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Indian Journal of Community Medicine

A study of Some Facets Reflecting in-patient care of Naxalbari Rural Hospital on Indo-Nepal Border of West Bengal and the Quality of the Care as Perceived by the Patients

Author(s): Vijay Thapa, J.B. Saha, Rama Ram, S.K. Lahiri, G.N. Sarkar

Vol. 26, No. 2 (2001-04 - 2001-06)

Deptt. of Community Medicine, North Bengal Medical College, P.O. Sushrutanagar, Distt. Darjeeling

Abstract:

Research question: How effective is the in-patient care and what are the feelings of patients regarding the quality of services in rural hospital?

Objective: To study some factors regulating the efficiency of in-patient service and to suggest ways for minimising the problems related to patient care.

Study design: Hospital based study with follow-up till the discharge of the patients from hospital.

Settings: Naxalbari rural hospital on Indo-Nepal border in West Bengal.

Participants: 653 patients admitted during the study period of 6 months.

Results: OPD and emergency admissions in the study beds were 26.6% and 73.4 respectively. 0.08 investigations per admission were done. Time lost between ordering of the investigation and receiving the report was 1.15 days. Cost of 'supplied' and 'purchased' medicines was least in children ward (Rs. 27.30 and Rs. 34.27 respectively) and more for male (Rs. 54.19 and 70.45 respectively) and female (Rs. 57.99 and 77.29 respectively) wards and moderate in labour ward (Rs. 47.38 and Rs. 54.35). Overall cost in all the wards being Rs. 49.73 and Rs. 62.92 respectively. Ninety percent of all patients (567) admitted for different diseases stayed in the hospital for not more than 4 days. Fatality rate was maximum in children ward and nil in labour ward. The fatality rate of 'All units' (1.39%) and of total admissions (1.70%) somewhat corresponds. Dissatisfaction of patients regarding different aspects of cleanliness, facilities and services ranged from 13.33% to 50%, 6.67% to 50% and 10% to 36.67% respectively.

Keywords: Patient admission. Investigation time, Length of stay, Cost of medicines, Staying time in hospital, Fatality rate, Patients' dissatisfaction

Introduction:

Efficient in-patient care in a hospital starts from channel of admission and includes the efficiency of the hospital diagnostic services viz. radiological investigation services, laboratory services and operating room services1. In a rural hospital, routine investigation services are available. The patients in rural hospitals are mainly from low socio-economic strata. They often try to ignore their ailments in the initial stage because of the fear of loss of daily earning. When they come to health institute they are already late and get themselves admitted more through emergency than through OPD2. The practice of admission through emergency increases the fatality rate. Further, the situation worsens if the drug supply in hospital does not match with the demand resulting in purchase of drugs by the patient and/or his family. The feelings of patients regarding the quality of services should also be taken as a feed-back for reshuffling the existing scenario because hospital administration requires the appropriate supporting services3. Considering these facets this study was carried out in Naxalbari rural hospital.

Material and Methods:

Study area: 50 bedded Naxalbari rural hospital situated on the Indo-Nepal border of West Bengal in the district of Darjeeling. This hospital caters to a population of 1.7 lacs in the entire block.

Study period: October 1998 to March 1999.

Sampling frame: This hospital has no cabin, intensive care unit or observation wards. It has one each of male, female, paediatric and labour wards. There are 16 beds in male, 16 beds in female, 8 in paediatrics and 10 in labour wards.

Sample: Simple random sampling technique was applied to take up 5 beds in male (M), 5 in Female (F) wards i.e. 30.1% each of male and female beds. Similarly, 2 beds in paediatrics ward (25% of total children beds) and 3 in labour ward (about 30% of labour beds) were also taken up. So, 15 beds in total (30% of al the beds) from all the four wards were taken up as study beds. Throughout the study period all the patients in the study beds were followed up from admission to discharge.

Thirty patients were chosen (5 persons per month for 6 months) after being selected randomly for knowing their experiences about cleanliness, facilities and services. The data were collected on a pre-designed and pre-tested proforma.

Results and Discussion:

Table I: Literacy status of the patients and channel of admission in the hospital.

Literacy status OPD admission Emergency admission Total
Illiterate 119 (18.2) 320 (49.0) 439 (67.2)
Primary education 31 (4.7) 109 (16.7) 140 (21.4)
Middle school education 16 (2.5) 33 (5.1) 49 (7.6)
Madhyamik 5 (0.8) 17 (2.8) 22 (3.6)
Higher secondary 3 (0.4) - - 3 (0.4)
College - - - - - -
University - - - - - -
Total 174 (26.6) 479 (73.4) 653 (100.0)

Figures in the parentheses are percentages.

It was found that in the study beds 174(26.6%) patients got themselves admitted though OPD and 479(73.4%) through emergency. Illiterate group alone consisted of 439(67.2%) patients and of these 119(18.2%) and 320(49.0%) came in through OPD and emergency respectively. Similarly, in middle school education group, out of 49(7.6%) patients, 16(2.5%) and 33(5.1%) had their admission through OPD and emergency respectively; in Madhyamik group, out of 22(3.6%) patients, 4(0.8%) and 17(2.8%) entered the indoor beds through OPD and emergency respectively. The admissions through OPD showed tapering figures of 119(18.2%), 31(4.7%), 16(2.5%), 5(0.8%) and 3(0.4%) patients from illiterate to primary, middle school, madhyamik and higher secondary groups respectively. Similarly, the admission through emergency drastically came down from 320(49.0%) in illiterate group to 109(16.7%), 33(5.1%) and 17(2.8%) patients educated upto primary, middle school and madhyamik standard respectively. In higher secondary group, however, there was no emergency admission. The number of patients admitted through OPD and emergency gradually decreased with increase in literacy status. College and university educated people did not have any admission during the study period due to either their absence in the area or their health care seeking behaviour from non-govt. health agencies. So, the hospital is utilised more by illiterate people who are (1) less conscious about their health, (2) possibly afraid of loss of daily wages due to hospital attendance unless compelled due to the advanced stages of the disease, (3) unable to pay for the health care available outside govt. health care delivery system even if they knew of such existence in their locality. Here lies the scope of educating people about why and when to seek for health care advice by the health workers of all strata. The study further indicates that improvement of literacy status of patients would put less pressure on the load of emergency deptt.

Table II: Time gap in days between investigations ordered and report received in different units.

Wards Average time
gap between
investigations
ordered and
specimens sent
(in days)
Average time
gap between
specimen sent and
report received
(in days)
Total time
gap between
investigations
ordered and
reports received
(in days)
Male (18) 0.34 0.91 1.25
Female (12) 0.37 0.78 1.15
Children (19) 0.37 0.74 1.11
Labour (8) 0.55 0.51 1.06
All wards (57) 0.38 0.77 1.15

It is observed in the study that more or less equal time gap existed between investigations ordered and specimens sent in different wards. The slight difference is due to the type of investigation ordered. The time gap between specimen sent and report received was 0.77 days, while the total time gap between investigations ordered and reports received was 1.15 days. This figure was compared with the average time lapse of 3.33 days as reported by Bhadra and others4 in a state hospital. In the study beds during the study period a total 57 investigations were done. Thus, there were only 0.08 investigations done per admission. This figure is rather low; but factors that suggest this figure were (a) that it is a rural hospital, (b) that the length of stay is rather short, (c) that less availability of reagents and (d) that referral of more complicated cases to higher level hospitals thereby minimising the need of more sophisticated investigations though these are not expected to be done in this setting.

Table III: The average annual cost of medicine per patient during the study period.

Ward No. of beds Total cost of medicine (Rs.) Average cost of medicine (Rs.)
Supplied Purchased Supplied Purchased
Male 194 10513.18 13668.55 54.19 70.45
Female 183 10613.03 14144.23 57.99 77.29
Children 86 2347.98 2947.88 27.30 34.27
Labour 190 9003.97 10327.29 47.38 54.35
All wards 653 32478.16 41087.95 49.73 62.92

It is observed that the cost of medicines was least for 'C' ward (Rs. 27.30 and Rs. 34.27) and more for the 'M' and 'F' wards. The cost of medicines for 'L' ward was moderate (Rs. 47.38 and Rs. 54.35). Out of total cost of medicines the amount (Rs. 62.92) under 'purchased' column is more than that of the 'supplied' (Rs. 49.73). The more cost under 'purchased' column indicates that the hospital supply of medicines was limited. The method for ordering medicines for the hospital was done through 'cyclic system' with quarterly indent but the supply depended on the availability of drugs at the district reserve store. The lesser cost for 'C; ward is due to the lesser dose prescribed for their treatment. The cost of medicines per patient was somewhat related to and varied with the average length of stay in the study beds.

Table IV: Diseases and the length of stay in hospital.

Diagnosis Length of stay in days
<1 1-2 2-3 3-4 4-5 5-6 6-7 >7 Total
Acute gastroenteritis 48 67 66 36 13 11 4 1 246
Pregnancy 67 47 33 15 2 2 1 1 168
Respiratory tract infections 14 22 8 6 2 2 1 1 57
Injury 13 14 6 6 6 3 1 2 48
Bronchial asthma 4 6 7 6 4 1 - 3 32
Pain abdomen 3 6 3 3 3 - - 2 20
Hypertension and cardiac diseases 3 2 1 3 3 1 - 3 16
Others 23 13 6 12 5 4 1 2 66
Total 175(26.6) 177(27.1) 130(20) 87(13.2) 37(6) 24(3.67) 8(1.2) 15(2.3) 653(100)

Figures in parentheses are percentages.

Maximum number (177) of patients stayed in the hospital for 1-2 days. The next group according to length of stay was less than I day (174 patients). Majority of patients with acute gastroenteritis (133 patients) had the 'length of stay' for 1-3 days. In majority of patients admitted with pregnancy (114 patients) the length of stay was less than 2 days, while only 6 patients out of 168 were admitted for more than 4 days. It was also seen that 90% of patents (567 patients) admitted for all diseases did not stay in the hospital for more than 4 days.

Table V: Showing fatality rate in study beds and total admission for the study period.

Ward No. of beds No. of deaths No. of discharges Fatality rate
Study beds
Male 5 4 191 2.09
Female 5 1 182 0.54
Children 2 4 82 4.87
Labour 3 0 191 0
All wards 15 9 646 1.39
Total admission
Male 16 11 622 1.76
Female 16 15 458 3.05
Children 8 9 248 3.62
Labour 10 0 664 0
All wards 50 34 1991 0.170

Fatality rate = Dx100/d; Where D = Number of in-patient deaths during a specified period; d = number of discharges during the specified period.

The fatality rate denotes the killing power of diseases. In this study, it denotes the seriousness/acuteness of patients admitted in different wards. The maximum fatality rate was observed in 'C' ward of both the study beds (4.87%) and total admission situation (3.62%). The 'L' ward had 'nil' fatality rate. The rate in 'F' ward in the study beds and 'total admission' somewhat contradicts i.e., 0.54% in study beds (lower than the corresponding figure of 2.09% in 'M' ward) and 3.05% in the 'total admission' (higher than the corresponding 'M' ward of 1.76%). The fatality rate of all wards (1.39%) and of 'total admission' (1.70%) somewhat corresponds. The 'nil' fatality rate for 'L' ward suggests the better antenatal check-ups in the periphery and timely referral of complicated cases. Facilities for the care of children, cleanliness (children succumb to infection) and timely treatment must be arranged in the hospital to a greater extent. Early initiation of patients for seeking medical care of children must be encouraged to bring down the fatality rate of children. Here Health Education for the common people by the health workers at any level can improve the situation. Opinion of patients regarding cleanliness, facilities and services to patients was separately taken from 5 patients selected randomly in each month for 6 months totaling to 30 patients.

Table VI: Opinion of patients regarding cleanliness, facilities and services to patients (n=30).

  No. of patients (%)
Items of Cleanliness
Beds not fit to sleep 13 (43.33)
Dirty bed sheets 10 (33.33)
Beds full of bed bugs 4 (13.33)
Wards dirty not cleaned 9 (30.0)
Toilets not usable 11 (36.67)
Regular cleaning of toilets not done 6 (20.0)
Slippery toilets 4 (13.33)
Bowls not cleaned 15 (50.0)
Items of Facilities
No proper lighting or fans 15 (50.0)
Drinking water not supplied 13 (43.33)
Food disliked 9 (30.0)
No mattress 14 (46.67)
No bed sheets 3 (10.0)
No mosquito nets 2 (6.67)
Investigations to be done outside 4 (13.33)
Usually referred to Medical College 2 (6.67)
Have to purchase medicine 6 (20.0)
Items of Services
Some members of the staff least bothered 11 (36.67)
Sweepers demand money 7 (23.33)
Some members of the staff are drunk 4 (13.33)
Some members of the staff are rude 8 (26.67)
Sometimes members of the staff are not present in the wards 4 (13.33)
Some doctors do not seem to care 3 (10.0)
Some doctors do not examine properly 5 (16.67)
Doctors not present during delivery 3 (10.0)
Doctors visit only once a day 10 (33.33)
Separate doctors visit each time 3 (10.0)
Some nurses are harsh 6 (20.0)
Some nurses do not listen at all 10 (33.33)
Medicines are not served at fixed time 5 (16.67)
Dressing not done in wards 3 (10.0)
Nurses do not attend 6 (20.0)

30 to 50% complaints were related to cleanliness of the bed, toilet and ward. Toilet not usable was the complaints of 36.67% of respondents. About half (43.33%) complained of unsuitable beds for sleeping. 20-50% experienced poor lighting, fans, food and drinking water supply.

More or less same responses were found in relation to services delivered by doctors, nurses and other member of the staff of the hospital. About 1/3rd of them complained about the apathy of some of the nursing and other staff and were not happy with one visit of doctor per day.

These problems can be solved by the Superintendent of the hospital by holding group meetings with the concerned staff and listening to their problems so that the can prioritise them and tries to solve the crucial ones immediately by boosting up the staff in their respective jobs. The problems really need redressal so that dismal picture can be improved.

Acknowledgement:

Authors acknowledge with thanks the kind co-operation extended by the superintendent of naxalbari rural hospital and his members of staff and the patients. Authors also acknowledge Dr. D.M. Munshi, D.L.O., M.S. (E.N.T.), Associate Professor, Deptt. of E.N.T., North Bengal Medical College, Sushrutanagar, Darjeeling, W.B., his wife Dr. (Mrs.) M. Munshi, D.O., Ophthalmologist, Siliguri Sub-divisional Hospital and their two sons Masters Debanjan Munshi and Arunava Munshi for their active involvement in computer processing of this paper.

References :

  1. Linnenberg CC. Measurement of economic benefits from Public Health Services. Public Health Service Publication 1178, Washington 1964.
  2. Anand RC, Anand TR, Ghei PN. Study of the non-emergent cases utilising the casualty and emergency department in three large hospitals in Delhi, NIHAE Bull 1976; 8: 57-61.
  3. Ellsworth John. A study on hospital administration. Journal of American Health Association 1977; 51: 29.
  4. Bhadra UK. An analysis of in-patient system of a state hospital in Calcutta. (Thesis submitted for Doctorate of Medicine in Social and Preventive Medicine. All India Institute of Hygiene and Public Health, Calcutta) 1984 (unpublished).
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