Strategic Assessment of Trauma Care Capacity in Ghana

Hepato-pancreato-biliary surgery in West Africa: a timely capacity assessment

BACKGROUND

West Africa has among the highest rates of hepato-pancreato-biliary (HPB) malignancies in the world. Although surgery is critical for treatment, the availability of HPB surgery in Africa is unknown. This cross-sectional study investigated the current HPB surgical capacity of West African hospitals.

METHOD

The Surgeons OverSeas Personnel, Infrastructure, Procedure, Equipment, and Supplies (PIPES) survey was modified to include HPB-specific parameters and quantify capacity. The survey was completed by consultant surgeons from West Africa. A PIPES index was calculated, and a higher score corresponded to greater HPB surgical capacity.

RESULTS

The HPB PIPES survey was completed by 35 institutions from The Gambia, Ghana, Ivory Coast, and Nigeria. Most institutions (94.2%) were tertiary referral centres; five had an HPB-trained surgeon. The most commonly available procedure was an open cholecystectomy (91.4%), followed by gastric bypass (88.6%). Major hepatic resections (14.3%) and the Whipple procedure (17.1%) were rare. ICU capabilities were present at 88.6% of facilities while interventional radiology was present in 25.7%.

CONCLUSIONS

This is the first HPB capacity assessment in Africa. This study showed the limited availability of HPB surgery in West Africa. These results can be used for regional quality improvement initiatives and as a baseline for future capacity assessments.

Emergency preparedness capacity of a university hospital in Ghana: a cross-sectional study

Background

The health and safety of people are often endangered during emergencies and disasters. Efficient emergency management systems ensure that mitigation, preparedness, response, and recovery actions exist to preserve the health, safety, and welfare of the public. Failure to carry out appropriate responses can have adverse consequences for both emergency responders and casualties; hence, the need for emergency preparedness. This study sought to assess the state of emergency preparedness capacity of the Kwame Nkrumah University of Science and Technology hospital in Ghana.

Methods

A facility-based cross-sectional study was conducted between December 2018 and February 2019 using three guidelines developed respectively by the World Health Organization, the Ministry of Health-Ghana, and the Ghana Health Service. The hospital's emergency preparedness was assessed regarding the emergency policies, plan, protocol, equipment, and medications.

Results

Overall, the hospital's emergency preparedness level was weak (57.36%). Findings revealed that the hospital had inadequate emergency equipment, and supplies for emergency care delivery, especially during upsurge. It also did not have an emergency planning committee. There were noticeable deficiencies in some emergency resources such as chest tubes, basic airway supplies, and many emergency drugs. Other vital emergency tools such as pulse oximeter, thermometer, and emergency medications were inadequate. The hospital had a strong emergency plan and policies on assessment (77.8% and 78%) respectively.

Conclusion

The Kwame Nkrumah University of Science and Technology hospital is not prepared sufficiently for an emergency surge, and this poses a major health challenge. Emergency items must be made available, and the organization and planning of emergency service provisions must be improved to avoid preventable deaths during an emergency surge.

Affordability impacts therapeutic intensity of acute management of severe traumatic brain injury patients: An exploratory study in Tanzania

Introduction

Quality health care in low and middle-income countries (LMICs) is constrained by financing of care.

Research question

What is the effect of ability to pay on critical care management of patients with severe traumatic brain injury (sTBI)?

Material and Methods

Data on sTBI patients admitted to a tertiary referral hospital in Dar-es-Salaam, Tanzania, were collected between 2016 and 2018, and included payor mechanisms for hospitalization costs. Patients were grouped as those who could afford care and those who were unable to pay.

Results

Sixty-seven patients with sTBI were included. Of those enrolled, 44 (65.7%) were able to pay and 15 (22.3%) were unable to pay costs of care upfront. Eight (11.9%) patients did not have a documented source of payment (unknown identity or excluded from further analysis). Overall mechanical ventilation rates were 81% (n=36) in the affordable group and 100% (n=15) in the unaffordable group (p=0.08). Computed tomography (CT) rates were 71.6% (n=48) overall, 100% (n=44) and 0% respectively (p<0.01); Surgical rates were 16.4% (n=11) overall, 18.2% (n=8) vs. 13.3% (n=2) (p=0.67) respectively. Two-week mortality was 59.7% overall (n=40), 47.7% (n=21) in the affordable group and 73.3% (n=11) in the unaffordable group (p=0.09) (adjusted OR 0.4; 95% CI: 0.07-2.41, p=0.32).

Discussion and Conclusion

Ability to pay appears to have a strong association with the use of head CT and a weak association with mechanical ventilation in the management of sTBI. Inability to pay increases redundant or sub-optimal care, and imposes a financial burden on patients and their relatives.

The state of surgery, obstetrics, trauma, and anaesthesia care in Ghana: a narrative review

Background

Conditions amenable to surgical, obstetric, trauma, and anaesthesia (SOTA) care are a major contributor to death and disability in Ghana. SOTA care is an essential component of a well-functioning health system, and better understanding of the state of SOTA care in Ghana is necessary to design policies to address gaps in SOTA care delivery.

Objective

The aim of this study is to assess the current situation of SOTA care in Ghana.

Methods

A situation analysis was conducted as a narrative review of published scientific literature. Information was extracted from studies according to five health system domains related to SOTA care: service delivery, workforce, infrastructure, finance, and information management.

Results

Ghanaians face numerous barriers to accessing quality SOTA care, primarily due to health system inadequacies. Over 77% of surgical operations performed in Ghana are essential procedures, most of which are performed at district-level hospitals that do not have consistent access to imaging and operative room fundamentals. Tertiary facilities have consistent access to these modalities but lack consistent access to oxygen and/or oxygen concentrators on-site as well as surgical supplies and anaesthetic medicines. Ghanaian patients cover up to 91% of direct SOTA costs out-of-pocket, while health insurance only covers up to 14% of the costs. The Ghanaian surgical system also faces severe workforce inadequacies especially in district-level facilities. Most specialty surgeons are concentrated in urban areas. Ghana’s health system lacks a solid information management foundation as it does not have centralized SOTA databases, leading to incomplete, poorly coded, and illegible patient information.

Conclusion

This review establishes that surgical services provided in Ghana are focused primarily on district-level facilities that lack adequate infrastructure and face workforce shortages, among other challenges. A comprehensive scale-up of Ghana’s surgical infrastructure, workforce, national insurance plan, and information systems is warranted to improve Ghana’s surgical system.

Factors Contributing to and Reducing Delays in the Provision of Adequate Care in Ghana: A Qualitative Study of Trauma Care Providers

BACKGROUND

Ghana has a large and growing burden of injury morbidity and mortality. There is a substantial unmet need for trauma surgery, highlighting a need to understand gaps in care.

METHODS

We conducted 8 in-depth interviews with trauma care providers (surgeons, nurses, and specialists) at a large teaching hospital to understand factors that contribute to and reduce delays in the provision of adequate trauma care for severely injured patients. The study aimed to understand whether providers thought factors differed between patients that were enrolled in the National Health Insurance Scheme (NHIS) and those that were not. Findings were presented for the third delay (provision of appropriate care) in the Three Delays Framework.

RESULTS

Key findings included that most factors contributing delays in the provision of adequate care were related to the costs of care, including for diagnostics, medications, and treatment for patients with and without NHIS subscription. Other notable factors included conflicts between providers, resource constraints, and poor coordination of care at the facility. Factors which reduce delays included advocacy by providers and informal processes for prioritizing critical injuries.

CONCLUSION

We recommend facility-level changes including increasing equity in access to trauma and elective surgery through targeted system strengthening efforts (e.g., a scheduled back-up call system for surgeons, anesthetists, other specialists, and nurses; designated operating theatres and staff for emergencies; training of staff), policy changes to simplify the insurance renewal and subscription processes, and future research on the costs and benefits of including diagnostics, medications, and common trauma services into the NHIS benefits package.

Achievement of Key Performance Indicators in Initial Assessment and Care of Injured Patients in Ghanaian Non-tertiary Hospitals: An Observational Study

INTRODUCTION

We aimed to determine the level of achievement of key performance indicators (KPIs) during initial assessment and management of injured persons, as assessed by independent observers, at district and regional hospitals in Ghana.

METHODS

Trained observers were stationed at emergency units of six district (first level) and two regional (referral) hospitals, from October 2020 to February 2021, to observe management of injured patients by health service providers. Achievement of KPIs was assessed for all injured patients and for seriously injured patients (admitted for ≥ 24 h, referred, or died).

RESULTS

Management of 1006 injured patients was observed. Road traffic crash was the most common mechanism (63%). Completion of initial triage ranged from 65% for oxygen saturation to 92% for mobility assessment. For primary survey, airway was assessed in 77% of patients, chest examination performed in 66%, and internal abdominal bleeding assessed in 43%. Reassessment rates were low, ranging from 16% for respiratory rate to 23% for level of consciousness. Thirty-one percent of patients were seriously injured. Completion of KPIs was higher for these patients, but reassessment remained low, ranging from 25% for respiratory rate to 33% for level of consciousness.

CONCLUSION

KPIs were performed at a high level, but several specific elements should be performed more frequently, such as oxygen saturation and assessment for internal abdominal bleeding. Reassessment needs to be performed more frequently, especially for seriously injured patients. Overall, care for the injured at non-tertiary hospitals in Ghana could be improved with a more systematic approach.

Preferences for Oral Rehydration Drinks among Healthy Individuals in Ghana: A Single-Blind, Cross-Sectional Survey to Inform Implementation of an Enterally Based Resuscitation Protocol for Burn Injury

BACKGROUND

Enterally based resuscitation for major burn injuries has been suggested as a simple, operationally superior, and effective resuscitation strategy for use in austere contexts. However, key information to support its implementation is lacking, including palatability and acceptability of widely available rehydration drinks.

METHODS

We performed a single-blinded, cross-sectional survey of 60 healthy children (5-14 years), adults (15-54 years) and older adults (≥55 years) to determine palatability and overall acceptability of five oral rehydration solutions (ORS) and a positive control drink (Sprite Zero®) in Ghana. Quantitative data were described and differences between our control drink and the others across age groups were visually examined with Likert plots. Qualitative responses were analyzed using a content analysis framework.

RESULTS

Twenty participants in each age group completed the study. Participants were as young as 5 years and as old as 84 years. Nearly two thirds of the sample identified as male (n = 38, 63% of all participants). The positive control was reported to taste 'good or 'very good' by the majority of participants (89%) followed by lemon-flavored ORS (78%) and orange-flavored ORS (78%). Conversely, homemade and low-osmolarity ORS were reported to taste 'good' or 'very good' by only 20% and 15% of participants, respectively. There were no major taste differences across the age groups. However, children more frequently reported positively (i.e., tastes 'good' or 'very good') about flavored and sweet drinks than did adults and older adults. When faced with the hypothetical situation of being critically injured and needing resuscitation, participants tended to be more agreeable to consuming all the drinks, even low-osmolarity and homemade ORS.

CONCLUSIONS

These findings can be used to support the development of protocols that may be more acceptable among patients undergoing enterally based resuscitation, thus improving the effectiveness of the treatment. Specifically, enterally based resuscitation should likely include citrus-flavored ORS when available, given superior palatability and the fact that different flavor additives for patients of different ages do not seem necessary.

Designing and conducting initial application of a performance assessment model for in-hospital trauma care

BACKGROUND

Trauma is a major cause of death worldwide, especially in Low and Middle-Income Countries (LMIC). The increase in health care costs and the differences in the quality of provided services indicates the need for trauma care evaluation. This study was done to develop and use a performance assessment model for in-hospital trauma care focusing on traffic injures.

METHODS

This multi-method study was conducted in three main phases of determining indicators, model development, and model application. Trauma care performance indicators were extracted through literature review and confirmed using a two-round Delphi survey and experts' perspectives. Two focus group discussions and 16 semi-structured interviews were conducted to design the prototype. In the next step, components and the final form of the model were confirmed following pre-determined factors, including importance and necessity, simplicity, clarity, and relevance. Finally, the model was tested by applying it in a trauma center.

RESULTS

A total of 50 trauma care indicators were approved after reviewing the literature and obtaining the experts' views. The final model consisted of six components of assessment level, teams, methods, scheduling, frequency, and data source. The model application revealed problems of a selected trauma center in terms of information recording, patient deposition, some clinical services, waiting time for deposit, recording medical errors and complications, patient follow-up, and patient satisfaction.

CONCLUSION

Performance assessment with an appropriate model can identify deficiencies and failures of services provided in trauma centers. Understanding the current situation is one of the main requirements for designing any quality improvement programs.

Trauma Care in Low- and Middle-Income Countries

Background  Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.

Methods  A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.

Results  Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.

Conclusion  Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BACKGROUND

The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.

METHODS

We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.

RESULTS

Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.

CONCLUSIONS

Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Unintentional falls among children in rural Ghana and associated factors: a cluster-randomized, population-based household survey

INTRODUCTION

falls contribute to almost one-fifth of injury-related deaths. The majority of these occur in low- and middle-income countries. The impact of fall injury in low- and middle-income countries is greater in younger individuals. We aimed to determine the epidemiology of falls among rural Ghanaian children.

METHODS

from March to May, 2018, we conducted a cluster-randomized household survey of caregivers in a rural Ghanaian sub-district, regarding household child falls and their severity. We utilized a previously validated survey tool for household child injury. Associations between household child falls and previously described predictors of household child injury were examined with multivariable logistic regression. These included age and gender of the child, household socioeconomic status, caregiver education, employment status, and their beliefs on why household child injuries occur.

RESULTS

three hundred and fifty-seven caregivers of 1,016 children were surveyed. One hundred and sixty-four children under 18 years had sustained a household fall within the past six months, giving a household child fall prevalence of 16% (95% C.I, 14%-19%). Mean age was 4.4 years; 59% were males. Ground level falls were more common (80%). Severity was mostly moderate (86%). Most caregivers believed household child injuries occurred due to lack of supervision (85%) or unsafe environment (75%); only 2% believed it occurred because of fate. Girls had reduced odds of household falls (adjusted O.R 0.6; 95% C.I 0.4-0.9). Five to nine year-old and 15-17 year-old children had reduced odds of household falls (adjusted O.R 0.4; 95% C.I 0.2-0.7 and 0.1; 95% C.I 0.02-0.3, respectively) compared to 1-4 year-olds. Caregiver engagement in non-salary paying work was associated with increased odds of household child falls (adjusted O.R 2.2; 95% C.I 1.0-4.7) compared to unemployed caregivers. There was no association between household child falls and caregiver education, socioeconomic status and beliefs about why household child injuries occurred.

CONCLUSION

the prevalence of household child falls in rural Ghana was 16%. This study confirms the need to improve supervision of all children to reduce household falls, especially younger children and particularly boys. Majority of caregivers also acknowledge the role of improper child supervision and unsafe environments in household child falls. These beliefs should be reinforced and emphasized in campaigns to prevent household child falls in rural communities.

Identifying Hospitals in Nepal for Acute Burn Care and Stabilization Capacity Development: Location-Allocation Modeling for Strategic Service Delivery

In Nepal, preventable death and disability from burn injuries are common due to poor population-level spatial access to organized burn care. Most severe burns are referred to a single facility nationwide, often after suboptimal burn stabilization and/or significant care delay. Therefore, we aimed to identify existing first-level hospitals within Nepal that would optimize population-level access as "burn stabilization points" if their acute burn care capabilities are strengthened. A location-allocation model was created using designated first-level candidate hospitals, a population density grid for Nepal, and road network/travel speed data. Six models (A-F) were developed using cost-distance and network analyses in ArcGIS to identify the three vs five candidate hospitals at ≤2, 6, and 12 travel-hour thresholds that would optimize population-level spatial access. The baseline model demonstrated that currently 20.3% of the national population has access to organized burn care within 2 hours of travel, 37.2% within 6 travel-hours, and 72.6% within 12 travel-hours. If acute burn stabilization capabilities were strengthened, models A to C of three chosen hospitals would increase population-level burn care access to 45.2, 89.4, and 99.8% of the national population at ≤2, 6, and 12 travel-hours, respectively. In models D to F, five chosen hospitals would bring access to 53.4, 95.0, and 99.9% of the national population at ≤2, 6, and 12 travel-hours, respectively. These models demonstrate developing capabilities in three to five hospitals can provide population-level spatial access to acute burn care for most of Nepal's population. Organized efforts to increase burn stabilization points are feasible and imperative to reduce the rates of preventable burn-related death and disability country-wide.

A Nationwide Enumeration of Operations Performed for Pediatric Patients in Ghana

INTRODUCTION

 Currently, there are no existing benchmarks for evaluating a nation's pediatric surgical capacity in terms of met and unmet needs.

MATERIALS AND METHODS

 Data on pediatric operations performed from 2014 to 2015 were obtained from a representative sample of hospitals in Ghana, then scaled up for national estimates. Operations were categorized as "essential" (most cost-effective, highest population impact) as designated by the World Bank's Disease Control Priorities versus "other." Estimates were then compared with pediatric operation rates in New Zealand to determine unmet pediatric surgery need in Ghana.

RESULTS

 A total of 29,884 operations were performed for children <15 years, representing an annual operation rate of 284/100,000 (95% uncertainty interval: 205-364). Essential procedures constituted 66% of all pediatric operations; 12,397 (63%) were performed at district hospitals. General surgery (8,808; 29%) and trauma (6,302; 21%) operations were most common. Operations for congenital conditions were few (826; 2.8%). Tertiary hospitals performed majority (55%) of operations outside of the essential category. Compared with the New Zealand benchmark (3,806 operations/100,000 children <15 years), Ghana is meeting only 7% of its pediatric surgical needs.

CONCLUSION

 Ghana has a large unmet need for pediatric surgical care. Pediatric-specific benchmarking is needed to guide surgical capacity efforts in low- and middle-income country healthcare systems.

Surgical care in district hospitals in sub-Saharan Africa: a scoping review

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.

Injured and broke: The impacts of the Ghana National Health Insurance Scheme (NHIS) on service delivery and catastrophic health expenditure among seriously injured children

Introduction

Ghana implemented a National Health Insurance Scheme (NHIS) in 2003 as a step toward universal health coverage. We aimed to determine the effect of the NHIS on timeliness of care, mortality, and catastrophic health expenditure (CHE) among children with serious injuries at a trauma center in Ghana.

Methods

We performed a retrospective cohort study of injured children aged <18 years who required surgery (i.e., proxy for serious injury) at Komfo Anokye Teaching Hospital from 2015 to 2016. Household income data was obtained from the Ghana Statistical Service. CHE was defined as out-of-pocket payments to annual household income ≥10%. Differences in insured and uninsured children were described. Multivariable regression was used to assess the effect of NHIS on time to surgery, length of stay, in-hospital mortality, out-of-pocket expenditure and CHE.

Results

Of the 263 children who met inclusion criteria, 70% were insured. Mechanism of injury, triage scores and Kampala Trauma Score II were similar in both groups (all p > 0.10). Uninsured children were more likely to have a delay in care for financial reasons (17.3 vs 6.4%, p < 0.001) than insured children, and the families of uninsured children paid a median of 1.7 times more out-of-pocket costs than families with insured children (p < 0.001). Eighty-six percent of families of uninsured children experienced CHE compared to 54% of families of insured children (p < 0.001); however, 64% of all families experienced CHE. Insurance was protective against CHE (aOR 0.21, 95%CI 0.08–0.55).

Conclusions

NHIS did not improve timeliness of care, length of stay or mortality. Although NHIS did provide some financial risk protection for families, it did not eliminate out-of-pocket payments. The families of most seriously injured children experienced CHE, regardless of insurance status. NHIS and similar financial risk pooling schemes could be strengthened to better provide financial risk protection and promote quality of care for injured children.

•

Despite strides toward universal health coverage with the National Health Insurance Scheme (NHIS) in Ghana, one third of injured children did not have insurance.

•

Families on uninsured injured children pay markedly more out-of-pocket costs than families of insured children.

•

Although families of uninsured children were more likely to experience catastrophic health expenditure (CHE), CHE was commonly experienced regardless of insurance.

•

These findings have useful implications for NHIS, agencies working toward universal health coverage, and trauma systems generally.

Assessment of local supply chains and stock management practices for trauma care resources in Ghana: a comparative small sample cross-sectional study

BACKGROUND

Injuries are a major public health problem globally. With sound planning and organization, essential trauma care can be reliably provided with relatively low-cost equipment and supplies. However, availability of these resources requires an effective and efficient supply chain and good stock management practices. Therefore, this study aimed to assess trauma care resource-related supply management structures and processes at health facilities in Ghana. By doing so, the findings may allow us to identify specific structures and processes that could be improved to facilitate higher quality and more timely care.

METHODS

Ten hospitals were purposively selected using results from a previously performed national trauma care capacity assessment of hospitals of all levels in Ghana. Five hospitals with low resource availability and 5 hospitals with high resource availability were assessed using the United States Agency for International Development (USAID) Logistics Indicators Assessment Tool and stock ledger review. Data were described and stock management practices were correlated with resource availability.

RESULTS

There were differences in stock management practices between low and high resource availability hospitals, including frequency of reporting and audit, number of stock-outs on day of assessment (median 9 vs 2 stock-outs, range 3-57 vs 0-9 stock-outs, respectively; p = 0.05), duration of stock-outs (median 171 vs 8 days, range 51-1268 vs 0-182 days, respectively; p = 0.02), and fewer of up-to-date stock cards (24 vs 31 up-to-date stock cards, respectively; p = 0.07). Stock-outs were common even among low-cost, essential resources (e.g., nasal cannulas and oxygen masks, endotracheal tubes, syringes, sutures, sterile gloves). Increased adherence to stock management guidelines and higher percentage of up-to-date stock cards were correlated with higher trauma resource availability scores. However, the variance in trauma resource availability scores was poorly explained by these individual factors or when analyzed in a multivariate regression model (r2 = 0.72; p value for each covariate between 0.17-0.34).

CONCLUSIONS

Good supply chain and stock management practices are correlated with high trauma care resource availability. The findings from this study demonstrate several opportunities to improve stock management practices, particularly at low resource availability hospitals.

Incidence of childhood burn injuries and modifiable household risk factors in rural Ghana: A cluster-randomized, population-based, household survey

BACKGROUND

We aimed to determine the incidence of childhood burn injuries in rural Ghana and describe modifiable household risk factors to inform prevention initiatives.

METHODS

We performed a cluster-randomized, population-based survey of caregivers of children in a rural district in Ghana, representing 2713 households and 14,032 children. Caregivers were interviewed regarding childhood burn injuries within the past 6 months and household risk factors.

RESULTS

357 households were sampled. Most used an open fire with biomass fuel for cooking (85.8%). Households rarely cooked in a separate kitchen (10%). Stove height was commonly within reach of children under five years (<1 m; 96.0%). The weighted annualized incidence of CBI was 63 per 1000 child-years (6.4% of children per year); reported mean age was 4.4 years (SD 4.0). The most common etiology was flame burn. Older age (OR 0.89, 95% CI 0.8-1.0) and households with an older sibling ≥12 years (OR 0.58, 95% CI 0.3-1.3) seemed to be associated with lower odds of CBI.

CONCLUSIONS

Childhood burn injury is common in rural Ghana. Opportunities exist to reduce the risk of childhood burn injury childhood burns in rural settings by supporting the transition to safer cooking arrangements, child barrier apparatuses in homes without older children, and/or development of formal childcare programs.

National health insurance and surgical care for injured people, Ghana

Objective

To determine the association between having government health insurance and the timeliness and outcome of care, and catastrophic health expenditure in injured patients requiring surgery at a tertiary hospital in Ghana.

Methods

We reviewed the medical records of injured patients who required surgery at Komfo Anokye Teaching Hospital in 2015-2016 and extracted data on sociodemographic and injury characteristics, outcomes and out-of-pocket payments. We defined catastrophic health expenditure as ≥ 10% of the ratio of patients' out-of-pocket payments to household annual income. We used multivariable regression analyses to assess the association between having insurance through the national health insurance scheme compared with no insurance and time to surgery, in-hospital mortality and experience of catastrophic health expenditure, adjusted for potentially confounding variables.

Findings

Of 1396 patients included in our study, 834 (60%) were insured through the national health insurance scheme. Time to surgery and mortality were not statistically different between insured and uninsured patients. Insured patients made smaller median out-of-pocket payments (309 United States dollars, US$) than uninsured patients (US$ 503; P < 0.001). Overall, 45% (443/993) of patients faced catastrophic health expenditure. A smaller proportion of insured patients (33%, 184/558) experienced catastrophic health expenditure than uninsured patients (60%, 259/435; P < 0.001). Insurance through the national health insurance scheme reduced the likelihood of catastrophic health expenditure (adjusted odds ratio: 0.27; 95% confidence interval: 0.20 to 0.35).

Conclusion

The national health insurance scheme needs strengthening to provide better financial risk protection and improve quality of care for patients presenting with injuries that require surgery.

Emergency Department Design in Low- and Middle-Income Settings: Lessons from a University Hospital in Haiti

Background:

Studies from high-income settings have demonstrated that emergency department (ED) design is closely related to operational success; however, no standards exist for ED design in low- and middle-income countries (LMICs).

Objective:

We present ED design recommendations for LMICs based on our experience designing and operating the ED at Hôpital Universitaire de Mirebalais (HUM), an academic hospital in central Haiti. We also propose an ideal prototype for similar settings based on these recommendations.

Methods:

As part of a quality improvement project to redesign the HUM ED, we collected feedback on the current design from key stakeholders to identify design features impacting quality and efficiency of care. Feedback was reviewed by the clinical and design teams and consensus reached on key lessons learned, from which the prototype was designed.

Findings and conclusions:

ED design in LMICs must balance construction costs, sustainability in the local context, and the impact of physical infrastructure on care delivery. From our analysis, we propose seven key recommendations: 1) Design the “front end” of the ED with waiting areas that meet the needs of LMICs and dedicated space for triage to strengthen care delivery and patient safety. 2) Determine ED size and bed capacity with an understanding of the local health system and disease burden, and ensure line-of-sight visibility for ill patients, given limited monitoring equipment. 3) Accommodate for limited supply chains by building storage spaces that can manage large volumes of supplies. 4) Prioritize a maintainable system that can provide reliable oxygen. 5) Ensure infection prevention and control, including isolation rooms, by utilizing simple and affordable ventilation systems. 6) Give consideration to security, privacy, and well-being of patients, families, and staff. 7) Site the ED strategically within the hospital. Our prototype incorporates these features and may serve as a model for other EDs in LMICs.

The preventability of trauma-related death at a tertiary hospital in Ghana: a multidisciplinary panel review approach

Introduction

The purpose of the study was to determine the preventable trauma-related death rate (PDR) at Komfo Anokye Teaching Hospital in Kumasi, Ghana three years after initiation of an Emergency Medicine (EM) residency

Method

This was a retrospective, cross-sectional study. A multidisciplinary panel of physicians completed a structured implicit review of clinical data for trauma patients who died during the period 2011 to 2012. The panel judged the preventability of each death and the nature of inappropriate care. Categories were definitely preventable (DP), possibly preventable (PP), and not preventable (NP).

Results

1) The total number of cases was forty-five; 36 cases had adequate data for review. Subjects were predominately male; road traffic injury (RTI) was the leading mechanism of injury. Four cases (11.1%) were DP, 14 cases (38.9%) were PP and 18 (50%) were NP. Hemorrhage was the leading cause of death (39%). Among DP/PP deaths there were 37 instances of inappropriate care. Delay in surgical intervention was the predominate event (50%). 2) The PDR for this study was 50% (0.95 CI, 33.7%–66.3%)

Conclusion

Fifty percent of trauma deaths were DP/PP. Multiple episodes of varying types of inappropriate care occurred. More efficient surgical evaluation and appropriate treatment of hemorrhage could reduce trauma morality. Large amounts of missing and incomplete clinical data suggest considerable selection bias. A major implication of this study is the importance of having a robust, prospective trauma registry to collect clinical information to increase the number of cases for review.

•

Correcting delays in surgical care and inappropriate treatment of hemorrhage may improve trauma outcomes.

•

Inadequacy of the clinical records within many low-resource settings hampers retrospective research system

•

The need for a robust, electronic trauma registry that collects detailed clinical information is apparent.

Assessing the capacity of Malawi's district and central hospitals to manage traumatic diaphyseal femoral fractures in adults

Background

The burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning.

Methods

We developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures–a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals.

Results

No district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41–90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71–85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations.

Conclusion

We identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.

Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana

BACKGROUND

The Lancet Commission on Global Surgery recommended 5000 operations/100,000 persons annually, but did not define condition-specific guidelines. New Zealand, Lancet Commission on Global Surgery's benchmark country, documented 1158 trauma operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought to determine Ghana's annual trauma operation rate compared with this benchmark.

METHODS

Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5 tertiary hospitals and scaled up for nationwide estimates. Trauma operations were grouped by hospital level and categorized into "essential" (most cost-effective, highest population impact) versus "other" (specialized) as per the World Bank's Disease Control Priorities Project. Ghana's annual trauma operation rate was compared with the New Zealand benchmark to quantify current met needs for trauma surgery.

RESULTS

About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed "essential". Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare.

CONCLUSIONS

Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels.

Improving Benchmarks for Global Surgery: Nationwide Enumeration of Operations Performed in Ghana

OBJECTIVE

To evaluate the operation rate in Ghana and characterize it by types of procedures and hospital level.

BACKGROUND

The Lancet Commission on Global Surgery recommended an annual rate of 5000 operations/100,000 people as a benchmark at which low- and middle-income countries could achieve most of the population-wide benefits of surgery, but did not define procedure-type benchmarks.

METHODS

Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district-level (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Operations were categorized into those deemed as essential procedures (most cost-effective, highest population impact) by the World Bank's Disease Control Priorities Project versus other.

RESULTS

An estimated 232,776 [95% uncertainty interval (95% UI) 178,004 to 287,549] operations were performed nationally. The annual rate of operations was 869 of 100,000 (95% UI 664 to 1073). The rate fell well short of the benchmark. 77% of the estimated annual national surgical output was in the essential procedure category. Most operations (62%) were performed at district-level hospitals. Most district-level hospitals (54%) did not have fully trained surgeons, but nonetheless performed 36% of district-level hospital operations.

CONCLUSION

The operation rate was short of the Lancet Commission benchmark, indicating large unmet need, although most operations were in the essential procedure category. Future global surgery benchmarking should consider both total numbers and priority levels. Most surgical care was delivered at district-level hospitals, many without fully trained surgeons. Benchmarking to improve surgical care needs to address both access deficiencies and hospital and provider level.

Population-based rates of hernia surgery in Ghana

PURPOSE

To estimate the population-based annual rate of hernia surgery in Ghana, so as to better define the met and unmet need and to identify opportunities to decrease the unmet need.

METHODS

Data on operations performed from June 2014 to May 2015 were obtained from representative samples of 48 of 124 district (first-level) hospitals, 9 of 11 regional (referral) hospitals, and 3 of 5 tertiary hospitals, and scaled-up to nationwide estimates. Rates of hernia surgery were compared to previously published annual incidence of symptomatic hernia in Ghana (210/100,000 population) and to published annual rates of hernia surgery in high-income countries (120-275/100,000).

RESULTS

Estimated 17,418 [95% uncertainty interval (UI) 8154-26,683] hernia operations were performed nationally. The annual rate of hernia operations was 65 operations/100,000 population (95% UI 30.2-99.0). The rate was considerably less than the annual incidence of new symptomatic hernia or rates of hernia surgery in high-income countries. Hernia operations represented 7.5% of all operations. Most hernia operations (74%) were performed at district hospitals. Most district hospitals (54%) did not have fully trained surgeons, but nonetheless performed 38% of district-level hernia operations.

CONCLUSIONS

The rate of hernia operations fell short of estimated need. Most hernia repairs were performed at district hospitals, many without fully trained surgeons. Future global surgery benchmarking needs to address both overall surgical rates as well as rates for specific highly important operations. Countries can strengthen their planning for surgical care by defining their total, met, and unmet need for hernia surgery.

Enumeration of Operations Performed for Elderly Patients in Ghana: An Opportunity to Improve Global Surgery Benchmarking

INTRODUCTION

The Lancet Commission on Global Surgery proposed 5000 operations/100,000 people annually as a benchmark for developing countries but did not define benchmarks for different age groups. We evaluated the operation rate for elderly patients (≥65 years) in Ghana and estimated the unmet surgical need for the elderly by comparison to a high-income country benchmark.

METHODS

Data on operations performed for elderly patients over a 1-year period in 2014-5 were obtained from representative samples of 48/124 small district hospitals and 12/16 larger referral hospitals and scaled-up for nationwide estimates. Operations were categorized as essential (most cost-effective, highest population impact) versus other according to The World Bank's Disease Control Priority project (DCP-3). Data from New Zealand's National Minimum Dataset were used to derive a benchmark operation rate for the elderly.

RESULTS

16,007 operations were performed for patients ≥65 years. The annual operation rate was 1744/100,000 (95% UI 1440-2048), only 12% of the New Zealand benchmark of 14,103/100,000. 74% of operations for the elderly were in the essential category. The most common procedures (15%) were for urinary obstruction. 58% of operations were performed at district hospitals; 54% of these did not have fully-trained surgeons. Referral hospitals more commonly performed operations outside the essential category.

CONCLUSION

The operation rate was well beneath the benchmark, indicating a potentially large unmet need for Ghana's elderly population. Most operations for the elderly were in the essential category and delivered at district hospitals. Future global surgery benchmarking should consider specific benchmarks for different age groups.

Exploring the Relationship Between Surgical Capacity and Output in Ghana: Current Capacity Assessments May Not Tell the Whole Story

OBJECTIVE

Capacity assessments serve as surrogates for surgical output in low- and middle-income countries where detailed registers do not exist. The relationship between surgical capacity and output was evaluated in Ghana to determine whether a more critical interpretation of capacity assessment data is needed on which to base health systems strengthening initiatives.

METHODS

A standardized surgical capacity assessment was performed at 37 hospitals nationwide using WHO guidelines; availability of 25 essential resources and capabilities was used to create a composite capacity score that ranged from 0 (no availability of essential resources) to 75 (constant availability) for each hospital. Data regarding the number of essential operations performed over 1 year, surgical specialties available, hospital beds, and functional operating rooms were also collected. The relationship between capacity and output was explored.

RESULTS

The median surgical capacity score was 37 [interquartile range (IQR) 29-48; range 20-56]. The median number of essential operations per year was 1480 (IQR 736-1932) at first-level hospitals; 1545 operations (IQR 984-2452) at referral hospitals; and 11,757 operations (IQR 3769-21,256) at tertiary hospitals. Surgical capacity and output were not correlated (p > 0.05).

CONCLUSIONS

Contrary to current understanding, surgical capacity assessments may not accurately reflect surgical output. To improve the validity of surgical capacity assessments and facilitate maximal use of available resources, other factors that influence output should also be considered, including demand-side factors; supply-side factors and process elements; and health administration and management factors.

Design and preliminary validation of a mobile application-based expert system to facilitate repair of medical equipment in resource-limited health settings

Background

One of the greatest barriers to safe surgery is the availability of functional biomedical equipment. Biomedical technicians play a major role in ensuring that equipment is functional. Following in-field observations and an online survey, a mobile application was developed to aid technicians in troubleshooting biomedical equipment. It was hypothesized that this application could be used to aid technicians in equipment repair, as modeled by repair of a pulse oximeter.

Methods

To identify specific barriers to equipment repair and maintenance for biomedical technicians, an online survey was conducted to determine current practices and challenges. These findings were used to guide the development of a mobile application system that guides technicians through maintenance and repair tasks. A convenience sample of technicians in Ethiopia tested the application using a broken pulse oximeter task and following this completed usability and content validity surveys.

Results

Fifty-three technicians from 13 countries responded to the initial survey. The results of the survey showed that technicians find equipment manuals most useful, but these are not easily accessible. Many do not know how to or are uncomfortable reaching out to human resources. Thirty-three technicians completed the broken pulse oximeter task using the application. All were able to appropriately identify and repair the equipment, and post-task surveys of usability and content validity demonstrated highly positive scores (Agree to Strongly Agree) on both scales.

Discussion

This research demonstrates the need for improved access to resources for technicians and shows that a mobile application can be used to address a gap in the access to knowledge and resources in low- and middle-income countries. Further research will include prospective studies to determine the impact of an application on the availability of functional equipment in a hospital and the effect on the provision and safety of surgical care.

Cleft-Related Infanticide and Abandonment: A Systematic Review of the Academic and Lay Literature

OBJECTIVE

We aimed to describe the scope of cleft-related infanticide and identify issues that might inform prevention strategies.

DESIGN

Systematic reviews of both academic (eg, PubMed, EBSCOhost) and lay literature (eg, LexisNexis Academic, Google) databases were performed to identify all primary reports of cleft-related infanticide. All languages were included. Records before 1985 were excluded. Reference lists of all included reports were screened for potentially relevant records.

MAIN OUTCOME MEASURES

Country of origin and excerpts that pertained to the concepts surrounding cleft-related infanticide were extracted. Extracted excerpts were examined using a content analysis framework.

RESULTS

Of the 1,151 records retrieved, 70 reports documented cleft-related infanticide from 27 countries. The largest number of reports was from China (14 reports; 48% of reports), followed by India (4; 14%) and Nigeria (4; 14%). However, 2 countries had 3 reports, 5 countries had 2 reports, and 17 countries had 1 report. Themes that emerged from excerpt analysis included stigma, lack of affordable cleft care, abandonment, orphanage overcrowding, and abuse and slavery.

CONCLUSIONS

Cleft-related infanticide is a global problem. Initiatives to sensitize communities to cleft lip and/or cleft palate, provide timely and affordable cleft care, and build support systems for affected families may prove beneficial. Cleft care organizations have the opportunity to advocate for these initiatives, reduce the incidence of infanticide by providing or supporting timely and affordable cleft care, and demonstrate that children with successful cleft repairs reassimilate well into their communities.

The Correlation Between Poverty and Access to Essential Surgical Care in Ghana: A Geospatial Analysis

BACKGROUND

Surgical disease burden falls disproportionately on individuals in low- and middle-income countries. These populations are also the least likely to have access to surgical care. Understanding the barriers to access in these populations is therefore necessary to meet the global surgical need.

METHODS

Using geospatial methods, this study explores the district-level variation of two access barriers in Ghana: poverty and spatial access to care. National survey data were used to estimate the average total household expenditure (THE) in each district. Estimates of the spatial access to essential surgical care were generated from a cost-distance model based on a recent surgical capacity assessment. Correlations were analyzed using regression and displayed cartographically.

RESULTS

Both THE and spatial access to surgical care were found to have statistically significant regional variation in Ghana (p < 0.001). An inverse relationship was identified between THE and spatial access to essential surgical care (β -5.15 USD, p < 0.001). Poverty and poor spatial access to surgical care were found to co-localize in the northwest of the country.

CONCLUSIONS

Multiple barriers to accessing surgical care can coexist within populations. A careful understanding of all access barriers is necessary to identify and target strategies to address unmet surgical need within a given population.

Learning from 2523 trauma deaths in India- opportunities to prevent in-hospital deaths

BACKGROUND

A systematic analysis of trauma deaths is a step towards trauma quality improvement in Indian hospitals. This study estimates the magnitude of preventable trauma deaths in five Indian hospitals, and uses a peer-review process to identify opportunities for improvement (OFI) in trauma care delivery.

METHODS

All trauma deaths that occurred within 30 days of hospitalization in five urban university hospitals in India were retrospectively abstracted for demography, mechanism of injury, transfer status, injury description by clinical, investigation and operative findings. Using mixed methods, they were quantitatively stratified by the standardized Injury Severity Score (ISS) into mild (1-8), moderate (9-15), severe (16-25), profound (26-75) ISS categories, and by time to death within 24 h, 7, or 30 days. Using peer-review and Delphi methods, we defined optimal trauma care within the Indian context and evaluated each death for preventability, using the following categories: Preventable (P), Potentially preventable (PP), Non-preventable (NP) and Non-preventable but care could have been improved (NPI).

RESULTS

During the 18 month study period, there were 11,671 trauma admissions and 2523 deaths within 30 days (21.6%). The overall proportion of preventable deaths was 58%, among 2057 eligible deaths. In patients with a mild ISS score, 71% of deaths were preventable. In the moderate category, 56% were preventable, and 60% in the severe group and 44% in the profound group were preventable. Traumatic brain injury and burns accounted for the majority of non-preventable deaths. The important areas for improvement in the preventable deaths subset, inadequacies in airway management (14.3%) and resuscitation with hemorrhage control (16.3%). System-related issues included lack of protocols, lack of adherence to protocols, pre-hospital delays and delays in imaging.

CONCLUSION

Fifty-eight percent of all trauma deaths were classified as preventable. Two-thirds of the deaths with injury severity scores of less than 16 were preventable. This large subgroup of Indian urban trauma patients could possibly be saved by urgent attention and corrective action. Low-cost interventions such as airway management, fluid resuscitation, hemorrhage control and surgical decision-making protocols, were identified as OFI. Establishment of clinical protocols and timely processes of trauma care delivery are the next steps towards improving care.

The Birth and Growth of the National Ambulance Service in Ghana

Introduction This study aimed to document the growth and challenges encountered in the decade since inception of the National Ambulance Service (NAS) in Ghana, West Africa. By doing so, potentially instructive examples for other low- and middle-income countries (LMICs) planning a formal prehospital care system or attempting to identify ways to improve existing emergency services could be identified.

METHODS

Data routinely collected by the Ghana NAS from 2004-2014 were described, including: patient demographics, reason for the call, response location, target destination, and ti1mes of service. Additionally, the organizational structure and challenges encountered during the development and maturation of the NAS were reported.

RESULTS

In 2004, the NAS piloted operations with 69 newly trained emergency medical technicians (EMTs), nine ambulances, and seven stations. The NAS expanded service delivery with 199 ambulances at 128 stations operated by 1,651 EMTs and 47 administrative and maintenance staff in 2014. In 2004, nine percent of the country was covered by NAS services; in 2014, 81% of Ghana was covered. Health care transfers and roadside responses comprised the majority of services (43%-80% and 10%-57% by year, respectively). Increased mean response time, stable case holding time, and shorter vehicle engaged time reflect greater response ranges due to increased service uptake and improved efficiency of ambulance usage. Specific internal and external challenges with regard to NAS operations also were described.

CONCLUSION

The steady growth of the NAS is evidence of the need for Emergency Medical Services and the effects of sound planning and timely responses to changes in program indicators. The way forward includes further capacity building to increase the number of scene responses, strengthening ties with local health facilities to ensure timely emergency medical care and appropriateness of transfers, assuring a more stable funding stream, and improving public awareness of NAS services. Zakariah A , Stewart BT , Boateng E , Achena C , Tansley G , Mock C . The birth and growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017;32(1):83-93.

Orthopaedic Trauma Care Capacity Assessment and Strategic Planning in Ghana: Mapping a Way Forward

BACKGROUND

Orthopaedic conditions incur more than 52 million disability-adjusted life years annually worldwide. This burden disproportionately affects low and middle-income countries, which are least equipped to provide orthopaedic care. We aimed to assess orthopaedic capacity in Ghana, describe spatial access to orthopaedic care, and identify hospitals that would most improve access to care if their capacity was improved.

METHODS

Seventeen perioperative and orthopaedic trauma care-related items were selected from the World Health Organization's Guidelines for Essential Trauma Care. Direct inspection and structured interviews with hospital staff were used to assess resource availability and factors contributing to deficiencies at 40 purposively sampled facilities. Cost-distance analyses described population-level spatial access to orthopaedic trauma care. Facilities for targeted capability improvement were identified through location-allocation modeling.

RESULTS

Orthopaedic trauma care assessment demonstrated marked deficiencies. Some deficient resources were low cost (e.g., spinal immobilization, closed reduction capabilities, and prosthetics for amputees). Resource nonavailability resulted from several contributing factors (e.g., absence of equipment, technology breakage, lack of training). Implants were commonly prohibitively expensive. Building basic orthopaedic care capacity at 15 hospitals without such capacity would improve spatial access to basic care from 74.9% to 83.0% of the population (uncertainty interval [UI] of 81.2% to 83.6%), providing access for an additional 2,169,714 Ghanaians.

CONCLUSIONS

The availability of several low-cost resources could be better supplied by improvements in organization and training for orthopaedic trauma care. There is a critical need to advocate and provide funding for orthopaedic resources. These initiatives might be particularly effective if aimed at hospitals that could provide care to a large proportion of the population.

Population-level Spatial Access to Prehospital Care by the National Ambulance Service in Ghana

BACKGROUND

Conditions requiring emergency treatment disproportionately affect low- and middle-income countries (LMICs), where there is often insufficient prehospital care capacity. To inform targeted prehospital care development in Ghana, we aimed to describe spatial access to formal prehospital care services and identify ambulance stations for capacity expansion.

METHODS

Cost distance methods were used to evaluate areal and population-level access to prehospital care within 30 and 60 minutes of each of the 128 ambulance stations in Ghana. With network analysis methods, a two-step floating catchment area model was created to identify district-level variability in access. Districts without NAS stations within their catchment areas were identified as candidates for an additional NAS station. Additionally, five candidate stations for capacity expansion (e.g., addition of an ambulance) were then identified through iterative simulations that were designed to identify the stations that had the greatest influence on the access scores of the ten lowest access districts.

RESULTS

Following NAS inception, the proportion of Ghana's landmass serviceable within 60 minutes of a station increased from 8.7 to 59.4% from 2004 to 2014, respectively. Over the same time period, the proportion of the population with access to the NAS within 60-minutes increased from 48% to 79%. The two-step floating catchment area model identified considerable variation in district-level access scores, which ranged from 0.05 to 2.43 ambulances per 100,000 persons (median 0.45; interquartile range 0.23-0.63). Seven candidate districts for NAS station addition and five candidate NAS stations for capacity expansion were identified. The addition of one ambulance to each of the five candidate stations improved access scores in the ten lowest access districts by a total 0.22 ambulances per 100,000 persons.

CONCLUSIONS

The NAS in Ghana has expanded its population-level spatial access to the majority of the population; however, access inequality exists in both rural and urban areas that can be improved by increasing station capacity or adding additional stations. Geospatial methods to identify access inequities and inform service expansion might serve as a model for other LMICs attempting to understand and improve formal prehospital care services.

Mapping Population-Level Spatial Access to Essential Surgical Care in Ghana Using Availability of Bellwether Procedures

IMPORTANCE

Conditions that can be treated by surgery comprise more than 16% of the global disease burden. However, 5 billion people do not have access to essential surgical care. An estimated 90% of the 87 million disability-adjusted life-years incurred by surgical conditions could be averted by providing access to timely and safe surgery in low-income and middle-income countries. Population-level spatial access to essential surgery in Ghana is not known.

OBJECTIVES

To assess the performance of bellwether procedures (ie, open fracture repair, emergency laparotomy, and cesarean section) as a proxy for performing essential surgery more broadly, to map population-level spatial access to essential surgery, and to identify first-level referral hospitals that would most improve access to essential surgery if strengthened in Ghana.

DESIGN, SETTING, AND PARTICIPANTS

Population-based study among all households and public and private not-for-profit hospitals in Ghana. Households were represented by georeferenced census data. First-level and second-level referral hospitals managed by the Ministry of Health and all tertiary hospitals were included. Surgical data were collected from January 1 to December 31, 2014.

MAIN OUTCOMES AND MEASURES

All procedures performed at first-level referral hospitals in Ghana in 2014 were used to sort each facility into 1 of the following 3 hospital groups: those without capability to perform all 3 bellwether procedures, those that performed 1 to 11 of each procedure, and those that performed at least 12 of each procedure. Candidates for targeted capability improvement were identified by cost-distance and network analysis.

RESULTS

Of 155 first-level referral hospitals managed by the Ghana Health Service and the Christian Health Association of Ghana, 123 (79.4%) reported surgical data. Ninety-five (77.2%) did not have the capability in 2014 to perform all 3 bellwether procedures, 24 (19.5%) performed 1 to 11 of each bellwether procedure, and 4 (3.3%) performed at least 12. The essential surgical procedure rate was greater in bellwether procedure-capable first-level referral hospitals than in noncapable hospitals (median, 638; interquartile range, 440-1418 vs 360; interquartile range, 0-896 procedures per 100 000 population; P = .03). Population-level spatial access within 2 hours to a hospital that performed 1 to 11 and at least 12 of each bellwether procedure was 83.2% (uncertainty interval [UI], 82.2%-83.4%) and 71.4% (UI, 64.4%-75.0%), respectively. Five hospitals were identified for targeted capability improvement.

CONCLUSIONS AND RELEVANCE

Almost 30% of Ghanaians cannot access essential surgery within 2 hours. Bellwether capability is a useful metric for essential surgery more broadly. Similar strategic planning exercises might be useful for other low-income and middle-income countries aiming to improve access to essential surgery.

Triage capabilities of medical trainees in Ghana using the South African triage scale: an opportunity to improve emergency care

Introduction

The incidence of emergency conditions is increasing worldwide, particularly in low- and middle-income countries (LMICs). However, triage and emergency care training has not been prioritized in LMICs. We aimed to assess the reliability and validity of the South African Triage Scale (SATS) when used by providers not specifically trained in SATS, as well as to compare triage capabilities between senior medical students and senior house officers to examine the effectiveness of our curriculum for house officer training with regards to triage.

Methods

Sixty each of senior medical students and senior house officers who had not undergone specific triage or SATS training were asked to triage 25 previously validated emergency vignettes using the SATS. Estimates of reliability and validity were calculated. Additionally, over- and under-triage, as well as triage performance between the medical students and house officers was assessed against a reference standard.

Results

Fifty-nine senior medical students (98% response rate) and 43 senior house officers (72% response rate) completed the survey (84% response rate overall). A total of 2,550 triage assignments were included in the analysis (59 medical student and 43 house officer triage assignments for 25 vignettes each; 1,475 and 1,075 triage assignments, respectively). Inter-rater reliability was moderate (quadratically weighted κ 0.59 and 0.60 for medical students and house officers, respectively). Triage using SATS performed by these groups had low sensitivity (medical students: 54%, 95% CI 49–59; house officers: 55%, 95% CI 48–60) and moderate specificity (medical students: 84%, 95% CI 82 - 89; house officers: 84%, 95% CI 82 - 97). Both groups under-triaged most ‘emergency’ level vignette patients (i.e. SATS Red; 80 and 82% for medical students and house officers, respectively). There was no difference between the groups for any metric.

Conclusion

Although the SATS has proven utility in a number of different settings in LMICs, its success relies on its use by trained providers. Given the large and growing burden of emergency conditions, training current and future emergency care providers in triage is imperative.

Consensus recommendations for essential vascular care in low- and middle-income countries

OBJECTIVE

Many low- and middle-income countries (LMICs) are ill equipped to care for the large and growing burden of vascular conditions. We aimed to develop essential vascular care recommendations that would be feasible for implementation at nearly every setting worldwide, regardless of national income.

METHODS

The normative Delphi method was used to achieve consensus on essential vascular care resources among 27 experts in multiple areas of vascular care and public health as well as with experience in LMIC health care. Five anonymous, iterative rounds of survey with controlled feedback and a statistical response were used to reach consensus on essential vascular care resources.

RESULTS

The matrices provide recommendations for 92 vascular care resources at each of the four levels of care in most LMICs, comprising primary health centers and first-level, referral, and tertiary hospitals. The recommendations include essential and desirable resources and encompass the following categories: screening, counseling, and evaluation; diagnostics; medical care; surgical care; equipment and supplies; and medications.

CONCLUSIONS

The resources recommended have the potential to improve the ability of LMIC health care systems to respond to the large and growing burden of vascular conditions. Many of these resources can be provided with thoughtful planning and organization, without significant increases in cost. However, the resources must be incorporated into a framework that includes surveillance of vascular conditions, monitoring and evaluation of vascular capacity and care, a well functioning prehospital and interhospital transport system, and vascular training for existing and future health care providers.

Availability of resources for emergency care at a second-level hospital in Ghana: A mixed methods assessment

Introduction

Emergency care is an essential component of health systems, particularly in low- and middle-income countries. We sought to assess the availability of resources to provide emergency care at a second-level hospital in Ghana. By doing so, deficits that could guide development of targeted intervention strategies to improve emergency care could be identified.

Methods

A qualitative and quantitative assessment of capacity for care of emergency patients was performed at the Emergency Centre of the Police Hospital, a second-level hospital in Accra, Ghana. Direct inspection and job-specific survey of clinical, orderly, administrative and ambulance staff was performed. Responses to quantitative questions were described. Qualitative responses were examined by content analysis.

Results

Assessment revealed marked deficiencies in many essential items and services. However, several successes were identified, such as laboratory capacity. Among the unavailable essential items, some were of low-cost, such as basic airway supplies, chest tubes and several emergency medications. Themes from staff responses when asked how to improve emergency care included: provide periodic training, increase bed numbers in the emergency unit, ensure availability of essential items and make personal protective equipment available for all staff caring for patients.

Conclusion

This study identified opportunities to improve the care of patients with emergency conditions at the Police Hospital in Ghana. Low-cost improvements in training, organization and planning could improve item and service availability, such as: developing a continuing education curriculum for staff in all areas of the emergency centre; holding in-service training on existing protocols for triage and emergency care; adding checklists to guide appropriate triage and safe transfer of patients; and perform a root cause analysis of item non-availability to develop targeted interventions.

District-level hospital trauma care audit filters: Delphi technique for defining context-appropriate indicators for quality improvement initiative evaluation in developing countries

INTRODUCTION

Prospective clinical audit of trauma care improves outcomes for the injured in high-income countries (HICs). However, equivalent, context-appropriate audit filters for use in low- and middle-income country (LMIC) district-level hospitals have not been well established. We aimed to develop context-appropriate trauma care audit filters for district-level hospitals in Ghana, was well as other LMICs more broadly.

METHODS

Consensus on trauma care audit filters was built between twenty panellists using a Delphi technique with four anonymous, iterative surveys designed to elicit: (i) trauma care processes to be measured; (ii) important features of audit filters for the district-level hospital setting; and (iii) potentially useful filters. Filters were ranked on a scale from 0 to 10 (10 being very useful). Consensus was measured with average percent majority opinion (APMO) cut-off rate. Target consensus was defined a priori as: a median rank of ≥9 for each filter and an APMO cut-off rate of ≥0.8.

RESULTS

Panellists agreed on trauma care processes to target (e.g. triage, phases of trauma assessment, early referral if needed) and specific features of filters for district-level hospital use (e.g. simplicity, unassuming of resource capacity). APMO cut-off rate increased successively: Round 1--0.58; Round 2--0.66; Round 3--0.76; and Round 4--0.82. After Round 4, target consensus on 22 trauma care and referral-specific filters was reached. Example filters include: triage--vital signs are recorded within 15 min of arrival (must include breathing assessment, heart rate, blood pressure, oxygen saturation if available); circulation--a large bore IV was placed within 15 min of patient arrival; referral--if referral is activated, the referring clinician and receiving facility communicate by phone or radio prior to transfer.

CONCLUSION

This study proposes trauma care audit filters appropriate for LMIC district-level hospitals. Given the successes of similar filters in HICs and obstetric care filters in LMICs, the collection and reporting of prospective trauma care audit filters may be an important step towards improving care for the injured at district-level hospitals in LMICs.

Assessment of risk of peripheral vascular disease and vascular care capacity in low- and middle-income countries

BACKGROUND

This study aimed to describe national peripheral vascular disease (PVD) risk and health burden, and vascular care capacity in Ghana. The gap between PVD burden and vascular care capacity in low- and middle-income countries was defined, and capacity improvement priorities were identified.

METHODS

Data to estimate PVD risk factor burden were obtained from the World Health Organization Study on Global Ageing and Adult Health (SAGE), Ghana, and the Institute of Health Metrics and Evaluation Global Burden of Disease (IHME GBD) database. In addition, a novel nationwide assessment of vascular care capacity was performed, with 20 vascular care items assessed at 40 hospitals in Ghana. Factors contributing to specific item deficiency were described.

RESULTS

From the SAGE database, there were 4305 respondents aged at least 50 years with data to estimate PVD risk. Of these, 57·4 per cent were at moderate to risk high of PVD with at least three risk factors; extrapolating nationally, the estimate was 1 654 557 people. Based on IHME GBD data, the estimated disability-adjusted life-years incurred from PVD increased fivefold from 1990 to 2010 (from 6·3 to 31·7 per 100 000 persons respectively). Vascular care capacity assessment demonstrated marked deficiencies in items for diagnosis, and in perioperative and vascular surgical care. Deficiencies were most often due to absence of equipment, lack of training and technology breakage.

CONCLUSION

Risk factor reduction and management as well as optimization of current resources are paramount to avoid the large burden of PVD falling on healthcare systems in low- and middle-income countries. These countries are not well equipped to handle vascular surgical care, and rapid development of such capacity would be difficult and expensive.

Changing Epidemiology of Intestinal Obstruction in Ghana: Signs of Increasing Surgical Capacity and an Aging Population

INTRODUCTION

This study aimed to describe the epidemiology and outcomes of intestinal obstruction at a tertiary hospital in Ghana over time.

METHODS

Records of all patients admitted to a tertiary hospital from 2007 to 2011 with intestinal obstruction were identified using ICD-9 codes. Sociodemographic and clinical data were compared to a previously published series of intestinal obstructions from 1998 to 2003. Factors contributing to longer than expected hospital stays and death were further examined.

RESULTS

Of the 230 records reviewed, 108 patients (47%) had obstructions due to adhesions, 50 (21%) had volvulus, 22 (7%) had an ileus from perforation and 14 (6%) had intussusception. Hernia fell from the 1st to the 8th most common cause of obstruction. Patients with intestinal obstruction were older in 2007-2011 compared to those presenting between 1998 and 2003 (p < 0.001); conditions associated with older age (e.g., volvulus and neoplasia) were more frequently encountered (p < 0.001). Age over 50 years was strong factor of in-hospital death (adjusted OR 14.2, 95% CI 1.41-142.95).

CONCLUSION

Efforts to reduce hernia backlog and expand the surgical workforce may have had an effect on intestinal obstruction epidemiology in Ghana. Increasing aging-related pathology and a higher risk of death in elderly patients suggest that improvement in geriatric surgical care is urgently needed.