategy was the first workshop held by the NHLS to stress the challenges faced when acquiring new technologies. The workshop participant’s described the present processes of IVD acquisition within the NHLS as incoherent. In particular, they emphasised the lack of clearly defined IVD evaluation and requisition procedures. The examples given were the following: the adoption of technologies on ad-hoc bases with limited consensus from all users, the lack or inadequate selection criteria for performance evaluations, the need to adopt standardised protocols and report templates and the absence of a national database to ensure monitoring and compliance of existing suppliers. Conclusions: The acquisition of IVD’s for pathology services is a universal requirement. The NHLS is unique as it provides pathology services to hospitals but is not incorporated as part of the hospital’s management system. However the impact of evaluating IVD’s is a requirement for developed and developing countries. The establishment of the HTA unit would provide an environment for the coordination and management all IVD requests. This unit would be a single port of entry at the NHLS for all IVD performance evaluations and in addition it would support laboratory accreditation as well as procurement decision making processes within the NHLS.

Background: The Health Technology Assessment (HTA) unit was established in 2012, under the auspices of the Quality Assurance Department at the National Health Laboratory services (NHLS) to address the national accreditation needs by supporting laboratory accreditation. Objectives: The global trend to address the burden of disease has led to an increase in the availability of Health Technology (HT). The influx of in vitro diagnostic (IVD) medical devices poses a challenge to the diagnostic pathology laboratories in adopting a selection criterion for procurement. This paper describes the current IVD medical device procurement system within the NHLS and how the influx of medical devices can be managed. Methods: Review of the organisation procurement processes; planning a strategic workshop to understand current IVD challenges within the organisation; implementation of laboratory staff training on HTA principles, practices and policy processes. Enable the drafting of a HTA policy and HT guideline documents. Results: The review of the procurement processes identified gaps in the areas of planning and needs assessment; commissioning, installation and monitoring of medical devices. The strategic workshop and HTA training presented the laboratories with current challenges regarding the influx of new technologies and deviations in medical device evaluation processes. The HTA Policy Forum finalised the HTA policy and the four guideline documents to address current organisational challenges and how to adopt Hospital-Based Health Technology Management (HB-HTM). Conclusion: This review enabled the organisation to initialise the HTA programme by harmonising and standardising current processes and creating the HTA unit as a single point of entry within the organisation for all new health technologies.

SETTINGSouth African miners suffer the highest tuberculosis (TB) rates in the world. Current efforts to stem the epidemic are insufficient. Historical legacies and persistent disease burden demand innovative approaches to reshape health care delivery to better serve this population.OBJECTIVETo characterize social and behavioral health determinants for successful TB care delivery and treatment from the perspective of miners/ex-miners, health care workers and policy makers/managers.DESIGNWe conducted applied ethnography with 30 miners/ex-miners, 13 family/community members, 14 health care providers, and 47 local policy makers/managers in South Africa.RESULTSMiners/ex-miners felt health care delivery systems failed to meet their needs. Many had experienced unnecessary physical and psychological harm due to limited health education about TB, minimal engagement in their own care, lack of trust in providers, and a system that did not value their experience. Stigma and fear associated with TB result in denial of symptoms and delays in care seeking. Health care providers and policy makers/managers felt discouraged by system constraints in providing optimal care.CONCLUSIONOur findings describe long-term effects of perpetual TB misinformation and stigma resulting from fear and disempowerment among miners and their families/communities. To reduce the TB burden, there is an urgent need to co-design a care delivery system with miners to better meet their needs.