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Abstract
OBJECTIVE To provide a general overview of the reported current surgical capacity and delivery in order to advance current knowledge and suggest targets for further development and research within the region of sub-Saharan Africa. DESIGN Scoping review. SETTING District hospitals in sub-Saharan Africa. DATA SOURCES PubMed and Ovid EMBASE from January 2000 to December 2019. STUDY SELECTION Studies were included if they contained information about types of surgical procedures performed, number of operations per year, types of anaesthesia delivered, cadres of surgical/anaesthesia providers and/or patients' outcomes. RESULTS The 52 articles included in analysis provided information about 16 countries. District hospitals were a group of diverse institutions ranging from 21 to 371 beds. The three most frequently reported procedures were caesarean section, laparotomy and hernia repair, but a wide range of orthopaedics, plastic surgery and neurosurgery procedures were also mentioned. The number of operations performed per year per district hospital ranged from 239 to 5233. The most mentioned anaesthesia providers were non-physician clinicians trained in anaesthesia. They deliver mainly general and spinal anaesthesia. Depending on countries, articles referred to different surgical care providers: specialist surgeons, medical officers and non-physician clinicians. 15 articles reported perioperative complications among which surgical site infection was the most frequent. Fifteen articles reported perioperative deaths of which the leading causes were sepsis, haemorrhage and anaesthesia complications. CONCLUSION District hospitals play a significant role in sub-Saharan Africa, providing both emergency and elective surgeries. Most procedures are done under general or spinal anaesthesia, often administered by non-physician clinicians. Depending on countries, surgical care may be provided by medical officers, specialist surgeons and/or non-physician clinicians. Research on safety, quality and volume of surgical and anaesthesia care in this setting is scarce, and more attention to these questions is required.
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Affiliation(s)
- Zineb Bentounsi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Grace Drury
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Chris Lavy
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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Saluja S, Mukhopadhyay S, Amundson JR, Silverstein A, Gelman J, Jenny H, Lin Y, Moccia A, Rashad R, Sood R, Raykar NP, Shrime MG. Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature. Int J Qual Health Care 2019; 31:166-172. [PMID: 30020489 DOI: 10.1093/intqhc/mzy141] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 03/28/2018] [Accepted: 06/13/2018] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Quality of care is an emerging area of focus in the surgical disciplines. However, much of the emphasis on quality is limited to high-income countries. To address this gap, we conducted a systematic review of the literature on the quality of essential surgical care in low- and middle- income countries (LMIC). DATA SOURCES We searched PubMed, Cinahl, Embase and CAB Abstracts using three domains: quality of care, surgery and LMIC. STUDY SELECTION We limited our review to studies of essential surgeries that pertained to all three search domains. DATA EXTRACTION We extracted data on study characteristics, type of surgery and the way in which quality was studied. RESULTS OF DATA SYNTHESIS 354 studies were included. 281 (79.4%) were single-center studies and nearly half (n = 169, 46.9%) did not specify the level of facility. 207 studies reported on mortality (58.47%) and 325 reported on a morbidity (91.81%), most commonly surgical site infection (n = 190, 53.67%). Of the Institute of Medicine domains of quality, studies were most commonly of safety (n = 310, 87.57%) and effectiveness (n = 180, 50.85%) and least commonly of equity (n = 21, 5.93%). CONCLUSION We find that while there are numerous studies that report on some aspects of quality of care, much of the data is single center and observational. Additionally, there is variability on which outcomes are reported both within and across specialties. Finally, we find under-reporting of parameters of equity and timeliness, which may be critical areas for research moving forward.
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Affiliation(s)
- Saurabh Saluja
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Department of Surgery, Weill Cornell Medicine, 525 E 68th St, New York, NY, USA
| | - Swagoto Mukhopadhyay
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Department of Surgery, University of Connecticut, 263 Farmington Avenue, Farmington, CT, USA
| | - Julia R Amundson
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Department of Education, Miller School of Medicine, University of Miami, 1600 NW 10th Avenue #1140, Miami, FL, USA
| | - Allison Silverstein
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA
| | - Jessica Gelman
- Department of Education, Miller School of Medicine, University of Miami, 1600 NW 10th Avenue #1140, Miami, FL, USA
| | - Hillary Jenny
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Icahn School of Medicine at Mt. Sinai, 1 Gustav Levy Place, New York, NY, USA
| | - Yihan Lin
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Department of Surgery, University of Colorado, 12631 E 17th Avenue, Aurora, CO, USA
| | - Anthony Moccia
- Harvard Initiative on Global Health Quality, Harvard Global Health Institute, 42 Church St, Cambridge, MA, USA
| | - Ramy Rashad
- Tufts University School of Medicine, 145 Harrison Ave, Boston, MA, USA
| | - Rachita Sood
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Department of Education, Miller School of Medicine, University of Miami, 1600 NW 10th Avenue #1140, Miami, FL, USA
| | - Nakul P Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, 110 Francis St, Boston, MA, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Boston, MA, USA
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A Sustainable and Scalable Approach to the Provision of Cleft Care: A Focus on Safety and Quality. Plast Reconstr Surg 2018; 142:463-469. [PMID: 30045182 DOI: 10.1097/prs.0000000000004580] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A global health model based on partnering with local hospitals and surgical teams, providing education and training for local providers, and mandating adherence to safety and quality standards to ensure safe surgery and anesthesia care can build local surgical capacity and strengthen existing health care systems in low- and middle-income countries. Smile Train uses this sustainable partnership model to provide responsible humanitarian aid while maintaining a bidirectional exchange with its international partners. METHODS A voluntary online survey is administered annually to Smile Train's global partners. One portion of this survey focuses on how Smile Train can best support providers' adherence to the Smile Train Safety and Quality Protocol and Anesthesia Guidelines for cleft care. RESULTS In 2014 and 2015, 1132 health care providers responded to Smile Train's annual partner survey (77 percent response rate). When asked how Smile Train could best support partners to continually meet the safety and quality standards, most partners reported that they could benefit from additional financial support (59.6 percent) and medical professional education and training opportunities (59.2 percent). CONCLUSIONS The results from the partner survey yield important insights into the programmatic needs of Smile Train partners. Smile Train uses this information to efficiently allocate and distribute resources and to strategically plan and implement training opportunities where needed. The partner survey helps to ensure that Smile Train patients around the world consistently receive safe and high-quality cleft surgery and anesthesia care.
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Munakomi S, Shah R, Shrestha S. A pilot study comparing pattern of damage sustained among instruments from different surgical units in a tertiary care centre in Nepal - reappraising the role of instrument reprocessing in retaining their value. F1000Res 2018; 7:102. [PMID: 30345016 PMCID: PMC6171723 DOI: 10.12688/f1000research.13699.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2018] [Indexed: 11/20/2022] Open
Abstract
Background: The quality of instruments plays a pivotal role in governing safe operating room culture. The reprocessing system followed in the institution determines their durability thereby ensuring patient safety as well as minimizing health spending. Rigorous reprocessing in a centralized instrument reprocessing department by well trained staff following formulated guidelines helps to achieve the target of "safe surgery saves lives" as formulated by the World Health Organization. Methods: We sought to determine the patterns of wear and tear sustained among sets of surgical equipment from two surgical units that had been sent to the repair department within a year of their purchase. Analysis of similar changes in the joints of the instrument, as well as pattern of fractures sustained was performed. Results: All patterns of wear and tear were common in both the general surgical arm and neurosurgical counterpart, with the exception of fractures and mal-alignments. Similar study was performed examining changes in the joints. Stains were the most commonly observed change pattern in both sets of instruments. Fractures were most frequent in the working ends in both sets of instruments. Conclusion: There is an alarming incidence of wear and tear patterns in the instruments used in the surgical units, even within the first year of their use. This supports the strict implementation of reprocessing guidelines by well trained workers and their quality assessments via audit checks. The quality of the purchased instruments also plays a pivotal role.
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Affiliation(s)
- Sunil Munakomi
- Department of Neurosurgery, Nobel Hospital, Biratnagar, 0977, Nepal
| | - Roshan Shah
- Department of Neurosurgery, Nobel Hospital, Biratnagar, 0977, Nepal
| | - Sangam Shrestha
- Department of Pediatrics, Koshi Zonal Hospital, Biratnagar, 0977, Nepal
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Mehta A, Goldstein SD, Makary MA. Global trends in center accreditation by the Joint Commission International: growing patient implications for international medical and surgical care. J Travel Med 2017; 24:4090960. [PMID: 28931151 DOI: 10.1093/jtm/tax048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Millions of patients travel internationally for medical and surgical care. We found that the annual number of centers accredited by the Joint Commission International increased from one center in 1999 to 132 centers in 2016; there are currently 939 accredited centers across 66 countries. Public health and medicolegal implications related to medical travel deserve attention.
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Affiliation(s)
- Ambar Mehta
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Seth D Goldstein
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Martin A Makary
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Blair KJ, Paladino L, Shaw PL, Shapiro MB, Nwomeh BC, Swaroop M. Surgical and trauma care in low- and middle-income countries: a review of capacity assessments. J Surg Res 2016; 210:139-151. [PMID: 28457320 DOI: 10.1016/j.jss.2016.11.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 10/04/2016] [Accepted: 11/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND Surgical and trauma capacity assessments help guide resource allocation and plan interventions to improve care for the injured in low- and middle-income countries (LMICs). To forge expert consensus on conducting these assessments, we undertook a systematic review of studies using five tools: (1) World Health Organization's (WHO) Guidelines for Essential Trauma Care, (2) WHO's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, (3) Personnel, Infrastructure, Procedures, Equipment, and Supplies tool, (4) Harvard Humanitarian Initiative tool, and (5) Emergency and Critical Care tool. MATERIALS AND METHODS Publications describing utilization of survey instruments to assess surgical or trauma capacity in LMICs were reviewed. Included articles underwent thematic analysis to develop recommendations. A modified Delphi method was used to establish expert consensus. Experts rated recommendations on a Likert-type scale via online survey. Consensus was defined by Cronbach's α ≥ 0.80. Recommendations achieving agreement by ≥80% of experts were included. RESULTS Two hundred and ninety-eight publications were identified and 41 included, describing evaluation of 1170 facilities across 36 LMICs. Nine recommendations were agreed upon by expert consensus: (1) inclusion of district hospitals, (2) inclusion of highest level public hospital, (3) inclusion of private facilities, (4) facility visits for on-site completion, (5) direct inspections, (6) checking surgical logs, (7) adaptation of survey instrument, (8) repeat assessments, and (9) need for increased collaboration. CONCLUSIONS Expert recommendations developed in this review describe methodology to be employed when conducting assessments of surgical and trauma capacity in LMICs. Consensus has yet to be achieved for tool selection.
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Affiliation(s)
- Kevin J Blair
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| | - Lorenzo Paladino
- Department of Emergency Medicine, State University of New York Downstate Medical Center, Brooklyn, New York
| | - Pamela L Shaw
- Galter Health Sciences Library, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Michael B Shapiro
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Benedict C Nwomeh
- Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Mamta Swaroop
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Abstract
INTRODUCTION Traffic-related injury is a major and increasing cause of global mortality, especially in low- and middle-income countries (LMICs). However, trauma systems, personnel, resources, and infrastructure are frequently insufficient to meet the needs of the population in this at-risk population in LMICs. In addition, these resources are not uniformly distributed, coordinated, nor well described within most countries. Trauma care resources have not previously been characterized in the Northern Region of Ghana. METHODS We performed uniform site evaluations and interviews at 92 hospitals in Northern Ghana. Trauma systems, material resources, and human resources were quantified. Equipment was characterized as available in the Emergency Department (ED), in the hospital only, or unavailable. Hospitals were categorized as primary, district, or referral. RESULTS Forty-two primary hospitals, 48 district hospitals, 3 regional hospitals, and 1 teaching hospital were surveyed. Over 95 % of hospitals reported having no training or systems for the care of injured patients. Substantial clinical equipment deficits were found at most primary hospitals. In over 90 % of these hospitals, the majority of circulation and monitoring, airway and breathing, and diagnostic imagining resources were not available. Equipment was also frequently unavailable at district and regional hospitals. When available, these resources were infrequently present in the ED. CONCLUSIONS Although resources may be unavoidably constrained, there are substantial opportunities to improve the systematic management of trauma care and improve the education of the medical providers regarding care of injured patients in the region studied.
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Ingabire W, Reine PM, Hedt-Gauthier BL, Hirschhorn LR, Kirk CM, Nahimana E, Nepomscene Uwiringiyemungu J, Ndayisaba A, Manzi A. Roadmap to an effective quality improvement and patient safety program implementation in a rural hospital setting. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2015; 3:277-82. [PMID: 26699357 DOI: 10.1016/j.hjdsi.2015.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 09/30/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
Implementation lessons: (1) implementation of an effective quality improvement and patient safety program in a rural hospital setting requires collaboration between hospital leadership, Ministry of Health and other stakeholders. (2) Building Quality Improvement (QI) capacity to develop engaged QI teams supported by mentoring can improve quality and patient safety.
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Affiliation(s)
| | | | - Bethany L Hedt-Gauthier
- Partners In Health/Inshuti Mu Buzima, Rwanda; Department of Global Health and Social Medicine, Harvard Medical School, USA
| | - Lisa R Hirschhorn
- Department of Global Health and Social Medicine, Harvard Medical School, USA; Ariadne Labs, Boston, MA, USA
| | | | | | | | | | - Anatole Manzi
- Partners In Health/Inshuti Mu Buzima, Rwanda; Partners In Health, USA.
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Assessing the impact of short-term surgical education on practice: a retrospective study of the introduction of mesh for inguinal hernia repair in sub-Saharan Africa. Hernia 2014; 18:549-56. [DOI: 10.1007/s10029-014-1255-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 04/10/2014] [Indexed: 12/31/2022]
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