The findings are organized and presented based on Donabedian model of quality of care. The findings show insights provided by the 15 doctors who participated in the study. The sample comprised of 5 females and 10 males from 2 private, 2 private not for profit and 1 public hospital. The doctors were from four departments; Accident and Emergency, Pediatrics, Medical and Intensive Care Unit wards.
Structure of pesticide poisoning care
The doctors emphasized that the hospital units including wards such as the ICU at hospitals in which doctors deliver care to pesticide poisoning patients determined the quality of care they give to the patients. Presence of facilities such as enough hospital beds to admit the patients, intensive care equipment to support unstable patients and having the necessary medicines enabled the health care staff save the lives of the pesticide poisoning patients they received.
One doctor stated:
“Over 98% of the pesticide poisoning patients fully recover. It is because we [this hospital] have all the necessary equipment and manpower to save their lives. We have the ICU services, ventilation, enough medicines needed. Therefore, if the patient is admitted on time, we are most likely be able to save their life” (Doctor 4, Medical ward).
Other doctors stated that even when the health care staff is well trained, limitations in physical settings such as insufficient equipment and medicine in the hospital constrained their ability to provide the necessary care to the pesticide poisoning patients.
“You might have a patient; you know what to do but you don’t have the necessary equipment or medicines to treat the patient. In that case, I have major limitations and can’t do anything but refer the patient. We sometimes lose patients due to such avoidable reasons” (Doctor 13: Medical ward)
The doctors also considered the presence of psychiatric units was an important factor in the quality of care offered to pesticide poisoning patients, especially those who were suicidal. All the doctors reported that their hospitals had a psychiatric unit where the patients who had taken pesticides for self-harm received further care to address the root cause of the poisoning.
“All poisoning cases that are suicidal must be linked to the psychiatric unit before they’re discharged. If we don’t treat the root cause of the problem, some of them can go back home and find another way of committing suicide.” (Doctor 2, Medical ward)
All the doctors elaborated that their hospital policies required them to respond to pesticide poisoning cases as emergencies and admit them to monitor their condition, and the average duration of the hospital stays was between 1 day to 2 weeks depending on the severity of the condition in which the patients were received.
“All cases of pesticide poisoning are treated as emergencies and even after they have stabilized, they must be admitted for at least a day or two as we monitor the signs and symptoms. It just applies as a general policy.” (Doctor 7, Accidents and Emergency)
Health workers’ characteristics
The doctors emphasized the importance of clinical expertise in the quality of care provided to pesticide poisoning patients. Doctors elaborated that they used continuous professional development platforms such as mini-rounds, grand-round and seminars to share experiences and enhance their clinical expertise.
“We hold these Continuous Medical Education (CME) sessions once a week to enable us to discuss interesting cases and share experiences with one another. We also have mini-rounds and grand-rounds, and these are also very important in sharing information. We also have seminars which can be held by different associations like the Medical Practitioners’ Association, Medical and Dental Council, Uganda Pediatric Association and others.” (Doctor 3, Pediatrics Ward).
Clinical processes for pesticide poisoning
The doctors considered proper diagnosis as a critical first step in ensuring that pesticide poisoning cases receive the appropriate care needed. This was done through taking history from the patients or caregivers to determine the possible cause of poisoning, approximate time of poisoning, route of exposure, quantity of poison taken, and any first aid given to the patient. All these parameters enabled doctors decide on how to handle the patient.
“When a patient is rushed in, our first concern is to determine the cause of illness. For most pesticide poisoning cases, we get all the history and circumstances of poisoning from the patient or caregiver. A proper history enables us make the right diagnosis and appropriate treatment plan for the patient.” (Doctor 7, Accidents and Emergency)
Some doctors however noted that obtaining the proper history from the patients or caregivers was a challenge due to the panic and emergency surrounding pesticide poisoning patients. One of doctors said:
“The challenge is that most of the caregivers cannot explain what the child took because they come rushing. It is quite difficult to treat the patient without enough history. Sometimes the caregivers lie about what happened and when you check the child, you find that it is something different.” (Doctor 6, Pediatrics Ward).
The doctors said that they mainly depended on the signs and symptoms to determine whether a case was a pesticide poisoning patient. They emphasized that pesticide poisoning patients had a set of similar signs and symptoms which varied depending on the severity of the poisoning.
“It’s quite easy to notice a pesticide poisoning patient and the signs and symptoms depend on the severity of the poisoning. Patients who had a slight dose come with a few signs like constricted pupils, nausea, vomiting, slight cardiovascular upsets, and diarrhoea but as severity progresses, we see drowsiness, drooling saliva and some become comatose. Very severe ones can get lingual spasms and bronchial spasms which cause de-circulation and hypertension” (Doctor 1, Accidents and Emergency Ward)
The doctors said that physical and logistical challenges such as the lack of toxicology laboratories hindered them from producing detailed toxicology reports for the patients and only identified the general class of the pesticide poisoning agent.
“Rarely do we go on to identify the specific kinds of pesticides or other poison, because our laboratories are not equipped to do such tests because they are very expensive. (Doctor 5, Accidents and Emergency)
The doctors emphasized the importance of standard guidelines and procedures in the proper treatment of pesticide poisoning patients. They identified the airway, breathing and circulation (ABC) protocol as the primary guidelines followed during treatment and most of these guidelines were pinned somewhere in the different wards where pesticide poisoning patients are treated.
“When treating a case, we first look at the vital signs: The blood pressure, heart rate and whether the patient breathing. This is the ABC protocol. If the airway is okay, then we look at the breathing and then the circulation. When they stabilize and make sure that the ABC is fine, then we take the patient to ICU if it is necessary” (Doctor 1, Accidents and Emergency)
For treatment anti-dotes, doctors said that they used atropine in the treatment of the pesticide poisoning cases. The frequency of administering atropine depended on the severity of the symptoms. However, it was the only anti-dote available in all hospitals.
“The treatment procedure includes rehydrating the patient and then atropinisation follows. We do have an atropinisation protocol, we administer atropine to all our patients within 15minutes of diagnosis and then we continue after every 15-30minutes until total atropinisation has occurred and the pupils are fully dilated.” (Doctor 6, Pediatrics ward)
Patient and system outcomes
Recovery and rehabilitation
The doctors noted that most of the pesticide poisoning patients they handled, fully recovered and were discharged. This was mainly attributed to the presence of the necessary physical structures including medical and psychiatric wards and following the right procedures.
“Most of our patient survive, get well and are discharged. I would say 95% of the pesticide poisoning cases are discharged unless they came in late with severe complications. We have adequate facilities to save lives” (Doctor 7, Accidents and Emergency)
Some doctors elaborated that the positive relationships between the self-harm patients and the psychiatrists was essential for enabling patients to overcome negative emotions and fully recover.
“We really recognize the need for psychiatric therapy. Most of the psychiatrists have a social work aspect and take time to understand and develop a positive relationship with the suicidal patients to enable them appreciate their self-worth and regain hope” (Doctor 9, Medical ward)
Improving health workers’ competence
The doctors highlighted that sharing experience of managing various pesticide poisoning cases increased their competence. Sharing their experiences with other health workers also reminded them of the best practices that are necessary in managing complex pesticide poisoning cases.
“Properly managing pesticide poisoning patients is very helpful because we keep learning and updating ourselves with new information. The junior members in the profession are also brought on board, we share experiences and it helps preserve the quality of the services offered.” (Doctor 13, Medical ward)
Health promotion and wellbeing
An increase in the number of pesticide poisoning patients in the hospitals prompted doctors to conduct community sensitization to tackle the root causes, promote health and prevent pesticide poisoning.
“As health workers, we feel the community has to know about pesticide poisoning because the source of poisoning is basically the community. We use the media and community outreaches to teach the community about poisoning, and how to handle it” (Doctor 1, Accidents and Emergency ward).
Some doctors added that the sensitization outreaches also led to better health care accessibility by the community. Having doctors and nurses in communities bridged the gap and improved the relationship between the health workers and the community.
“The community sensitization that we carry out narrows the gap between the community and the health workers. The people get to understand that we can easily be approached in case they need help.” (Doctor 5, Accidents and Emergency)