The world population growth is increasing the demand for food production. Furthermore, the reduction of the workforce in rural areas and the increase in production costs are challenges for food production nowadays. Smart farming is a farm management concept that may use Internet of Things (IoT) to overcome the current challenges of food production. This work uses the preferred reporting items for systematic reviews (PRISMA) methodology to systematically review the existing literature on smart farming with IoT. The review aims to identify the main devices, platforms, network protocols, processing data technologies and the applicability of smart farming with IoT to agriculture. The review shows an evolution in the way data is processed in recent years. Traditional approaches mostly used data in a reactive manner. In more recent approaches, however, new technological developments allowed the use of data to prevent crop problems and to improve the accuracy of crop diagnosis. The challenge of food production in the 21st century is an increasingly relevant theme as population growth increases year after year. It is estimated that by 2050 the world will have between 9.4 and 10.1 billion people who depend on the world’s biodiversity to live, increasing the demand for dedicated food production areas—specifically for planting and livestock ,4. For eMoreover, recent technological developments in areas relevant to IoT facilitates an easier adoption and use of smart farming with IoT . Such teSeveral reviews have been published on IoT solutions for smart agriculture in recent years which denotes that this research field is being constantly receiving new contributions and constant improvement. Existing reviews usually focus on topics like network technologies, embedded system platforms, unmanned aerial vehicles (UAV) devices, network protocols and topologies and enabling cloud platforms. For instance  focuses This study aims to identify how IoT is used with smart farming by (i) presenting a systematic review of the state of the art of the IoT adoption in smart agriculture and (ii) identifying the most commonly used hardware, platforms, network protocols and technologies and their applicability to the proposed solutions. To give a more up-to-date view to the reader about the smart agriculture research field, this review article surveys literature until year 2020 and evaluates the acceptance of (new) IT technologies, such as big data, computer vision, artificial intelligence, blockchain and fuzzy logic in the smart agriculture field. This review complements the analysis already carried out by the academy by performing a comprehensive review of the state-of-the-art of IoT in smart farming. To do so, we rely on an IoT architecture with 4 layers  to identify the technologies that enable IoT in smart farming. From this approach, the present work identifies an increasing use of modern techniques and technologies for processing the collected data in recent years, such as big data, machine learning, computer vision and blockchain. Moreover, this review contributes to the existent literature by reporting a change in the treatment of data in recent works: while previous work showed that the majority of decision support systems used simple processing mechanisms to handle data collected in real-time, more recent work showed an increasing number of management systems that use complementary technologies that rely on cloud and big data computing for processing large amounts of data. In terms of research domain, this article addresses the agriculture economic sector, including indoor and outdoor agriculture . However, the livestock farming (both indoors and outdoors) was left out because, due to its specificities like impact on nature, associated mobility, different species  deserves a separated and specific review.For this purpose, the remaining work is organized as follows: To better understand the questions related to the use of IoT in agriculture during the 21st century, it is important go deeper in some fundamental concepts.Smart farming can be defined as the application of supplementary technologies to agricultural production techniques to help minimize waste and boost productivity.For such, intelligent farms use technological resources that help in various stages of the production process, such as monitoring of plantations, soil management, irrigation, pest control, delivery tracking, etc. . Such reThe integration of technological resources into the agricultural production process is a relevant issue. From an economic point of view, the precision agriculture market is expected to have a revenue of US$10 billion in 2023  with oppIoT can be understood as a network of interconnected intelligent devices capable of communicating with each other, generating relevant data about the environment in which they operate. Thus, virtually any device capable of establishing a connection to the Internet can be considered a “thing” within the context of IoT, such as household appliances, electronics, furniture, agricultural or industrial machinery and even people .Although the idea of IoT is not new, its adoption has increased in recent years, mainly thanks to the development of technologies that support it, among which the improvement of hardware—with the consequent reduction in size and power consumption—improvements in connectivity with the Internet and between devices via wireless connection, cloud computing, artificial intelligence and big data. All these technological components help build a network of devices capable of sharing data and information, as well as acting actively based on network inputs .According to , the arcThe IoT architecture proposed in  and 23]23], and The perception layer relates to the physical devices in the solution and how they interact with each other and with the transport layer. These devices are responsible for collecting data, enabling the communication of the so-called “things”. This can be done by using commercial solutions—such as UAV devices , sensor The transport layer refers to the network and transport capabilities such as network and application protocols . IoT solAs shown in Different topologies can be used for implementing networks, such as tree, star and mesh. Star networks have a central node and several peripheral nodes. The communication in such topology occurs as follows: peripheral nodes send data directly to the central node. The central node can implement capabilities for routing messages and communicating through multiple network protocols . Tree neData is sent to the destination through application protocols such as the message queueing telemetry transport (MQTT)  or the cThe processing layer comprises data storage, visualization and processing resources. In this context, big data allows distributed storage and parallel data processing, enabling the extraction of information in the shortest possible time . Such inFinally, the application layer comprises IoT applications that, supported by the other mentioned layers, provide management information to farmers, being able to manage the entire production process in the plantations.Several related works are being developed in recent years. This rich literature has already been analyzed by the academia from multiple perspectives with objective of determining the state of the smart farming development. Thus  presenteTo reach the proposed objectives, this study has used the Preferred Reporting Items for Systematic Reviews (PRISMA) methodology, which is a framework developed to support reports and systematic reviews of literature .(“Smart Farming” OR “Smart Agriculture” OR “Precision Farming” OR “Precision Agriculture”) AND (“IoT” OR “Internet of Things” OR “internet-of-things”) AND (LIMIT-TO(ACCESSTYPE(OA)))As a research strategy, in October 2019 a search was made in the Scopus database through the search tool available on the website. In addition, in June 2020 a new search was made in the same database to include papers published in 2020. The choice of this database took into consideration its scope and relevance in the academia, since this database indexes several journals and catalogues, such as IEEE, ACM and Elsevier, besides being widely used in similar bibliographic reviews, as in  and 51]51]. In aIt should be noted that the quotation marks have the function of ensuring that terms composed of multiple words were searched together, thus preventing words from being considered individually.After extracting the articles that resulted from the search, they were manually reviewed through the analysis of the title, keywords, abstract and text. Initially, based on this review, the works identified in the researched database were consolidated, thus eliminating duplicate articles.Subsequently, the articles were validated as to their framing in the objectives proposed for this study and considered valid when: (i) they were not a review or bibliographical research (ii) they were related to theme (iii) they presented a technology or solution based on IoT to solve problems related to agriculture (iv) they were published in English, Portuguese or Spanish. Furthermore, works were also excluded when they were related to livestock activities instead of agriculture.The process of searching and selecting papers for this study followed the workflow summarized in In the identification phase 463 articles were selected with the search tool.During the screening phase, a manual review of the articles was carried out to identify in the titles, abstract and key words the papers adherent to the objectives proposed for this study, following the criteria mentioned in this section. Among these, 257 were considered invalid and discarded. About 62% of the discarded items did not consider smart farming to be the focus of the work, although some presented improvements for IoT that could benefit smart farming indirectly. Additionally, almost 31% of the discarded papers were studies or literature reviews related to smart farming and the use of various technologies. A smaller number of papers related to smart farming but not addressing IoT (about 5%) and papers where the abstract or text were not available (about 2%) were also discarded.During the eligibility phase, the content of the 206 resulting articles were reviewed and the papers were classified using the same criteria used in the previous step. In this phase 47 articles were discarded. Among the discarded articles 29% were not related to IoT and 30% were not related to smart farming. The other 41% of the discarded papers were paper reviews or papers without content available. This analysis resulted in 159 articles considered eligible which were included as a sample for this study.Based on the results obtained in the analysis of the articles considered for this study, it was possible to observe a growth trend in the number of publications related to IoT and smart farming since 2011, with special emphasis from 2016 onwards, as shown in It is possible to observe an expressive increase of 278% in the number of published papers in 2017/2018. It’s also possible to observe a very similar number of published papers in 2019/2020, until the first semester of 2020. The amount of published papers in recent years evidences the increasing in discussion and the relevancy of the topic IoT applied to smart farming.Within the reviewed papers it was identified the main scenarios and environments of agriculture. As shown in Chemical control .Crop monitoring.Disease prevention.Irrigation control.Soil management.Supply chain traceabilityVehicles and machinery control.Within the reviewed papers it was also identified that the most common applications of IoT solutions for smart farming are:As shown in Each agricultural environment presented in To cover these scenarios commercial electronic sensors are used by 96% of the reviewed papers. This expressive usage can be justified by the fact that such sensors are affordable, certified, ready-to-market and meet the main monitoring needs in IoT solutions for smart farming. Such sensors are used for collecting real-time data about multiple agricultural parameters, such as climatic data, substrate information, luminosity, CO2 concentration and images through cameras and multispectral sensors, as shown in Different types of sensors are used in agriculture for collecting data from different aspects of agriculture such as crop monitoring, substrate monitoring and environment monitoring.As presented in The choice of hardware is a very important aspect of the IoT project development because it impacts the costs and the technologies that can be used. 60% of the reviewed papers mentioned the hardware used to support the IoT solution. Furthermore, SBCs were mentioned by 40% of the reviewed papers. The use of SBCs can be justified by the fact that these devices are affordable and versatile , enablinAs shown in In addition, Data obtained with sensor nodes are usually sent to the destination  through a wired or wireless network. Within the reviewed papers, 60% have mentioned the network protocol used in the IoT solution. Among the mentioned network protocols, CAN and Ethernet were the most used ones for wired networks. Likewise, LoRaWAN and protocols for cellular network  were the most used protocols for long-range wireless networks. Analogously, ZigBee, Wi-Fi and Bluetooth were the most used protocols for short and mid-range wireless networks. As shown in Besides the distance between sensor nodes, gateways, and other network elements, the vegetation itself can be an obstacle for sensor communication, as demonstrated by  and 70]70] who aNetwork topology is another important aspect of an IoT solution. According to  the topoFurthermore, embedded system platforms have been used to support network topologies. The chart in As mentioned in IoT devices transmit information to cloud-based platforms or applications through application protocols . Such prFinally, although the power consumption is not an exclusive topic within the transport layer, according to  the highAmong the analyzed papers it was possible to observe that initially, the main objective of IoT solutions was to collect and store data from sensor nodes. However, in more recent years, it is possible to observe an increasing number of IoT solutions that used supplementary techniques and technologies to treat the collected data, such as cloud computing and big data. Likewise, it is possible to observe an increasing number of works that used simultaneously two or more techniques or technologies for processing data. As shown in Cloud-based platforms provide scalability for IoT solutions by relying on cloud computing to process and data. For instance, some platforms shown in Due to the scalability provided by these platforms, the large amount of data generated by the sensors is stored in databases to form the so-called big data, an unstructured set of information that is used to generate information about crops. According to  big dataIoT solutions use different types of techniques and technologies for processing the collected data. As demonstrated in In addition, automatic management with IoT depends on the manipulation of multiple variables. Initially, the simple observation of soil humidity and temperature can be used to trigger irrigation or cooling systems, as proposed by . NeverthFuzzy logic, as indicated in Similarly, as shown in Finally, blockchain proved to be an opportune technology for systems that need to implement traceability of the supply chain, as shown in 2 or image) to collect data in indoor or outdoor environments.IoT solutions for smart farming take advantage of the scalability provided by platforms and cloud computing to store large amounts of data obtained by sensors. These big data of specific information may be processed with artificial intelligence techniques—such as machine learning—to improve the management of smart farming. For example, the processing of big data may be used to obtain crop insights, optimize water resources and increase the crop quality by preventing disease and reducing the amount of chemical products employed. Crop monitoring solutions use SBC  or UAV  together with sensors . The use of wired network on indoor agriculture may be justified by the fact that in this scenario the physical components of the network are less susceptible to climatic agents impacts. Likewise, generally distance between sensor nodes in indoor agriculture enables this type of connection. Wireless connection, on the other hand, is used both in indoor and outdoor agriculture. Wi-Fi is the most mentioned protocol within the analyzed projects, due to its ubiquitous utilization in the daily life. However, power consumption and signal range characteristics may limit use of Wi-Fi in larger projects or in projects with power restrictions. To overcome the power consumption issue, energy-efficient protocols such as ZigBee, BLE or LoRa are used for communication in wireless networks.Furthermore, it is worth mentioning that this review investigated papers where the IoT solution for smart farming was applied to agriculture only. However, the use of IoT for smart farming can also be applied to other activities related to farming, such as livestock . MoreoveThis work presented a systematic review of the state-of-the-art of IoT adoption in smart agriculture and identified the main components and applicability of IoT solutions. This review reported a change in the treatment of data in recent works: while previous work showed that the majority of decision support systems used simple processing mechanisms to handle data collected in real-time, more recent work showed an increasing number of management systems that use complementary technologies that rely on cloud and big data computing for processing large amounts of data. Furthermore, it was observed in this review that in recent work the use of artificial intelligence and image processing techniques has become more common to improve the management of smart farming. From the identified applications of IoT for smart farming it was observed that the most common application is the monitoring of crops. This review also showed that different network protocols may be simultaneously used in IoT solutions for smart farming. In addition, the comparison of types of network connections used in IoT solutions for smart farming revealed that wired networks are used in indoor scenarios  while wireless networks are used both in indoor and outdoor scenarios . Moreover, the review discussed in this work suggests the increasing relevance of IoT solutions for smart farming. Future work may extend this review by including other relevant articles and complementary analysis of project costs, usability and regional challenges intrinsic to IoT applications. Another important future research direction could be the analysis of the edge and fog computing usage in smart agriculture as a way to deal with challenges associated with traditional centralized cloud solutions such as high communication latencies, lack of support for real-time reaction to detected events, large bandwidths, etc.


Point-of-care testing (POCT) is defined as testing done near or at the site of patient care with the goal of providing rapid information and improving patient outcomes. Point-of-care testing has many advantages and some limitations which affect its use and implementation.The aim of the audit was to determine the current practices, staff attitudes and training provided to hospital clinical staff.The audit was conducted with the use of a questionnaire containing 30 questions. One hundred and sixty questionnaires were delivered to 55 sites at Tygerberg Academic Hospital in Cape Town, South Africa, from 21 June 2016 to 15 July 2016. A total of 68 questionnaires were completed and returned (42.5% response rate).Most participants were nursing staff , and the rest were medical doctors . Most participants  performed glucose testing, 16/68 (24%) performed blood gas testing and 17/68 (25%) performed urine dipstick testing. Many participants  reported having had some formal training in one or more of the tests and 25/68 (37%) reported having never had any formal training in the respective tests. Many participants  reported that they never had formal assessment of competency in performing the respective tests.Participants indicated a lack of adequate training in POCT and, thus, limited knowledge of quality control measures. This audit gives an indication of the current state of the POCT programme at a tertiary hospital and highlights areas where intervention is needed to improve patient care and management. The Royal College of Pathologists of Australia has a framework for POCT in the laboratory and at POCT sites that can be adapted for use at independent sites offering POCT.5 These are some of the goals for a POCT programme applicable to the hospital environment.The ideal POCT programme must meet several requirements; these include organisation, supervision, written procedures, operator training and competency testing, instrument evaluation, proficiency testing, quality control, and appropriate result recording and notification.5 Documentation, information management and record keeping are also an important part of the POCT process. Ideally, the systems should be linked to the laboratory information systems; if this is not available, the POCT team should develop programmes to ensure that this is done.7 This process includes documentation of non-conformances, and protocols on how to identify, investigate and take appropriate corrective and preventative measures. Indirect costs associated with POCT may also include training of personnel, quality control, maintenance, external quality control/proficiency testing, etc.9 Incidents of nosocomial infections related to sharing of devices between patients, as well as viral infections related to contaminated lancet holders, have been reported.10 These are some of the reasons why it is recommended to have a POCT committee which ensures proper training and compliance with both local and international guidelines for the implementation and management of a POCT programme.Part of quality management may include internal quality control and external quality assurance (EQA), depending on the type of POCT device in use. Nursing staff form an essential part of the clinical team and routinely perform POCT; therefore, a regular provision of training should be provided to ensure adequate knowledge and compliance with the above requirements.South Africa currently has no formal national policy on POCT and training of personnel for healthcare facilities. Different hospitals implement their own programmes and it is not clear if the same protocols are followed everywhere. Point-of-care testing is widely available for use in the general and some emergency hospital units. National guidelines are necessary to inform the planning of POCT programmes, training and assessment of practitioners, or guidance on issues around quality management. Hospital and facility managers are often the main stakeholders involved in POCT programmes, without involvement of any laboratory representatives. It is against this background that different hospitals operate their POCT programmes, without national guidelines; this is also applicable to Tygerberg Academic Hospital .Healthcare workers who use POCT at Tygerberg Hospital in Cape Town, South Africa, include approximately 550 medical staff  and nursing staff . A variety of point-of-care tests are in use. For example, medical wards, such as the internal medicine and endocrine wards, use glucose meters and urine dipsticks on a regular basis, as do the diabetes and renal clinics. The intensive care and high care units use these POC tests as well as arterial blood gas analysers, which are benchtop POCT devices that require more skill to operate than the other two tests and are often performed by medical staff, professional nurses or technicians, when available.This study audited current practices and training provided to hospital personnel who regularly use POCT at Tygerberg Hospital, to determine whether collaboration is necessary between the laboratory and the hospital management team responsible for the current POCT instruments used. The audit aimed to determine the current training provided to clinical staff about the use of POCT devices, investigate staff practices and attitudes towards POCT, and to ascertain the general level of training and knowledge of quality control in the practice of POCT. The information gathered will help to give feedback to the stakeholders on areas that can be improved in the current POCT programme. Such areas include staff training, competency assessment, and regular refresher courses on both the theory and the practical aspects of POCT. The stakeholders include hospital administration, nursing staff, doctors, clinical technologists, laboratory technologists and pathologists of the relevant disciplines. The audit was not requested by the hospital; it was laboratory initiated.Ethics approval was obtained from the University of Stellenbosch health research ethics committee (Reference: S15/11/269). Written permission was also obtained from the hospital management to conduct the audit in the hospital medical wards and outpatient clinics. Participants were given information leaflets and signed informed consent forms after agreeing to participate in the study.This study is a descriptive, cross-sectional audit conducted with the use of a questionnaire containing 30 questions (Supplementary Document 1). A questionnaire was chosen as the most ideal and feasible format for conducting this qualitative audit. The questions were designed to cover the important aspects, based on the ISO 22870 guideline.The questionnaire was developed by the primary investigator, with the input and supervision of the co-investigators, based on a thorough literature review. This initial draft was further adapted to include the relevant sections from ISO 22870 in order to incorporate quality management aspects. Questions included general knowledge about POCT at the different sites, theoretical knowledge around POCT, formal training and competency assessment of POCT operators, quality control measures and current perceptions of operators on their respective tests. Formal training was defined as a lecture-type session lasting approximately 1 hour, including a practical demonstration and practice in the use of the specific POCT device. Questions were grouped in sections, with a few confirmatory questions which did not follow a specific order. Routine performance of tests was assessed by asking about the frequency of tests performed per week; that is, participants were asked to indicate the average number of times they performed each test applicable to them (more than one test could be selected from a table). The questionnaire was validated at two locations and with colleagues within the department to ensure the questions were understandable prior to distribution of questionnaires.This study was conducted at Tygerberg Academic Hospital, a tertiary hospital with an inpatient capacity of 1384 beds situated in the northern suburbs of Cape Town, Western Cape, South Africa. The hospital serves a community of approximately 3.6 million from the public health system. Three point-of-care tests – blood glucose, blood gases and urinalysis – were chosen for the audit, because they are performed routinely throughout the hospital and fall under the expertise of the study team. All POCT devices used in the hospital are from Roche ACCU-CHEK® . Other non-chemistry point-of-care tests, such as those for HIV haemoglobin, were not included in the audit as they fall outside the scope of the investigators’ expertise.An average of three questionnaires was delivered to 55 sites in the hospital, comprising wards, emergency units and outpatient clinics, between 21 June 2016 and 15 July 2016. A few sites only accepted one or two questionnaires, because the nursing managers could not identify anyone else who was suitable to participate, so the total number of questionnaires delivered was 160. Site inclusion criteria included any hospital site that routinely uses POCT as part of patient management. This included all general medical and surgical wards, emergency units, intensive care units and high care units.The psychiatric and orthopaedic wards and clinics were excluded, because of the low likelihood for use of POCT at these sites.Ward managers were approached to help with selection of suitable nursing staff to complete the questionnaires. We expected professional nurses, staff nurses and nursing assistants to form the majority of participants from the nursing side. We also expected interns, medical officers and registrars to form the majority of participants from the medical staff. This expectation was based both on their respective clinical duties and on their close involvement in daily patient care as medical doctors without the competing managerial duties applicable to senior and higher rank medical consultants and specialist doctors. Students were excluded from the study because they were not employed by the hospital and were at different levels of study.Participants were given an option to complete the questionnaire at the time of delivery or to complete it in their own time when not busy with core duties. All participants were encouraged to complete the questionnaire as comprehensively as possible and all those who delayed in completing the questionnaire were given a second or third chance to do so.Information from the questionnaires was captured on Microsoft Excel 2016 version 16.0 , which was used to calculate basic descriptive statistics for the data. In the analyses, each ward or clinic included in the study counted as a single site. Missing data included questionnaires that were returned uncompleted and those which were completed only in part. The latter group was included in the data analysis as most of them had completed over 80% of the questions. Missing data were also taken into account when specific questions were reported. Responses are reported as percentages of the final sample size. Each question analysed includes an indication of the percentages of those who did not answer the specific question  and 2. NOut of the 160 questionnaires delivered, 68 were returned completed (42.5% response rate) . Most paAlthough a majority  indicated that they had formal training, many indicated that they had not  . Those pn = 21) of participants indicated they used a recording system in addition to patient files, 28% (n = 19) indicated they did not require use of a recording system, and 16% (n = 11) were unaware of a recording system in their ward or clinic. Nineteen percent (n = 13) of participants indicated using other means of record control, mostly involving duplicating of result entries in the nursing notes as well as the designated charts on patient files; one participant indicated that doctors enter POCT results on their computer for future reference. Six percent (n = 4) of participants selected more than one of the four answer options, thus providing conflicting responses.The present study found that 31% (When asked about the important step(s) before performing a point-of-care test, 47/68 (69%) correctly indicated that patient preparation was vital, whilst 9/68 (13%) indicated that confirmation of results was an important first step. A large proportion  indicated that the laboratory method was more accurate for glucose measurement in a patient with dehydration or shock, whilst 23/68 (34%) felt the glucose meter was as accurate as the laboratory; a further 11/68 (16%) indicated that the blood gas measurement is the most reliable if a patient is dehydrated. Record keeping of test results was another parameter used as a marker of quality management in POCT; 21/68 (31%) of participants said they used a recording system, 19/68 (28%) felt there was no need for it, and 24/68 (35%) either did not know if there was a recording system or selected other forms of a recording system. More than half of the participants  viewed POCT as being an important part of patient management .11 Staff confidence requires formal skills training and competency testing in order to minimise the risk of errors.12 Errors can be attributed to several underlying reasons, including poor technique, abnormal haematocrit, failure to adhere to the correct procedure, and presence of interfering substances. For example, the POCT devices used in the hospital are Roche ACCU-CHEK® devices, which are known to be prone to galactose, ascorbic acid and ceftriaxone interference, and which may deliver false high or -low glucose results in the presence of interference.13 The package insert also states that the use of the glucose meter is not advised in patients with peripheral vascular disease or with dehydration from several causes. Without theoretical knowledge relevant to the test performed, the clinical personnel are at a disadvantage and are not fully equipped to perform these tests. All persons involved in POCT should be aware of potential interferences, why patient preparation is important, and the concepts of accuracy and precision. Such knowledge requires training by experts in the field, such as laboratory professionals who would provide valuable input in the training of clinical personnel.Most respondents to this audit of the use of POCT by clinical staff at a South African tertiary hospital found that POCT was a vital part of patient care; this is important, as it is likely to ensure that the staff is open to learning and keeping up to date with new information and practices. The second main observation was that there is a lack of formal training of hospital staff in the practice of POCT, and most of the participants indicated that they needed formal training in POCT. This is an important issue which requires consideration by stakeholders as it may impact patient outcomes and improve staff confidence in performing the tests.n = 37) who were not aware of any EQA involvement in their ward or clinic and the 53% (n = 36) who did not know if any device validation or verification was performed prior to the use of new POCT devices in their wards or clinics. This is related to the lack of training in POCT basics and principles. The purpose of POCT device validation, internal quality control and EQA is to ensure that the results obtained are of a good quality and give confidence to the clinician who will initiate or change the treatment of the patient based on the result obtained from a POCT device. Laboratories are required to participate in internal quality control and EQA activities in order to be accredited to international standards. Point-of-care testing programmes also benefit from such quality control measures, as this would allow them to compare with other POCT sites and allow early identification of non-conformances. International guidelines, such as ISO 22870:2016 and (CLIA) POCT04, recommend operator training in both the theory and the practice of internal quality control of POCT devices.3The participants showed a limited awareness of quality control procedures, such as POCT device validation and EQA. This was indicated by the high number of participants  may lead to overestimation of glucose, whilst a haematocrit above 45% may lead to underestimation of glucose results by some POCT devices. Some of the above factors have predictable effects, such as overestimation or underestimation of tests such as glucose, or to the delivery of false-positive dipstick results because of exposure of the strips to humidity. Exposure of glucose meter reagent strips to humidity does not have a predictable effect of over- or underestimation of glucose results, unlike the aforementioned examples. Some POCT devices for glucose have been shown to have poor accuracy at critical glucose levels  and to have significant bias compared to other devices and the central laboratory method.17 It is therefore important for POCT operators to know when to question a POCT device result and to confirm with the central laboratory method. Some studies have also shown that POCT in high-risk patient groups, such as those patients in either adult or paediatric intensive care units, can lead to misdiagnosis.18 This requires staff to be very knowledgeable about potential sources of error, dealing with critical values and the use of protocols to guide POC test use in these settings.Some countries, such as Australia and New Zealand, have local guidelines on the use and implementation of POCT based on both national and international recommendations.1 With the increasing use of POCT, there is also an increasing need to adopt and practise global principles to avoid medical errors and ensure patient safety.2 Potential disadvantages of POCT include insufficient validation of trained and certified operators, insufficient supervision, limited understanding of quality control testing, little or no security of patient test results and quality control data and limited connectivity of POCT devices.12 This audit sought to evaluate the current state of POCT practice at Tygerberg Hospital by focusing on the most widely-available and commonly-used tests in the hospital. In agreement with international practices in the hospital setting,12 nurses form the bulk of the POCT operators in this study. However, Nnakenyi et al. showed different findings in their audit of 5 hospitals in Nigeria. Their study had 40% physicians, 32% nurses and 27% technologists, with a total of 98 participants across all five hospitals.19 The study above is comparable to the present study in terms of sample size and recorded a good response rate from doctors. Our study was targeted at clinical staff, namely, nurses and doctors only. Great effort was made to recruit doctors in this study; the poor response rate from the doctors in this study may indicate the low level of interest of doctors in POCT. This finding supports the recommendation by some to keep POCT programmes under the control of the laboratory. This would mean that the Head of Chemical Pathology or the principal chemical pathologist becomes the chair of the POCT committee in the hospital, and she or he would be directly involved in the decision making and running of the programme as recommended by international guidelines.Point-of-care testing has become an integral part of healthcare in both the primary care and the hospital setting.In many hospitals in sub-Saharan Africa, POCT is performed by clinical staff because of the limited availability of medical technologists, who are primarily employed in core laboratories with limited numbers, if any, involved in hospital POCT. Clinical staff are therefore at the forefront of hospital POCT in sub-Saharan Africa and a good source of information about the practices, successes, and limitations of hospital POCT in this setting.20 This study used an interviewer-administered questionnaire on doctors at two different hospitals in Nigeria. The sample selection method was not explained clearly; the response from the two hospitals seems to have been 22% for one and 32% for the other. There is no specific mention of how the selection process was conducted and the rationale behind the exclusion of nursing staff in their study. Our study, by contrast, mainly included nursing staff who are the main operators of POCT in the hospital setting. The questionnaire was designed to obtain information, to identify current gaps in the system and to find solutions that may be easy to implement. Some questions were asked to elicit information about record keeping and maintaining a clear paper trail. This has been shown to be a limitation of many POCT programmes where devices do not have connectivity to the laboratory system and rely only on the manual transcription of results.21A study conducted in Nigeria included only doctors, which provided a different perspective but limits a direct comparison between the different African studies.There were varied responses to these questions in this study, and this may point to the lack of a formalised system for recording POCT results separate from the entries in patient files.23 Most participants of these focus groups indicated that they valued POCT, but were dissatisfied with the implementation and their exclusion from the planning process. In our setting, the use of focus groups was not feasible, because of staff shortages and the limited time available to engage with the nursing staff whilst they concentrated on their clinical duties. The present study found that the majority of participants  also valued POCT and regarded it as being an important component of patient care in their environment. Many  indicated that they would want formal training in POCT, 25% (n = 17) indicated no desire to have training in POCT, and 9% (n = 6) did not answer the question. The questionnaire did not specifically include questions about views on implementation or involvement of participants in the planning of the POCT programme in the hospital. The focus was primarily on the practice of POCT, knowledge of POCT theory, and perceptions of participants regarding POCT in the wards and clinics where POCT programmes are already implemented.Focus group discussions have been conducted amongst personnel to determine their perception and operational impact of POCT on clinical duties in parts of rural Australia and Uganda .24 A similar approach can be applied to other POCT programmes to improve their quality.The findings of the study are mainly applicable to Tygerberg Hospital and to other tertiary hospitals that do not currently have a POCT training programme, and where the central laboratory is not involved in POCT. These findings may not apply to other hospitals in South Africa who have a different POCT management system. The training of nurses should be explored in other institutions in South Africa to give a comprehensive picture of the POCT programmes in local hospitals. This should be followed by the development of training programmes and regular re-training to ensure that clinical personnel keep their knowledge and skills up to date. At the time this audit was conducted, there were no national guidelines or policies guiding the practice of POCT in South African hospitals. There is limited published information on current practices in POCT in South Africa and within the rest of the African continent. Many of the studies available in Africa have looked at implementation of specific POCT instruments and clinical outcomes. These studies do not primarily look at the availability of local guidelines and training of personnel on POCT and therefore cannot be compared directly with the current study. Compared with other POCT programmes, such as HIV-POCT, general POC biochemistry tests have been around for much longer. A collaborative study of Zambia and South Africa on HIV-POCT found that intensive training, supervision and robust quality assurance mechanisms were required to optimise community HIV-POCT.This audit is the first of its nature to be conducted and reported in South Africa. It will provide a basis for the laboratory and hospital to determine the need for collaborative training of clinical staff.The limitations of the study include the small number of questionnaires sent, which was estimated based on the knowledge that not all staff in the ward perform POCT and that those who do are usually busy with clinical duties and we did not want to distract them from service delivery. The response rate was quite low overall; in some sites, available staff members were busy when questionnaires were distributed and even upon follow-up, they still did not have time to complete them.This applied to both nursing staff and the mid-level/junior medical staff.The questionnaire did not focus on the views of participants regarding planning and implementation of POCT programmes in the hospital, this information would have been valuable and used to gauge the general attitude of participants in being directly involved in the planning and implementation of POCT in the hospital. Some questions may not have been clear or explicit enough for participants to provide accurate feedback; even though the questionnaire was piloted with nursing staff and medical doctors, some participants may still have found some questions unclear.We recommend the introduction of training and certification programmes for point-of-care test operators in keeping with international guidelines. We also recommend that a POCT coordinator be appointed to lead the current programmes with the assistance of a dedicated POCT team in the hospital, as well as the involvement of the clinical laboratory for the continuous evaluation and improvement of the current programme.This audit found that a significant percentage of the participants did not receive adequate training in POCT and had very limited knowledge of quality control measures. This audit gives an indication of the current state of the POCT programme in the hospital and highlights areas where intervention is most needed to improve patient care. Current guidelines recommend that hospital personnel have basic knowledge and skills to perform routine POCT. Appropriate implementation of a POCT service requires focus on all aspects, including staff training and quality assurance. This information is also important to inform the Department of Health of the need to consider implementing guidelines and policies on POCT in all health facilities in South Africa.


Hypertension is one of the most relevant causes of cardiovascular and renal morbidity and mortality worldwide. About 10% of hypertensive people are not able to reach and maintain optimal blood pressure (BP) values, despite the simultaneous use of 3 antihypertensive agents of different classes at optimal doses, and are considered “resistant”.The management of resistant hypertension remains problematic: different approaches, including lifestyle modifications and/or a more intensified antihypertensive therapy, have largely failed to improve patients' outcomes and to reduce risk of renal and cardiovascular adverse outcomes.As the renal nerve plexus plays a central role in regulating arterial blood pressure and renal sympathetic hyperactivity is a major driver of resistant hypertension, minimally-invasive catheter based renal sympathetic ablation  has been proposed as an alternative treatment for resistant hypertension, but the results of clinical study remains ambiguous.Recently, Blankestijn and Meijvis commented the results of SPYRAL HTN prospective, randomized controlled trial providing evidence of the safety and efficacy of catheter based renal denervation (RD) in unmedicated patients, inserting itself in a long discussion in which hope and disappointment alternated about the safety and efficacy of this method . The firThe Symplicity HTN-1  and SympHowever, the results of Symplicity HTN-3, the first randomized sham-controlled trial, failed to demonstrate a significant difference in BP reduction between RD and t sham control group .Despite of the setback following the SYMPLICITY HTN-3 trial and two other sham-controlled, randomized studies, the Symplicity Flex  and the However, the treatment differences observed in SPYRAL HTN study between RD and sham procedure of 3.9 mmHg for 24 h systolic BP and 6.5 for office systolic BP, again raise in Blankestijn the doubt about widespread acceptance of RD as therapy for hypertension in general population. He rightly claims that hypertension is a heterogeneous condition and that it is unrealistic to think that RD could be a panacea for all hypertensive patients. Several issues have to be resolve before RD overcome all the disappointments of recent years and be ready for prime time of hypertension treatment: identification of clinical or biomarker effect predictors, assessment of long-term efficacy, evaluation the effects on cardiovascular and end-organ damage, but most of all the identification of patients with the highest likelihood of response.At the moment, however, for many of these problems the real solution seems to be far away.RD efficacy is correlate to an overactivity of sympathetic system in renal nerves. In healthy people, renal nerve activity is usually low and the direct assessment is impossible while the effectiveness of the method procedure evaluation is far from clinical use , 9.Starting from these unsolved issues Blankestijn concludes that is time to refine the focus of research in the renal denervation field. Perhaps, as indicated by the autosomal dominant polycystic kidney disease (ADPKD) lesson, called into question by the same author, more simply is the time first to improve the hypertensive population selection.Hypertension is common in ADPKD: prevalence is 50to 62% when renal function is still normal and increases to almost 100% in patients with chronic renal failure with fewer than 30% achieve BPs less than 130/80 mmHg despite the treatment . On thesin vitro studies, is the real first step to take for the different RD techniques to become ready for prime time in the hypertension treatment scenario.Consistent with this, several case reports have suggested that RD is effective for BP control and able to improve characteristic abdominal pain in ADPKD patients. Without doubt we should learn le lesson of Symplicity trials in RD safety and efficacy evaluation and we are convinced that case reports and uncontrolled studies is not enough. However, the experience in ADPKD it seems to indicate that the correct selection of the patient population, with a preference for those where sympathetic hyperactivity as a key factor in the genesis of hypertension is demonstrated in animal and human models and supported by AP had the original idea. ER and CG collected data. AP, ER, and CG wrote the paper. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Safety culture is still a poorly studied subject in primary care and home care, although these settings are considered gateways to access to healthcare. This study aims to evaluate safety culture in primary and home care settings.An observational cross-sectional study was carried out with 147 professionals from nine districts covered by one home care program and six primary healthcare centres. The Safety Attitudes Questionnaire (SAQ) was used to evaluate the safety culture, in which scores ≥75 are indicative of a positive safety culture.A total of 56  questionnaires returned from the home care professionals and 91  from the primary care professionals. The Job satisfaction domain was the best evaluated, achieving a score of 88.8 in home care and 75.1 in primary care. The achievement of high scores on Safety Climate, Job Satisfaction, Teamwork Climate, and Total SAQ was related to male gender, and time of professional experience of three to 4 years. Perception of management and Working conditions had the lowest scores, and this result was related with long time of experience.It is concluded that professionals working in home care gave higher scores for safety culture in their workplace than the primary care workers. Providing safe care means changing attitudes and practices of all professionals involved in patient care. In the workplace, this requires a safety culture that strengthens the commitment and performance of the multidisciplinary team, as well as specific competencies to ensure patient safety .According to the World Health Organization (WHO), patient safety is the reduction of risk of unnecessary harm associated with health care to an acceptable minimum. To ensure patient safety in Brazil, the National Patient Safety Program (PNSP in Portuguese) stands out promoting safety culture and emphasizing the importance of learning about patient safety and organizational improvement. This program reinforces that professionals must adhere to incident prevention and that institutions must develop safer systems and processes that avoid individual accountability for success or failure of care .Safety culture is the product of a set of values, attitudes, perceptions, competencies, and behaviours that determine the commitment, style, and competence of an individual or a group in safety promotion. These behaviours include how managers and professionals act to improve healthcare, for example through collective learning and correction of errors . HoweverPatient safety is sometimes neglected in primary and home care centres. Actions and research in this theme are mostly conducted in hospitals and clinics since the culture of patient safety outside the hospital is still a challenge to be overcome , 7.In Brazil, primary care is recognized as the gateway to the health system. Services provided in Brazilian primary care facilities directly affect the well-being of Brazilian families and the use of public resources. Consequently, insecure, inadequate, or ineffective primary care can increase preventable morbidity and mortality or lead to unnecessary use of hospital resources .Home care services are part of a federal program that seeks to expand and qualify care within the Brazilian Unified Health System (SUS in Portuguese). The system is composed of services and actions that complement other levels of care, especially the tertiary and outpatient levels, ensuring the continuity of care and the integration of services within the network .In principle, the SUS offers a patient-centred approach. Qualified professionals are assigned to geographical areas enabling the establishment of relationships between individuals and healthcare providers, in a way in which the professionals are familiar with the community’s routine, culture, and families. This approach favours the execution and articulation of actions such as rehabilitation, prevention, education, and health promotion. Thus, the Brazilian SUS is recognized as a system that favours patient safety movements and the implementation of a safety culture , 11.The prioritization of patient safety in high complexity services led to a scarcity of studies on the subject in primary and home care settings, representing gaps in research and practices , 13. SafInstruments that assess patient safety are important tools to measure aspects such as organizational conditions that lead to incidents during health care, contributing to awareness of safety issues. This type of investigation helps to diagnose factors that influence the safety culture and patient safety , 15.The Safety Attitudes Questionnaire (SAQ) is one of the tools created to provide a situational diagnosis of a service and/or institution, which enables an accurate assessment of factors that need to be improved and that influence safety, such as teamwork, job satisfaction, and working conditions .Thus, the objective of this study was to evaluate safety culture in primary and home care settings and to verify relationships between the SAQ domains and variables related to gender, type of service (primary or home care), and time of professional experience.This is a cross-sectional study conducted in one home care service and in six primary care centres located in the metropolitan region of Fortaleza, Brazil. The data collection took place from January to July 2019.The metropolitan region of Fortaleza in the state of Ceara consists of 19 cities, however, only nine are covered by the “Best at Home” program, namely: Cascavel, Eusebio, Guaiuba, Itaitinga, Horizonte, Maranguape, Maracanau, Pacatuba, and Sao Goncalo do Amarante. The six primary care centres included in the study are located in Fortaleza (one centre) and Acarape (five centres). These centres were chosen by convenience as they were accessible for the researchers involved, and due to willingness to participate.All 69 professionals working in the Multiprofessional Home Care Team (MHCT) of the nine cities, and all 95 professionals working in the six primary care centres were invited to participate . Professionals developing their work activities during the data collection and with 6 months or more of time of experience were included. Professionals who were on leave or vacation were excluded.The Safety Attitudes Questionnaire (SAQ) in its Brazilian translated and validated version was used for data collection . The queThe SAQ is divided in two parts. The first part contains 41 items divided into six domains and the second part refers to professionals’ information. The domains are: Teamwork climate, Job satisfaction, Perception of unit and hospital management, Safety climate, Working conditions, and Perception of stress. The questionnaire items are presented in a 5-point Likert scale format. The final score of the SAQ ranges from zero to 100, in which zero corresponds to the worst perception and 100 to the best perception of safety culture, and scores ≥75 are indicative of a positive safety culture .p < 0.05.The collected data were tabulated in an Excel 2007® spreadsheet and analysed using the Statistical Package for Social Science (SPSS) version 22.0. To investigate the existence of differences between the mean scores of the SAQ domains, we used the analysis of variance (ANOVA) for quantitative variables and the Kruskal-Wallis test for qualitative variables, considering a significance level of Multiple regression analysis was performed for the adjustment of the predictive model. Dependent or response variables were defined considering the scores of each SAQ domain and the total SAQ value, for the following independent variables: gender, type of service (primary care or home care), and time of professional experience.Before starting the research, consent from the managers of each study site was obtained. In agreement with the ethical and legal aspects, all participants were invited to participate in the research by signing an informed consent form. The study was approved by two Institutional Review Boards at the universities in which the project took place (protocols no. 2.943.854 and no. 2.522.957).During data collection, a total of 65 questionnaires were distributed to the home care teams and 56 returned, while 105 questionnaires were distributed in the primary care centres and 91 returned. Four professionals were absent due to vacation or leave. In addition to these, six professionals did not return the questionnaire or refused to participate. This resulted in a rate of return of 86.1% from home care professionals and 86.6% from primary care professionals.From the 147 participants, 98 (66.7%) were female and 91 (61.9%) were primary care workers, with up to 2 years of professional experience . Community Health Agents (CHA) represented 23 (15.6%) participants of the sample, followed by 22 (15%) nursing technicians and 20 (13.6%) physicians , indicating that the primary and home care services evaluated, in general, did not reach a positive value for the safety culture . The scores of the SAQ domains ranged from 57.3 to 80.4. Job satisfaction obtained the highest value , which means that professionals were satisfied with their job; on the other hand, Working conditions and Management perception presented the lowest scores Table .Table 2p < 0001). Men from the home care teams, with 3 to 4 years of professional experience evaluated safety culture in their workplace more positively , time of professional experience, and the SAQ domains were significant in regard to gender, as men gave higher scores for the domains Safety climate, Perception of stress, and Management perception than women. Home care professionals gave higher scores than primary care professionals for all domains, except Perception of stress. In addition, professionals working for 3 to 4 years tended to attribute high scores to the domains Safety climate, Job satisfaction, Teamwork climate and Total SAQ score .Safety culture was evaluated by 147 healthcare professionals working in primary and home care services. Most of them were female and worked as community health agents, with time of professional experience of one to 2 years. In Brazil, community health agents have an important role in establishing “the link” between families and the primary care providers. Their work is essential for the successful approach of the families as it provides essential elements to the understanding of the families’ health problems and needs .The total score obtained in the present study considering both types of service was below the cutoff value that classifies a positive safety culture. Besides that, there was a significant difference showing that home care workers gave higher scores of safety culture in their workplace than primary care workers. Although no studies have been found in the literature comparing the perceptions of primary and home care workers about safety culture, SAQ scores given by primary care workers in another study were close to ours .A study conducted in a primary care setting at the southern region of Brazil found negative scores for safety culture in almost all SAQ domains . An oppoIt was also found that Job satisfaction achieved the highest value, while Working conditions and Management perception had the lowest scores, with significant differences related to type of service and time of experience. These findings indicate that the participants do what “they like to do”. However, the low scores of management perception indicate that they do not approve  actions of their leaders regarding patient safety issues. These results agree with previous studies that used SAQ in Brazil and in other countries. A study conducted with professionals from five homes in Tonsberg, Norway, found high scores of Job satisfaction, followed by Teamwork climate and Safety climate . In anotA Brazilian study also found that health professionals working in primary care have difficulty in working relationships with their managers and avoid commenting on work-related problems because they do not feel safe. In relation to this issue, managers recognized that communication problems are real in their workplace . These sIn the present study, men who work in home care with three to 4 years of experience attributed high scores for Safety Climate, Job Satisfaction, Teamwork Climate, and the total SAQ. This means that these professionals enjoy the work that they do and have a positive view of the relationships that occur in their workplace. Until the completion of this study, no research was identified that justifies the difference in perceptions of safety culture between men and women. However, a study conducted in China with 2584 professionals identified that women gave higher scores than man to all SAQ domains, different from what was identified in our study .Positive scores in the SAQ domains may indicate that professionals are satisfied with their own performance at work in situations where patient care may not be ideal. For this reason, managers should interpret the results with caution and consider the need for quality improvement interventions .Regarding the type of service, a study identified a similar result when assessing safety culture in home care services . In addiRegarding time of professional experience, a study shows that professionals with long time of experience tend to be more critical regarding management actions and work environment characteristics , which mThe statistically significant correlations do not necessarily indicate an underlying relationship between the variables. Our analyses measured how much independent variables explains the response variable, through multiple linear regression. The regression model showed that gender, type of service, and time of professional experience contributed (positively and negatively) to Safety climate, Job satisfaction, Perception of stress, Teamwork climate, Management perception, Working conditions, and Total SAQ. Other studies have similar results and report, from multiple linear regression equations, that demographic factors such as gender, age, and participation in training significantly affect SAQ , 30.This study has some limitations. First, self-reported surveys like the SAQ depend on the respondents’ recall and may be subject to reporting bias. However, the validity of the data gathered in the study is supported by their consistency and by the fact that the SAQ is widely used and has good psychometric qualities. Second, the cross-sectional approach limits our ability to establish assertions about change through time. Third, the convenience sample and the local level of the study limits the generalizability of the findings to other contexts.In addition, there is a scarcity of studies evaluating safety culture in primary and home care settings, and the number of studies about the dimensions of SAQ and its relationship to demographic variables is small. We suggest that further studies are needed with a larger number of health units, in other regions of the country and in other countries, to determine which factors influence safety culture in different contexts. Such factors can be used in the formulation of public policies aimed at strengthening the safety culture in primary and home care settings.It is concluded that professionals working in home care gave higher scores for safety culture in their workplace than the primary care workers. In addition, men from the home care teams, with 3 to 4 years of professional experience evaluated safety culture in their workplace more positively and professionals with long time of experience were more critical regarding Working conditions and Management perception.It should be noticed that this study comprehends perceptions, which are only a part of safety culture. Patient safety is not necessarily and solely associated with high quality diagnoses, adequate treatment, and patient-centred care. To further explore this subject, it is necessary to investigate associations between safety culture and the occurrence of incidents in settings like the ones investigated in this study.Finally, as an implication of this study, the findings can motivate managers to promote the safety culture in the participant settings and can increase professional awareness of the factors that influence safety culture and consequently patient safety.