JEDDAH , KSA, FOR THE WHO
FOCUS GROUP DISCUSSION REPORT
VALIDATION OF EXISTING AND REVISED DENGUE CLINICAL GUIDELINE AND CASE
CLASSIFICATION
user
11/9/2009
Principle researcher: Dr.Khalid Zhafar.Co investigators: Dr.Sami Badawood, Dr.Nuha Dashash,
Dr.Naeema Akbar, Dr. Tarik Madani, Dr. Rajaa Raddadi , et al.
SUMMARY
This report includes the focal group discussion conducted at hospitals involved in the validation study
of the existing and revised dengue clinical guidelines and case management. Total of 6 hospitals and 49
staff were included in 5 sessions. Two sessions were conducted at King AbdulAziz and Oncology Center
(KAAH) due to the larger number of staff on the other hand three hospital were included in one session.
Sessions were arranged and conducted by a team of 2-3 persons;
Gp organizer: usually the research coordinator at the hospital who determine time and place of the
session and the participants.
Gp moderator: to guide the FGD, explain the purpose of the session and distribute the consent forms,
and get signature for agreement.
Gp facilitator: to encourage audience to participate.
Name of facilities included in the focal group discussion and number of suspected cases reported to
MOH is summarized in table 1.
Table 1: Health facilities included in the focal group discussion and number of reported ( suspect) DF
cases from 2006- October 2009
Facility
2006
2007
2008
2009
1
KAAH
379
47
324
379
2
KFAH
24
48
`107
167
3
KAUH
26
37
140
162
4
Dr.Soliman Faqeeh H
39
21
32
44
5
Dr. Khaled Edrees H
11
50
27
97
8
Dr.Hala Bin Laden H
0
0
0
15
2
SESSION 1
PRIVATE HOSPITALS
Dr. Khalid Edrees Hospital and Dr. Hala bin Laden Hospital
Date: August 18, 2009G
Time: 1:30 Pm – 3:00Pm
Venue: Training and Continuous Medical Education Center- Al Hamra District.
Target Audience: Physicians and nurses at different levels of the health care system
Gp. Moderator Dr.Tarteel M. Shaikh
Gp. Facilitator : Dr.Naeema Akbar
Gp controller of mobile phone – recorder: Miss. Fatima Haddadi
Gp. Organizer: Mr. Esam Arabi
Transcription and reported by : Dr. Tarteel Mohammad Shaikh
Participants
No
Names
Characteristics
Hospital
1
Basel Dahha (Participant::1)
Specialist- Internal
Medicine
Dr. Khalid Edrees
2
Numan Edrees (Participant::2)
Hospital
Physician (Resident)
Internal medicine
3
3
Maria Naogas (Participant 3)
Nurse
4
Cissy Varghese (Participant 4)
Nurse
5
Dr. Abdul Hakeem (Participant 5)
Consultant Internal
Medicine
6
(Participant 6)
Nurse
7
(Participant 7)
Nurse
8
(Participant 8)
Nurse
Dr. Hala bin Laden
Hospital
BEGIN
The group facilitator together with the moderator started the meeting by welcoming and thanking the
Participant::s for coming despite of their busy schedules.
Consent forms had been distributed read loudly and explained by the gp. Moderator and all
Participant::s signed for agreement.
Also, it had been explained that the discussion will be guided by the potential questions that had been
suggested in the study proposal.
Transcribed text from mobile phone-recorder and the MP3 recorder
1. INTRODUCTION
Q1: How many dengue cases occur monthly/ yearly in this hospital?
During 2009 around 90 cases from Dr. Khaled Edrees hospital and 15 from Dr. Hala bin Laden hospital
Q2- What do you find most challenging in the diagnosis and treatment of dengue?
They all agreed that prediction of outcome of DF cases is the most challenging in diagnosis and
treatment of DF.
2. CLASSIFICATION
Q1: How comfortable do you feel using the revised classification system into levels of
severity (D-/D+/SD) as compared to the ones you used before (DF/DHF/DSS)?
Participant 1: The new classification are very good and very simple, it made the work easier and it
became very simple to differentiate cases.
Participant 2: I only have a few number of Dengue cases. I think that the new classification is very easy
to be applied.
Participant 5: Sorry, I have no experience in the new ones. This is the first year for me in Jeddah. My
colleague who has a good experience in them is on vacation, so I came instead of him.
Participant 3: We are applying the booklet that you gave us, it is very helpful to the nurses & it became
easy to follow up patients step by step. The new guidelines go direct to the point.
Participant 4: We are using the poster that you gave us to categorize patients.
Q2. [10 min] Could personnel offer an example of a time when the guidelines were applied
and had a positive outcome? An undesirable outcome?
Participant 1: An undesirable outcome: No! Almost 90% of the cases give positive outcome. Once, I had
a severe case: patient came with plasma leakage: Pleural effusion, abdominal ascitis and platelets of
21,000/mm3 but after monitoring the patient survived.
Participant 2: I have no enough experience.
4
Participant 5: I only applied the discharge criteria of the new guidelines which I think are very helpful.
Participant 1: Agreed with Participant 2
Participant 2: Agreed with Participant 2
Q.3: [5 min] Do current guidelines work, are they easy to use?
Gp. Moderator: I think this had been covered during answering Q.1 (gp. facilitator and Participants
agreed).
Q.4: [10 min] What changes would the personnel make if given the opportunity?
Participant 1: No additions. I think they are suitable for now at least.
Participant 2: Agreed with Participant 1
Participant 5: Agreed with Participant1
Participant 3: Agreed with Participant1
Participant 4: Agreed with Participant1
Q.5: [20 min] Comment on the revised case classification into levels of severity as compared
to the DF/DHF/DSS classification:
A) What are the advantages and disadvantages?
Participant 1: Before (old classification), it was very complicated and not giving us a good idea on how
to deal and what to do. Here, the new classification is simple, easy and goes directly to the main
problem and how to solve it. Every stage is very clear and very simple: if you like to treat like that, you
can do like this and like that, if the patient is not responding, you do like this, if responding, you do like
that....etc.
Participant 2: I can’t compare, I don’t have any experience in the old classification
Participant 5: I read about the old classification which is classic/ hemorrhagic/... etc, it was much easier
than the new classification picking up the patient weather classic or hemorrhagic- only 2 classes(simplicity!)
Participant 3: The new classification is clear to be followed, defines clearly what to do, for example
when it comes to patient hydration
Participant 4: Agreed with Participant 3
B) The limitation and opportunities?
Participant 5: I apply only the discharge criteria. For admission, I depend on the clinical sense in picking
up the more needy patients.
During the last 2 months (June and July), we used to receive 10-15 pts/ day (Outbreak in Thuwal), I
have no time to read about the new classification, we have limited resources apart from the difficulties
we’re facing with the insurance companies (private hospital).
C) What would you suggest to improve?
5
Participant1: I think for improving the work, we need more access or something to be reached directly.
It is very nice to have a website for this purpose.
I think this is very important because especially now the disease is becoming very bad and the doctor
needs more time to judge.
Participant 2: Till now the new classification is enough. May be if other viruses appeared in the future,
we might need another classification!!
BREAK [10 min]: an afternoon snack had been offered.
CLOSING REMARKS:
[Thank you very much!!]
Impression / Group Dynamics:
1. Most of the group members where participating actively during the discussion
2. The predominant Participant: was Participant:1, since he used to manage >90% of DF cases that
come to his hospital, he was obviously feeling proud and enthusiastic.
3. Participant 1 and Participant 2 were remarkably interested in sharing their experiences with the
other gp. Members, unlike Participant 3, Participant 4 and Participant 5 who remained silent during the
whole discussion and claimed afterwards that they have no idea about the new classification and asked
several times to be able to get trained to do so.
4. Participant 5 seemed to be confused, yet, he is a hard worker and keen to help patients. Since his
experienced colleague -who applied the new classification & was supposed to attend and participate in
the FGD- was absent; it had been decided to exclude Participant 5 from the analysis of FGD.
6
SESSION 2
KING FAHD ARMED FORCE HPSPITAL
Date: 5 October 2009
Time: 1:30 Pm – 3:00Pm
Venue: lecture room at medical department - KFAH.
Target Audience: Physicians
Gp. Facilitator: Dr.Naeema Akbar
Gp. Moderator-mobile phone, and mp4 recorder: Miss. Fatima Haddadi
Gp. Organizer: Dr. Taha Essa
Participants
No
Names
Characteristics
1
Dania (Participant 1)
Specialist- Infection control practitioner
2
Badr (Participant 2)
Consultant- Pediatric Internal medicine
3
Karam (Participant 3)
Consultant- Medicine and gastroenterology
4
Taha Esa (Participant 4)
Specialist- Epidemiology, Head of Infection
control Department
5
Dr. Abdul Rahman (Participant 5)
Specialist- Medicine and gastroenterology
6
Dr. Adnan (Participant 6)
Consultant- Medicine and gastroenterology head
of Isolation units
BEGIN
The group facilitator welcomed and thanking the audience for their valuable participation
Consent forms had been distributed read loudly and explained by the gp. Facilitator and all Participants
signed for agreement. Verbal agreement was also taken for mobile and mp4 recorder
Also, it had been explained that the discussion will be guided by the potential questions that had been
suggested in the study proposal.
Transcribed text from mobile phone-recorder and the MP4 recorder by Dr. Naeema Akbar
7
1. INTRODUCTION
Q1.How many dengue cases occur monthly/ yearly in this hospital?
Around 167 since the start of this year
Q2.What do you find most challenging in the diagnosis and treatment of dengue?
They all agreed that case definition and decision on type of treatment is the most challenging in Df
management
2. CLASSIFICATION
Q1.
How comfortable do you feel using the revised classification system into levels of
severity (D-/D+/SD) as compared to the ones you used before (DF/DHF/DSS)?
Participant 1: Comfortable
Participant 2: Comfortable
Participant 3: Comfortable
Participant 4: Comfortable
Participant 5: Comfortable
Participant 6: Comfortable.
Q2. Is it easier for you to classify patients using the new classification?
Participant 1: Yes, more confident to send patient home using home care card
Participant 2: Yes
Participant 3: Yes
Participant 4: Yes
Participant 5: Yes
Participant 6: Yes
Q3. Can you better distinguish between those patients who go home, those who have to stay
in general ward and those who have to go to ICU?
Participant 1: Yes more confident to send group A patient home using home care card and more sure
that group C patient need ICU
Participant 2: same as Participant1
Participant 3: both the current and the revised case definition were the same
8
Participant 4: more confident to send patient home using home care card and also clear criteria to
admit patient to ICU and to advocate for the patients right for admission.
Participant 5: Better criteria for admission
Participant 6: The current case definition will miss sever cases who have signs of impending
hemorrhage and leaky capillaries but the revised case definition include rising HT and leaky capillaries.
3. CASE MANAGEMENT
Q1: Do you think the dengue treatment guideline is user-friendly?
Q2: If not, do you have any advice that could help to make the guideline more user- friendly?
Participant 1: Yes, it simplifies the definition and management
Participant 2: Yes
Participant 3: Yes
Participant 4: Yes
Participant 5: Yes
Participant 6: Yes
Q3: Comment on the revised case classification into levels of severity as compared to the
DF/DHF/DSS classification:
A- What are the advantages/disadvantages?
Participant 1: It simplifies the definition and management of dengue cases
Participant 2:
Participant 3:
Participant 4:
Agree
Participant 5:
Participant 6:
B- What are the limitations and opportunities?
C- What would you suggest to improve?
Participant 1: Giving figures for management is helpful, eg: at what level of platelets we will transfuse or
to safely discharge the patient.
Participant 2: Suggest two categories A and B only, and leave group C for the physician to decide for
patient management depending on clinical picture regardless of the figures and numbers.
Participant 3: The criteria are fine
9
Participant 4: The criteria are fine
Participant 5: Suggest inclusion of malaria as deferential diagnosis in our region
Participant 6: The revised case definition lack details of when to transfuse the patient, there should be a
cut down number for platelet and creatinine, suggest platelets 10,000 could be a limit for transfusion,
also should include CK in the severity of DF
Impression / Group Dynamics:
Although this hospital is one of the large tertiary hospitals in Jeddah that receives and report large
number of DF (around 60 cases / year over the past 4 years), Participants (except for participant 6, the
head of infection control and isolation units) were not very familiar with the revised case management
guideline, even though they have expressed their comfort towards the revised dengue classification.
This could be due to the fact that only small number ( not representative of hospital staff) of physicians
were selected for the purpose of FGD.
10
SESSION 3
DR. SULIMAN FAQEEH HOSPITAL
Date: 12 October 2009
Time: 1:30 Pm – 3:00Pm (discussion conducted during the lunch hour)
Venue: Main Auditorium 7th floor- Dr. Suliman Faqeeh Hospital.
Target Audience: Physicians and nurses
Gp. Facilitator: Dr.Naeema Akbar
Gp. Moderator Mp4 recorder as well as controller of mobile phone – recorder: Miss. Fatima Haddadi
Gp. Organizer: Dr. Majed al Magrapi
Participants
No
Names
Characteristics
1
Emelda (Participant 1)
Specialist Infection control practitioner
2
Sameer Sabree (Participant2)
Consultant- Internal medicine
3
Prof. Nader Fareed (Participant 3)
Consultant- Medicine and gastroenterology
4
Gada Rabea (Participant4)
Consultant- Medicine and gastroenterology
5
Dr. Waleed Abdul Razek
(Participant 5)
Specialist- Medicine and gastroenterology
6
Profissa (Participant 6)
profession Indoor Nurse
7
Dorthy (Participant 7)
Nurse
8
N. Soderano (Participant 8)
Nurse- ICN
BEGIN
Audience welcomed and their Participation was appreciated. Consent forms and verbal agreement for
MP4 recorder
Also, it had been explained that the discussion will be guided by proposed questions from the WHO
Transcribed text from MP4 recorder by Dr. Naeema Akbar
11
INTRODUCTION
Q1.How many dengue cases occur monthly/ yearly in this hospital?
Around 42 since the start of this year
Q2. What do you find most challenging in the diagnosis and treatment of dengue?
They all agreed that case definition and decision on level of care at hospital is the most challenging in
managing DF cases
2. CLASSIFICATION
Q1.
How comfortable do you feel using the revised classification system into levels of
severity (D-/D+/SD) as compared to the ones you used before (DF/DHF/DSS)?
Participant 1: Comfortable
Participant 2: Neutral
Participant 3: Comfortable.
Participant 4: Comfortable
Participant 5: V. Comfortable
Participant 6: I don’t have role in diagnosis. I only forward the MOH CRF to the preventive department
and the physician is the one responsible about diagnosis.
Participant 7: I only facilitate the work of physician
Participant 8: Same as participant 7
Q2. Is it easier for you to classify patients using the new classification?
Participant 1: The validated classification is OK, although I don’t have much experience with the current
classification
Participant 2: I’m still using the current guideline
Participant 3: The revised cases definition is very simple
Participant 4: We admit all cases with thrombocytopenia and leucopenia
Participant 5: from the clinical aspect the revised case definition is much easier
Participant 6: Agree with participant 3
Participant 7: Same as participant 3
Participant 8: Same as participant 3
Q3. Can you better distinguish between those patients who go home, those who have to stay
in general ward and those who have to go to ICU?
12
Participant 1: No as patient may transfer from group A to group B, in addition the home care card make
patient think that he got the symptoms
Participant 2: No comment
Participant 3: No because at early stages of the disease if no warning signs, the patient may wrongly be
classified as mild, and then he/she develops complications during the disease course ( so we admit all
cases of suspected DF) . We admitted all cases of suspected DF during the epidemic
Participant 4: No because home care card makes the patient think that he got the sever symptoms
(medical student syndrome).
Participant 5: No as in the revised case definition there is no clear cutline between mild, moderate and
sever, as patient my transfer from one group to another group, eg group A to B and the hospital will be
blamed if patient was discharged from the beginning. Although more than 95% of our cases were mild
still we admit all cases suspect to have DF
Participant 6: all patients were admitted to general wards
Participant 7: Agree with Participant 6
Participant 8: Agree with Participant 6
3. CASE MANAGEMENT
Q1: Do you think the dengue treatment guideline is user-friendly?
Q2: If not, do you have any advice that could help to make the guideline more user- friendly?
Participant 1: As infection control practitioner I am not involved in management of patients.
Participant 2: Still using the current guideline
Participant 3: Yes
Participant 4: The revised case management is very simple and easy
Participant 5: Yes
Participant 6: Yes
Participant 7: Yes
Participant 8: Yes
Q3: Comment on the revised case classification into levels of severity as compared to the
DF/DHF/DSS classification:
a- What are the advantages/disadvantages?
Participant 1: The revised case classification is easy
Participant 2: Still using the current guideline
13
Participant 3: did not see any case of DHF or DSS during this period and the current case definition will
only discover the cases late when the patient already shocked, the validated case definition can give
warning signs before complication occur and easily predict course of the disease.
Participant 4: The revised case management is very simple and easy
Participant 5: Agree with participant 4
Participant 6: Agree with participant 4
Participant 7: Agree with participant 4
Participant 8: Agree with participant 4
a. What are the limitations and opportunities?
b. What would you suggest to improve?
Participant 1: No comment
Participant 2: Still using the current guideline
Participant 3: Suggest add social level of the patient as most complicated cases are among low social
status, also add nutritional status, and status of secondary infection (2ry DF infection)
Participant 4: Suggest add CK level as indication of sever DF
Participant 5: disadvantage is late retrospective diagnosis. Suggest add Serotype of the infection and
inform the patient about the serotype and register the type in patients file
Participant 6: Agreed with prf. Nader participant 3
Participant 7: Agreed with prf. Nader participant 3
Participant 8: Agreed with prf. Nader participant 3
[Thank you very much!!]
Impression / Group Dynamics:
The predominant participant was Participant3, since he was assigned as research coordinator at the
hospital and was responsible of staff training and distribution of training material to different hospital
departments.
Participant1, Participant2, Participant4 and Participant5 were interested in sharing their experiences
with the other gp. Members, although Participant1, has experience in the validated case definition and
management only .On the other hand Participant2 has experience in the current case definition and
management only, while the three nurses a greed most of the time with physicians notes.
We had the impression that physician’s decision towards admission was according to hospital policy of
admitting any suspect case of dengue (being a private sector)
14
SESSION 4
KING ABDUL AZIZ UNIVERSITY HOSPITAL
Date: 26 October 2009
Time: 10:30 Pm – 12:30Pm
Venue: Meeting room at medical departemen- KAUH.
Target Audience: Physicians (registrars, consultants and internist)
Gp.: Facilitator Dr. Naeema Akbar
Gp. Moderator and MP3 recorder Miss. Fatima Haddadi
Gp. Organizer: Dr. Eyaz Khan - registrar Infection control
Participants
15
No
Names
Characteristics
1
Tarik Madani (Participant 1)
Professor of medicine and Infectious disease
2
Abeer Al Najjar (Participant 2)
Registrar in pediatrics
3
Shehata AbdulGhani (Participant 3)
Registrar Internal medicine
4
Saleh Damnan (Participant 4)
Consultant and Director ICU
5
Abdul Aziz al Gethani (Participant 5)
House officer Registrar Internal medicine
6
Anoud Al Jiffry (Participant 6)
ID senior registrar
7
Nisreen Ba Junaid (Participant 7)
ID Fellow
8
Abdullah al Gamdi (Participant 8)
House officer Registrar Internal medicine
9
Hanan Al Shamrani (Participant 9)
Senior Registrar ER
10
Dr. Suha (Participant 10)
Resident internal medicine
11
Dr. Nahid Qashgari (Participant 11)
Resident internal medicine
12
Ebtihal Abdul Al (Participant 12)
Resident internal medicine
13
Eyaz Khan (Participant 13)
registrar Infection control
BEGIN [15 MIN]
The current and revised case definition and management guideline were revised and all manuals
available (poster, chart and booklet) were reviewed.
The following text was transcribed from MP3 recorder by Dr. Naeema Akbar
1. INTRODUCTION
Q1.How many dengue cases occur monthly/ yearly in this hospital?
Around 159 since the start of this year
Q2. What do you find most challenging in the diagnosis and treatment of dengue?
They agreed that awareness of the case definition of DF and that DF is endemic in the area, and also
patient compliance to follow up. Some think that it was difficult to select patients for admission and
discharge
2. CLASSIFICATION
Q1.
How comfortable do you feel using the revised classification system into levels of
severity (D-/D+/SD) as compared to the ones you used before (DF/DHF/DSS)?
Participant 1: OK I agree it is comfortable, (although seems conservative in giving clear agreement
message)
Participant 2: Comfortable
Participant 3: Comfortable
Participant 4: Clear and comfortable
Participant 5: Comfortable
Participant 6: Easier for junior staff
Participant 7: Easier
Participant 8: Comfortable
Participant 9: Easier especially in ER
Participant 10: Never seen case of DF
Participant 11: Comfortable
Participant 12: Easy to remember and easy to apply
Participant 13: Comfortable
16
Q2. Is it easier for you to classify patients using the new classification?
Participant 1:
Participant 2:
Participant 3:
Participant 4:
Participant 5:
Participant 6:
Yes
Participant 7:
Participant 8:
Participant 9:
Participant 10:
Participant 11:
Participant 12:
Participant 13:
Q3. Can you better distinguish between those patients who go home, those who have to stay
in general ward and those who have to go to ICU?
Participant 1: One of the advantages of the new case definition is its celerity in distinguishing between
cases in severity. Some of patients with sever dengue not necessarily admitted to ICU but at least
receive special or intensive care. Emergency is not the correct word as even group B need emergency IV
fluids.
Participant 2: Yes
Participant 3: Yes
Participant 4: Agree with participant 1
Participant 5: Yes
Participant 6: Yes
Participant 7: Yes
Participant 8: Yes
Participant 9: Yes
Participant 10: Yes
Participant 11: Yes
17
Participant 12: Yes
Participant 13: Yes
Q4: Comment on the revised case classification into levels of severity as compared to the
DF/DHF/DSS classification:
A- What are the advantages/disadvantages?
Participant 2: No comment
Participant 3: Easy classification
Participant 4: Advantage of the revised is more clear categories and clear management, and less
categories and less error.
Participant 5: Agree with (Participant4),
Participant 6: Agree with (Participant4)
Participant 7: Agree with (Participant4)
Participant 8: Agree with (Participant4)
Participant 9: Agree with (Participant4)
Participant 10: Agree with (Participant4)
Participant 11: Agree with (Participant4)
Participant 12: Agree with (Participant4)
Participant 13: Agree with (Participant4)
Participant 1: Agree with (Participant4)
B- What are the limitations and opportunities?
C- What would you suggest to improve?
Participant 1: Issue of fluid accumulation in category B of the revised classification is not logical because
it is sign of leaky capillaries, and haemoconcenteration should be a sign of severity rather than a
warning sign, now there is no clear cut between mild and sever bleeding (subjective) why mucosal
bleeding (epistaxis) is not sever dengue because it is gastrointestinal bleeding, also; microscopic
haematurea which category. There is also a gap in the diagnosis of hepatitis, is diagnosis of hepatitis
laboratory based or clinically based, the severity of symptoms does not correlate with severity of
hepatitis. So if lab investigations such as LFT, PTT not available at the primary level then hepatitis
should be removed from group C. There is correlation between CK and severity of DF (CK is an
important lab maker of sever hemorrhagic fevers).
Participant 2: Need fluid calculations for pediatric patients
Participant 3: No comment
18
Participant 4: Include LFT, renal FT, and the PTT in the primary investigations for the patients to
decide about the severity.
Participant 5:
Participant 6:
Participant 7:
Participant 8:
Participant 9:
No Comments
Participant 10:
Participant 11:
Participant 12:
Participant 13:
Q5 What would be the requirements for moving from the current to the revised
classification system?
- How should the revised case classification/ guideline be introduced?
Participant 1: Raise awareness and practice using different approach methods and targeting different
departments involved in management of DF, (ER, pediatric , medical) by courses, meetings. He also
suggested to make the guideline in pocket size.
Participant 2: Teaching
Participant 3: Education, all hospital staff should be approached (holistic, multidisciplinary approach)
Participant 4: Dissemination of training material with Larger posters, and larger font of the flow chart
Participant 5: Training
Participant 6: Training
Participant 7: Training
Participant 8: Include educational material in basic student books
Participant 9:
Participant 10:
Participant 11:
Participant 12:
Participant 13:
19
Agree with participant 1, 4 and 8
3. CASE MANAGEMENT
Q1: Do you think the dengue treatment guideline is user-friendly?
Q2: If not, do you have any advice that could help to make the guideline more user- friendly?
Participant 1: He explained to other audience that user friendly means easy to remember, and he think
that this guideline is not user friendly because it is not easy to remember, at the same time he think that
it is easier than the current guideline for the Junior staff.
Participant 2: Yes it is user friendly
Participant 3: No it is difficult to remember
Participant 4: Not sure
Participant 5: Easier than the current case definition and guideline but need more details
Participant 6: Yes it is user friendly
Participant 7: Yes it is user friendly
Participant 8: Yes it is user friendly, simple scheme
Participant 9: Management of group A, DF is easy to use but group B need to be memorized by physician
also need patients education. While management guideline for group C is easy, as the patient will be
admitted and managed as a hole.
Participant 10: Agree in regard to user friendliness, but she don’t agree on categorizing patient into A
and B, she think patient should be managed as hole
Participant 11: She agree with participant 10 in regard to patient categorization, she also think it is not
clear after how long the patient should be reassessed. She also suggests that numbers of fluid units
should be revised and written in a more user friendly figure (easier to remember) eg: instead of a range
of 5-7 give one discreet number eg 6.
Participant 12: The daily visit to hospital is not applicable, probably in the outpatient clincs
Participant 13: No comment
Q 3 Comment on the new guideline
a- What are the advantages/disadvantages?
b- What are the limitations and opportunities?
c- What would you suggest to improve?
Participant 2: No comment
Participant 3: Not easy to remember the management guide line.
Participant 4: The word “improve” is a vague terminology – criteria and vital signs for improvement
should be clearer, also he suggested that type of colloid should be specified
Participant 5: Agree with Participant 4
20
Participant 6: No comment
Participant 7: No comment
Participant 8: No comment
Participant 9: She think that assessment for improvement is not clear whether it is clinical or lab based?
Participant 10: No comment
Participant 11: No comment
Participant 12: There is mixing between category B and C
Participant 13: No comment
Participant 1: The revised definition is more easy than the current case definition.
Q 4. Do you think the new guideline will help to improve the management of patients/ the
clinical outcome?
All participants agreed that the new guideline will help in improving the management of patients/ the
clinical outcome
Q 5- What changes would you make in the guideline given the opportunity?
Participant 1: left the room
Participant 2: Add pediatric management, make fluid replacement guideline clear
Participant 3: define mucosal bleeding mild, moderate and sever and which patients need ICU or high
dependency units eg: suggest that epistaxis and gum bleeding is mild while Melina and haematemisi is
sever. Patients with dengue encephalitis should be managed in high dependency units ( not necessarily
in ICU) while patients with hypotension should be admitted to ICU
Participant 4: Transfusion criteria is not clear eg: group C children or pediatric patients, transfusion of
the patients if HT is < 45% is very vague, I will not transfuse, unless patient is bleeding (avoid
unnecessary over transfusion)
Participant 9: Agree with Participant4
Participant 5:
Participant 6:
Participant 7:
Participant 8:
Participant 10:
Participant 11:
Participant 12:
Participant 13:
21
No answer
Impression / Group Dynamics:
All participants were physicians, they have different levels of knowledge and experience, ranging from
professors to internist, they were also from different departments including the ER, general medicine,
and pediatrics, intensive care unit, and isolation unit.
Participation of the highly experienced (Participant1, Participant4, and Participant9) was higher than
the less experienced internist; they raised new issues in categorization such as lab investigations and in
managements such as details of IV fluids replacement. Although Participant 1 agreed that the new case
definition and management guideline was easier for junior physicians, he was hesitant to accept many
definitions and measures and thought of many opportunities to improve the guideline.
Other specialties such as radiology, nurses, and laboratory personnel did not attend the group
discussion, as they are not involved in the diagnosis and the management of patients.
22
SESSION 5
PART 1 -KING ABDULAZIZ HOSPITAL AND ONCOLOGY CENTER
Date: 17 October 2009
Time: 9:00 Am – 10:30Am (conducted during the morning physicians meeting)
Place: Meeting room at the ER – (KAAH & OC)
Target Audience: Physicians working at the ER and head of infection control unit.
Gp. Facilitator: Dr. Naeema Akbar
Gp. Moderator and MP3 recorder Dr. Naeema Akbar
Gp. Organizer: Nurse. Salwa – Assistant head of Infection control department
Participants
No
Names
Characteristics
1
Sami Al Sabhani
(Participant1)
Consultant of medicine - director of ER
2
Mansoor Qudsi (Participant2)
Consultant of medicine - assistant director of ER
3
Majed Al Hom (Participant3)
Registrar Internal medicine - ER
4
Hani Al Ramadi (Participant 4)
Resident Internal medicine -ER
5
Mohamed
Haseeb(Participant5)
Specialist Internal medicine - ER
6
Aysha Motwali (Participant6)
Specialist - head of infection control department
BEGIN [10 MIN]
The objectives of the meeting and current and revised case definition and management guideline were
revised. Consent form was read loudly and written signature was obtained, in addition verbal for MP3
recording agreement was taken from audiance.
The following text was transcribed by Dr. Naeema Akbar from MP3 recorder
23
1-INTRODUCTION
Q1.How many dengue cases occur monthly/ yearly in this hospital?
Around 400 during 2009 and mean of 324 during the last 4 years
Q2.What do you find most challenging in the diagnosis and treatment of dengue?
As an emergency department at a public hospital more specific case definition, will facilitate selection of
patients for admission to the general ward or to the ICU.
2. CLASSIFICATION
Q1.
How comfortable do you feel using the revised classification system into levels of
severity (D-/D+/SD) as compared to the ones you used before (DF/DHF/DSS)?
Participant 1:
Participant 2:
Participant 3:
Participant 4:
Comfortable
Participant 5:
Participant 6:
Q2. Is it easier for you to classify patients using the new classification?
Participant 1:
Participant 2:
Participant 3:
Yes
Participant 4:
Participant 5:
Participant 6: Yes and it saves time, and effort
Q3. Can you better distinguish between those patients who go home, those who have to stay
in general ward and those who have to go to ICU?
Participant 1: Yes
24
Participant 2:
Participant 3:
Participant 4:
Participant 5:
Yes
Participant 6:
Q4: Comment on the revised case classification into levels of severity as compared to the
DF/DHF/DSS classification:
a- What are the advantages/disadvantages?
b- What are the limitations and opportunities?
c- What would you suggest to improve?
Participant 1: An important task of this department is diagnosis and decision on regard to admission, so
he suggested addition of serology test in the hospital in order to confirm the diagnosis before admitting
the patient thus reduce hospital burden. This will also help in assuring the illegal expatriates of the
diagnosing the disease locally instead of sending his blood to the regional lab.
Participant 2: More easy to catch complications as soon as possible in group A patients. And also
suggest to add serology test for dengue at the primary health care centers, and private hospitals
because private hospitals admit all cases of suspected DF even group A patients.
Participant 3: Add serology and CK
Participant 4 :Add serology because without the test we depend on patient decision in regard to
admission
Participant 5: Agree to add serology test for two reasons, first because when we ask patients about
warning signs they will be biased and answer yes to be admitted, the second reason is that if the patient
is suspected to have hemorrhagic disease early exclusion of DF will save time and money needed to
reach to a final diagnose.
Participant 6: Agree to add serology test, because many patients after admission to the ward are found
to be dengue negative. During the last few years physicians became aware of the diagnosis of DF.
3. CASE MANAGEMENT
Q1: Do you think the dengue treatment guideline is user-friendly?
Q2: If not, do you have any advice that could help to make the guideline more user- friendly?
25
They all agreed that their role usually end by either admitting the patient to the hospital or else by
discharging the patient with the advice to follow up at the outpatient clinic
Q3- What would be the requirements for moving from the current to the revised
classification system?
- How should the revised case classification/ guideline be introduced?
They all agreed on raising awareness through training and distribution of training materials
Impression / Group Dynamics:
All participants were actively participating in particular the ER director, they all stressed on the
importance of more specific tests in order to be able to adequately triage patients for admission.
26
SESSION 6
PART 2- KING ABDEL AZIZ HOSPITAL AND ONCOLOGY CENTRE
Date: 03 November 2009
Time: 9.00-9.30 am (conducted during physician’s morning meeting)
Venue: King Abdel Aziz Hospital and Oncology Centre (KAAH & OC) Meeting Room
Target Audience: Physicians and nurses who are potentially seeing/managing dengue patients
Method: Focus group
Gp. Facilitator and recorder 1: Dr. Ghaiath Hussein
Gp. Moderator and hand reporting: Mr. Mamdouh Al-Malki
Gp. Organizer: Dr. Aisha Motwali
Participants
No
Titles & Names
Characteristics
1
Dr. Mohamed Iqbal (participant 1)
Consultant Physician of Internal Medicine
6
Dr. Aisha Motwali (participant 6)
Specialist infection Control
7
Dr. Samira Khorshid (participant 7)
Consultant of internal medicine
2
Dr. Iman Lobad (participant 2)
Specialist Physician of Internal medicine
3
Dr. Fahad Al-Abasy (participant 3)
Consultant physician of internatl medicine and
endoscopy
4
Dr. Medhat Dakhakhny (participant 4)
Specialist physian of internal medicine
5
Dr. Ibtesam (participant 5)
Specialist of internal medicine
8
Dr.Sari (participant 8)
Resident of pediatrics
9
Dr. Rihab (participant 9)
Resident of pediatrics
BEGIN
The group facilitator together with the moderator started the meeting by welcoming and thanking the
participants. He also explained to them the study, its main objectives and how the information they
27
share will help in achieving these goals. Moreover, the future utilization of this information was
explained.
Consent was taken verbally on the promise to send it written later. Moderator and all participants
agreed to participate.
Also, it had been explained that the discussion will be guided by the potential questions that had been
suggested in the study proposal.
1. INTRODUCTION
Q1. How many dengue cases occur monthly/ yearly in this hospital?
Around 400 since the start of this year
Q2. What do you find most challenging in the diagnosis and treatment of dengue?
Participant 1: Symptoms are non-specific and hard to differentiate from other common diseases let
alone other hemorrhagic fevers.
Participant 3: It is hard to make a good estimation on the outcome/prognosis of the individual patient.
'Will my patient be from the unlucky 2-3% who develops deadly complications?'
Participant 2: I agree and with such uncertainty, it is hard to decide to send the patient home or keep
him/her in ward or prepare an ICU bed, until the clinical picture develops evidently. This is sometimes
too late.
2. CLASSIFICATION
Q1. How comfortable do you feel using the revised classification system into levels of
severity (D-/D+/SD) as compared to the ones you used before (DF/DHF/DSS)?
Participant 1: it is very clear in terms of the warning signs. This helps in better classifying the patient.
Participant 4:
Participant 6: The current (old) classification is rather misleading by ignoring many symptoms o signs.
For example, we used to refer patients with abdominal pain and tenderness for surgical assessment to
exclude acute abdomen. Now, it is clear that could be a warning sign related to dengue and not another
co-morbid condition. Similarly, we give more attention and make better interpretation of any fluid
accumulation found in radiological tests.
Participant 4 :The revised version has well specified parameters which the treating doctor can follow Is
it easier for you to classify patients using the new classification?
Participant 2: Warning signs give so much better indicators on which patients need more attention and
alertness. It is unfortunate that I lost few of my dengue patients this year. The current guidelines were
quite helpless.
28
Participant 3: The revised version is now more comprehensive and provides useful guidelines for the
classification and management of patients
Participant 7: I agree, for example, patients without warning signs could be sent home, while those with
warning signs will be treated in the ward.
Q2. Can you better distinguish between those patients who go home, those who have to stay
in general ward and those who have to go to ICU?
Participant 5: The revised version is now more comprehensive and provides useful guidelines for the
classification and management of patients. For example, patients without warning signs could be sent
home, while those with warning signs will be treated in the ward.
Participant 1: I like specific measures, e.g. HCT is an easy to get and specific monitor for the patient's
status/outcome.
Participant 9: for practitioners with less experience, it is important to have better clues on how to
classify and manage. Many signs are quite similar and some used to be ignored to refered to surgery for
instance.
Participant 8: This is true especially for the fluid accumulation whether clinically or radiologically
Participant 10:
Q3.Comment on the revised case classification into levels of severity as compared to the
DF/DHF/DSS classification:
a- What are the advantages/disadvantages?
Participant 2: The challenges and limitations are basically those related logistic and personnel issues.
Participant 1: It needs more patient-keen more devoted nursing staff. This needs prior recruitment of
new staff, especially nursing, and training for the available staff.
b- What are the limitations and opportunities?
Participant 1: Our experience in the KAAH is a good one. We have been using the revised guidelines for
almost six months now. We felt the need for new guidelines from seeing some dengue patients dying in
the hospital.
Participant 3: We need more time to see the further impact of the new guidelines, in terms of mortality
rates.
Participant 2: notification takes place as soon as patient is suspected and may be hard to report the
patient's classification early with the notification.
c- What would you suggest to improve?
Participant 1: follow up is crucial, both for the clinical pprogreess of patient or from the MOH to follow
up on that. This follow up needs clear criteria as well.
Participant 9: more specifications about dengue in infants and adolescents may be needed.
Participant 2: I believe that may also be required for dengue with pregnancy
29
Q 4- What would be the requirements for moving from the current to the revised
classification system?
Participant 5: I believe that it needs a setup of trained staff, especially nursing, and equipped ICUs
ready to recive patients early.
Q5- How should the revised case classification/ guideline be introduced?
Participant 1: What we made in KAAH &OC to facilitate this transition included a set of interventions,
for example we started regular teaching of staff, within our discharge clinics and rounds, especially the
new residents.
Participant 2: we also distribute the posters with the new case classification and definition and the
management of each.
3. CASE MANAGEMENT
Q1-Do you think the dengue treatment guideline is user-friendly?
Q2-If not, do you have any advice that could help to make the guideline more userfriendly?
Participant 8: The revised guidelines are more user-friendly and eye-capturing. Algorithms are helpful,
especially the use of colors
Participant 4: So far, it seems adequate. However, it may need some modifications to be clear even if
photocopied in black and white, and not only in color.
Other points raised
The way MOH through Dengue Fever Operation Room managed in helping the hospital was crucial in
achieving the transition to the revised version. For example, the posters and the colored printouts
helped in visualizing the new guidelines.
The role of prevention by the municipality has been referred to more than once.
Key statements: __________________________
The revised version of dengue guidelines and case definition are more helpful in classifying the
patients, which helps in improving the outcome.
The implementation of the revised guidelines needs to be accompanied by recruitment of more
nursing staff and to train the working ones.
Posters and hand-held brochures helped in familiarization of staff with the new guidelines.
Impression / Group Dynamics:
1. Most of the group members where willing to participate actively during the discussion.
30
2. The discussion was most of the time dominated by the consultants, probably because they see more
degue patients that specialists and residents or residents are usually hesitant to say something different
from their 'boss''s viewpoint.
3. It would have been more useful and representative to have nurses in the FGD. This could be one
setback of this session.
4. Participant 6 was DF coordinator at KAAH & Co, she participated in both sessions at the hospital, she
was very enthusiastic and active part.
END OF REPORT
11/11/2009
Contributors:
Dr. Naeema A. Akbar
Dr. Tarteel M. Shaikh
Dr. Ghaith H. Abbas
31