Summary This paper is intended to provide an overview of the Colonial War Memorial Hospital’s response to the Covid-19 pandemic in Fiji. It presents the management and organizational systems and processes developed to ensure effective and timely management of potential COVID-19 cases presenting within CWM. It presents the theoretical model developed to support the Outbreak Management Team in determination of appropriate responses that required to be modified in the light of new knowledge and experience. The paper describes actions taken to ensure the preparedness of CWM; the development of process algorithms required to ensure consistency across the organization; the establishment of an Emergency Management Centre that provides 24 hour oversight of the CWM Covid-19 response; arrangements for quarantine of staff etc. It will also present the Covid-19 Preparedness Assessment Tool that was developed in CWM and subsequently used to assess the state of preparedness at other facilities nationally.

Abstract This paper explores the introduction of a quality improvement initiative in Kiribati’s primary health care (PHC) system.

Abstract In low-resource settings such as Melanesia, gestational diabetes often goes undiagnosed due to many factors, including the unsuitability of current tests. Ideally a gestational diabetes test for low-resource settings should meet criteria related to acceptability, test performance and operational characteristics, with minimal impositions on individual patients or the wider health system. None of the six tests recommended in country-specific gestational diabetes guidelines in Melanesia (2-hour oral glucose tolerance test, glucose challenge test, fasting plasma glucose, random plasma glucose, 2-hour postprandial glucose and glycated haemoglobin) meet criteria related to these attributes. Additionally, each Melanesian country has different, complex algorithms that use multiple tests in different combinations. With a high and increasing burden of diabetes mellitus (and therefore assumed gestational diabetes), Melanesian health practitioners and policymakers should be aware of the limitations of recommended tests for gestational diabetes and be open to alternative technologies that may be more appropriate.

Background: In Fiji, 1 in every 3 Fijian is being diagnosed with diabetes. The contribution of chronic kidney disease (CKD) to mortality in Fiji has increased to become the fourth leading cause of death in the country. Fiji Ministry of Health and Medical Services data show that admissions to hospitals for CKD are increasing and treatment of end‐stage kidney disease (ESKD) is a growing burden. Since renal replacement therapy is not readily available or affordable in Fiji, it is advisable to prevent or slow the progression of renal disease to ESKD. Early deduction of renal impairment in diabetic patient is paramount and foremost is to identify proteinuria in the earliest stage. Angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) offer reno-protection. These agents reduce proteinuria, a risk marker for renal disease progression. Aim: To evaluate and provide evidence for use ACE-I and ARB in prevention of diabetic nephropathy in our clinical setting. Method: An online search using MESH terms that best answered our research question was conducted on the Medline database. Four seminal papers were identified after shifting through abstracts of 210 studies. These papers were evaluated and conclusions discussed. Results ACE-I and ARBs are equally reno-protective agents when used individually; it slows the progression of diabetic renal impairment to ESKD and reduces proteinuria to almost normal levels. ARBs are likely to be used as first line agent in patients who have already developed significant diabetic proteinuria since additional blood pressure lowering capabilities of this class of drug may have accentuated benefits. Additionally, ARB’s should be used in patients who cannot tolerate ACE-I induced side effects. For prevention and conversion of diabetic nephropathy to normo-proteinuria; moderate to maximum doses of ACE-I or ARB should be used in clinical practice. Combination of ACE-I plus ARB in management is not recommended. ACE-I still remains the most cost-effective drug for a low resourced clinical setting such as ours.

Objective: To determine the incidence of acute spinal blockade complications and the association of frequent spinal blockade complications and acute spinal blockade complications. Methodology: A prospective, qualitative survey of 685 adults at Labasa Hospital was done from November 2019 to November 2020 to determine the incidence of having spinal blockade complications in 24 hours. Cross tabulation was used to determine the strength of association between frequent spinal blockade complications and the incidence of acute post spinal blockade complications. Results: The incidence of acute post spinal complications was 18%. 685 participants were entered into analysis. 17% of patients thereby had frequent spinals during the study period. The Odds Ratio of frequent spinal blockade complications to acute post spinal complications was found to be 2.56 (Confidence Interval: 1.62-4.02). Conclusion The study describes the cohort getting spinal blockades in Labasa Hospital. In addition, this audit highlights the incidence of acute post spinal blockade complications. The strong association of acute post spinal blockade complications and frequent spinal blockades is confirmed. The author believes that this lays groundwork for studies showing the validity of doing post anaesthesia visits and increasing research into the dangers of having frequent spinal blockades.

Introduction: Perioperative pain is a major problem for patients undergoing surgery. Inadequate pain relief can lead to complications like pneumonia, extended hospital stay, re-admissions and patient dissatisfaction. The aim of this research was to determine adequacy of perioperative pain management on immediate post-operative analgesia for elective Intra-abdominal procedures done under general anaesthesia. Method: This is a retrospective study which involved auditing inpatient folders from the 1st of January to 31st of December, 2015.The inclusion criteria were those between the ages of 18 to 60years who had Elective Intra-abdominalprocedure done under general anesthesia.Each folder was audited for perioperative pain management from surgical and anaesthetic charts and data were entered into a proforma list. EpiInfo 3.1 software and Microsoft Excel Spreadsheetwere used for analysis of the extracted data. Results: 159 records met the inclusion criteria but only 127 folders were recovered. 28% of patients recorded pain in the immediate postoperative period. There were more females than males and Total Abdominal Hysterectomies was the most common procedure. The age between 31 to 40 years, reported the most pain. Open cholecystectomy’s procedures recorded the most pain complaints and hernia repairs had the least. Verbal response was the highest pain indicator used and 11% of patients who indicated having some pain went from PARU untreated. There were no records of usage of pain scales in any folder retrieved. Discussion: Pain recording in the recovery unit was heavily dependent on the recovery nurse and the patient. The incidence of immediate postoperative pain from this study group was lower when compared to other studies. This could be due to a lack of documentation or a reflection on how well perioperative pain treatment has been done in Lautoka. Conclusion Overall management of perioperative pain still needs improvement. The anaesthetic team should seriously look at this problem as Anaesthetists are still unaware of their patients pain. It is highly recommend that the formulation of an Acute Pain Management Protocol for Fiji to ensure that Pain be included as the 5th vital sign.

Introduction: It is well known that inappropriately inflated ETT cuff pressure may result in significant patient complications. Clinical guidelines recommend objective measurements of cuff pressure using standard manometric tools with regular monitoring to maintain ETT cuff pressure within the recommended range (20-30cmH2O). Estimation techniques in assessing cuff pressure are unreliable and patients may still be exposed to unfavourable pressure. The aim of this baseline study was to carry out a descriptive audit on the current practice to determine whether ETT cuffs are inflated to correct pressure, and to assess whether cuff pressure were routinely monitored by the nursing staff at the CWM Hospital ICU, over a 3 month period. Method: An on-site prospective clinical audit that evaluated 47 ventilated ICU patients using convenience sampling. Auditor entered ICU without prior notice to carry out measurements using a single standard aneroid manometer and reviewed patient’s charts. Inclusion and exclusion criteria were used to identify patient’s eligibility into the study. Results: More than 50% of ETT cuff pressures were out of range (8% low and 51% high pressure); only 41% were inflated to within the ideal cuff pressure (20-30cmH2O). There was no manometer available to ICU staff during the study period, therefore monitoring and documentation of cuff pressure was not possible. Pressure variabilities and often high cuff pressures were observed among patients who required prolonged intubation (>7 days). A potentially faulty ETT size was identified that require further evaluation. Conclusion The current practice on endotracheal tube cuff care at the Intensive Care Unit of CWM Hospital is below the recommended standard for best practice. Patients are exposed to unsafe ETT cuff pressure without objective measurements and regular monitoring. Staff training and availability of manometer are needed to improve current practice to ensure quality and safe patient care. Further audits may benefit patients, and a more comprehensive study to evaluate patient clinical outcome is recommended.

Background: Many benefits are associated with early antenatal booking which include but are not limited to accurate dating, early detection of medical and obstetrical disorders that could make the pregnancy a high-risk pregnancy and affect its outcome, and objective assessment of maternal baselines such as identifying pre-existing risk factors, taking weight, blood pressure, blood sugar level and urinalysis. If done early, it may provide a picture of the pre-pregnancy condition of the woman. Aim: In the time period and setting looked at in this research, it was found that majority of the mothers booked late, however reasons for booking late were not sought as this was only a quantitative retrospective cohort study. From the outcomes measured, it was seen that anaemia was the most significant outcome associated with late bookers. PPH was also found to be significant amongst late bookers however other statistical analysis deemed it insignificant. Results The results of this study found that majority of the women (76,58%) booked late. Of these, women who booked late fell in the 15 to 25 age range, were of I-taukei ethnicity, were married, did domestic duties, attended secondary level of education and were multiparous. The most significant pregnancy outcome that was associated with late booking was found to be anaemia. The remaining outcomes were found to be insignificant.

A series of experiences shared by frontline medical doctors in Fiji during the Covid-19 pandemic

Introduction: Breast cancer is a major health problem in Fiji. There are very few literature found on breast cancer in the Pacific. This study aims to provide a platform for future studies on breast cancer, by describing the demographics of breast cancer in Fiji, based on histological reports analysis. Method: This was a retrospective study of histologically-diagnosed breast cancer specimens in Fiji between 2009 and 2014. Histological reports of the eligible samples were screened and information regarding the following variables were collected and analysed. Results: Breast cancer cases are increasing over the years. There are 840 breast cancer cases noted, 20 of which were from male patients and 817 from females. The Ethnic group distribution shows 481 samples from the iTaukei Ethnic group, 327 samples were from the Fijian-of-Indian Descent (FID) group. Breast cancer is seen throughout all age groups, however majority of the cases are distributed between the age of 30 and 70 years. The majority of the Tumour sizes falls in between 2cm and 5cm. Grade 2 is the commonest grade that we see and there are usually more than 3 lymph nodes involved. The left and right breast have similar occurrence for cancer. There is an increase of Positive ER and PR cases. More ITaukei in the Central/Eastern division are diagnosed with Breast cancer, whilst there are more FID in the Western division diagnosed with breast cancer. Breast cancer incidence is 54.9/100000 population and this is lower than figures from Australia (118/100000) USA (125/100000) and UK (164/100000). Conclusion There is an increase in breast cancer cases in Fiji. The incidence of breast cancer is lower than figures from developed countries. People living in rural areas have lower incidence of developing breast cancer. Incomplete histology report is a problem in Fiji. Further studies need to be carried out, to profile each variable in detail.