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Serrato P, Msosa V, Kondwani J, Nkhumbwah M, Brault MA, Heckmann R, Weiner S, Sion M, Mulima G. Perioperative Process Mapping to Identify Inefficiencies at a Tertiary Hospital in Malawi. J Surg Res 2024; 302:329-338. [PMID: 39126874 DOI: 10.1016/j.jss.2024.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/07/2024] [Accepted: 07/03/2024] [Indexed: 08/12/2024]
Abstract
INTRODUCTION Same-day surgical case cancellation consumes resources, disrupts patient care, and has a global prevalence of 18%. A retrospective analysis found that 44% of scheduled elective surgeries were canceled at a public tertiary hospital in Lilongwe, Malawi. To better characterize these cancellations, this study defines a process map for surgical case completion and investigates hospital staff and patient perspectives on contributing factors and burdens of cancellation. METHODS We conducted participatory process mapping and in-depth interviews with hospital staff (n = 23) and patients (n = 10) to detail perioperative processes and perspectives on cancellations. We used purposive sampling to recruit staff by hospital role and patients whose surgery had been canceled. Interviews were audio-recorded, translated, and transcribed for process mapping accuracy and thematic analysis using the constant comparative method and NVivo software. RESULTS Staff delineated specific steps of the perioperative process, generating a process map that identifies inefficiencies and opportunities for intervention. Hospital staff described unavoidable causes of case cancellation, such as unreliable water supply and material shortages. Modifiable causes linked to wasted time and resources were also evident, such as chronic tardiness, communication barriers, and inadequate preoperative assessment. Thematic analysis of perceived impacts of cancellation revealed compromised provider-patient relationships, communication breakdown, and emotional distress. Staff and patients expressed frustration, embarrassment, fear, and demoralization when planned surgeries were canceled. CONCLUSIONS We demonstrate the use of process mapping as a tool to identify implementation targets for reducing case cancellation rates. Hospital systems can adapt this approach to address surgical case cancellation in their specific setting.
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Affiliation(s)
- Paul Serrato
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Vanessa Msosa
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Jephta Kondwani
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Mwai Nkhumbwah
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Marie A Brault
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut; Department of Health Promotion and Behavioral Sciences, University of Texas Health Science Center at Houston School of Public Health, San Antonio, Texas
| | - Rebekah Heckmann
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sally Weiner
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut
| | - Melanie Sion
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut.
| | - Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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Gajewski J, Pittalis C, Borgstein E, Bijlmakers L, Mwapasa G, Cheelo M, Juma A, Sardana M, Brugha R. Critical shortage of capacity to deliver safe paediatric surgery in sub-Saharan Africa: evidence from 67 hospitals in Malawi, Zambia, and Tanzania. Front Pediatr 2023; 11:1189676. [PMID: 37325346 PMCID: PMC10265866 DOI: 10.3389/fped.2023.1189676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/18/2023] [Indexed: 06/17/2023] Open
Abstract
Introduction Paediatric surgical care is a significant challenge in Sub-Saharan Africa (SSA), where 42% of the population are children. Building paediatric surgical capacity to meet SSA country needs is a priority. This study aimed to assess district hospital paediatric surgical capacity in three countries: Malawi, Tanzania and Zambia (MTZ). Methods Data from 67 district-level hospitals in MTZ were collected using a PediPIPES survey tool. Its five components are procedures, personnel, infrastructure, equipment, and supplies. A PediPIPES Index was calculated for each country, and a two-tailed analysis of variance test was used to explore cross-country comparisons. Results Similar paediatric surgical capacity index scores and shortages were observed across countries, greater in Malawi and less in Tanzania. Almost all hospitals reported the capacity to perform common minor surgical procedures and less complex resuscitation interventions. Capacity to undertake common abdominal, orthopaedic and urogenital procedures varied-more often reported in Malawi and less often in Tanzania. There were no paediatric or general surgeons or anaesthesiologists at district hospitals. General medical officers with some training to do surgery on children were present (more often in Zambia). Paediatric surgical equipment and supplies were poor in all three countries. Malawi district hospitals had the poorest supply of electricity and water. Conclusions With no specialists in district hospitals in MTZ, access to safe paediatric surgery is compromised, aggravated by shortages of infrastructure, equipment and supplies. Significant investments are required to address these shortfalls. SSA countries need to define what procedures are appropriate to national, referral and district hospital levels and ensure that an appropriate paediatric surgical workforce is in place at district hospitals, trained and supervised to undertake these essential surgical procedures so as to meet population needs.
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Affiliation(s)
- Jakub Gajewski
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
| | - Chiara Pittalis
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eric Borgstein
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Leon Bijlmakers
- Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerald Mwapasa
- Department of Surgery, College of Medicine Malawi, Blantyre, Malawi
| | - Mweene Cheelo
- Surgical Society of Zambia, University Teaching Hospital Lusaka, Lusaka, Zambia
| | - Adinan Juma
- East Central and Southern Africa Health Community, Arusha, Tanzania
| | - Muskan Sardana
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruairi Brugha
- Institute of Global Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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Laudanski K, Wain J, Pizzini MA. An In-Depth Analysis of Providers and Services of Cancellation in Anesthesia Reveals a Complex Picture after Systemic Analysis. Healthcare (Basel) 2023; 11:healthcare11030357. [PMID: 36766932 PMCID: PMC9914780 DOI: 10.3390/healthcare11030357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/02/2023] [Accepted: 01/03/2023] [Indexed: 01/28/2023] Open
Abstract
The variances in operating room (OR) cancellation rates between different service lines and operators within these service lines were assessed by reviewing the electronic medical record (EMR) covering 34,561 cases performed by 199 OR operators in 2018. We assumed that cancellations would differ between different service lines, but the between-operators variance was minimal within the service line. We hypothesized that most variability would be secondary to patient-specific (weekdays, time of year, and national holidays), seasonal and administrative issues. Of 4165 case cancellations, the majority (73.1%) occurred before the patient arrived at the hospital. A total of 60% of all cancellations were within gastroenterology, interventional cardiology, and orthopedics. Cancellation rate variability between surgeons operating within the same service line greatly varied between services from very homogenous to very diverse across providers. The top reasons for cancellation were: date change, canceled by a patient, or "no show". The highest cancellation rates occurred on Mondays and Tuesdays, in January and September, and during weeks associated with national holidays. In summary, cancellation variability must be analyzed at the level of individual specialties, operators, and time variability.
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Affiliation(s)
- Krzysztof Laudanski
- Department of Anesthesiology and Perioperative Care, Mayo Clinic, Rochester, MN 55905, USA
- Correspondence: ; Tel.: +1-(815)-483-4779
| | - Justin Wain
- School of Osteopathic Medicine, Campbell University, Lillington, NC 27546, USA
| | - Mark-Alan Pizzini
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Mac Quene T, Smith L, Odland ML, Levine S, D'Ambruoso L, Davies J, Chu K. Prioritising and mapping barriers to achieve equitable surgical care in South Africa: a multi-disciplinary stakeholder workshop. Glob Health Action 2022; 15:2067395. [PMID: 35730572 PMCID: PMC9225684 DOI: 10.1080/16549716.2022.2067395] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical healthcare in South Africa is inequitable with a considerable lack of resources in the public health sector. Identifying barriers to care and creating research priorities to mitigate these barriers can contribute to strategic interventions to improve equitable access to quality surgical care. OBJECTIVE To use the Four Delays Framework to map barriers to surgical care and identify priorities to achieve equitable and timely access to quality surgical care in South Africa. METHODS A multi-disciplinary stakeholder workshop was held in Cape Town, South Africa in January 2020. A Four Delays Framework (delays in seeking care, reaching care, receiving care, and remaining in care) was used to identify barriers that occur at each delay and the top 10 priorities for intervention. Barriers were categorised into overarching themes and schematically mapped. RESULTS Thirty-four stakeholders including health service users, health service providers, and community members participated in this exercise. In total, 34 barriers were identified with 73 connections to various delays. Specifically, 14 barriers were related to delays in seeking care, 11 were related to delays in reaching care, 20 were related to delays in receiving care, and 28 were related to delays in remaining in care. The highest priority barriers across the delays were Lack of service provider's knowledge, training and experience, and Limited surgical outreach. The barrier Lack of decentralised services was related to all four delays. Barriers were interconnected and potentially reinforcing. CONCLUSIONS This workshop is the first of its kind to generate evidence on the delays to surgical care in South Africa. Mapping crucial interconnected, potentially reinforcing barriers, and priority interventions demonstrated how a multifaceted approach may be required to address delays to access. Further research focused on the identified priorities will contribute to efforts to promote equitable access to quality surgical care in South Africa.
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Affiliation(s)
- Tamlyn Mac Quene
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Luné Smith
- Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Maria Lisa Odland
- Institute for Applied Health Research, University of Birmingham, Birmingham, UK
| | - Susan Levine
- Department of Anthropology, Humanities Faculty, University of Cape Town, Cape Town, South Africa
| | - Lucia D'Ambruoso
- Aberdeen Centre for Health Data Science, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, Scotland, UK
| | - Justine Davies
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.,Institute for Applied Health Research, University of Birmingham, Birmingham, UK.,Faculty of Health Sciences, Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, University of Witwatersrand, Johannesburg, South Africa
| | - Kathryn Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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Efthymiou CA, Cale AR. Implications of equipment failure occurring during surgery. Ann R Coll Surg Engl 2022; 104:678-684. [PMID: 35446701 PMCID: PMC9685966 DOI: 10.1308/rcsann.2021.0345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Few formal studies have been performed investigating the frequency of equipment failure during surgery. Surgeons are unable to operate without the plethora of instruments and equipment surrounding them in the operating theatre. As with any mechanical component, instruments and equipment are subject to time- and use-dependent degradation in their performance. Yet no formal requirements exist for the routine inspection or maintenance of instruments. Owing to this lack of information regarding equipment failure we undertook the first investigation of intraoperative equipment malfunction occurring during cardiac surgical procedures. METHODS Over a 12-month period cardiac surgeons were required to report equipment malfunction during each procedure. Operating theatre equipment was divided into three categories broadly based on equipment portability and function: group 1, theatre infrastructure and components; group 2, large medical equipment; and group 3, surgical instruments. RESULTS In a highly significant proportion of operations performed (92%) there was an issue with equipment. The most common issues occurred in group 3 with fine surgical instrument malfunctions; most commonly worn-out needle holders and blunt scissors. Theatre infrastructure and large medical equipment failures (groups 1 and 2) resulted in the cancellation of four cases. Some intraoperative instrument failures were potentially catastrophic. CONCLUSIONS The incidence of equipment failure during cardiac surgery is unacceptably high. In some instances, cases were cancelled and revenue lost owing to equipment malfunction. A balance between the safety and quality of equipment and cost effectiveness is required. These findings suggest that surgical instruments warrant an annual compulsory inspection.
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Affiliation(s)
| | - AR Cale
- Hull University Teaching Hospitals NHS Trust, UK
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Negash S, Anberber E, Ayele B, Ashebir Z, Abate A, Bitew S, Derbew M, Weiser TG, Starr N, Mammo TN. Operating room efficiency in a low resource setting: a pilot study from a large tertiary referral center in Ethiopia. Patient Saf Surg 2022; 16:3. [PMID: 34996487 PMCID: PMC8742370 DOI: 10.1186/s13037-021-00314-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 12/13/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The operating room (OR) is one of the most expensive areas of a hospital, requiring large capital and recurring investments, and necessitating efficient throughput to reduce costs per patient encounter. On top of increasing costs, inefficient utilization of operating rooms results in prolonged waiting lists, high rate of cancellation, frustration of OR personnel as well as increased anxiety that negatively impacts the health of patients. This problem is magnified in developing countries, where there is a high unmet surgical need. However, no system currently exists to assess operating room utilization in Ethiopia. METHODOLOGY A prospective study was conducted over a period of 3 months (May 1 to July 31, 2019) in a tertiary hospital. Surgical case start time, end time, room turnover time, cancellations and reason for cancellation were observed to evaluate the efficiency of eight operating rooms. RESULTS A total of 933 elective procedures were observed during the study period. Of these, 246 were cancelled, yielding a cancellation rate of 35.8%. The most common reasons for cancellation were related to lack of OR time and patient preparation (8.7% and 7.7% respectively). Shortage of facilities (instrument, blood, ICU bed) were causes of cancelation in 7.7%. Start time was delayed in 93.4% (mean 8:56 am ± 52 min) of cases. Last case completion time was early in 47.9% and delayed in 20.6% (mean 2:54 pm ± 156 min). Turnover time was prolonged in 34.5% (mean 25 min ± 49 min). Total operating room utilization ranged from 10.5% to 174%. Operating rooms were underutilized in 42.7% while overutilization was found in 14.6%. CONCLUSION We found a high cancellation rate, most attributable to late start times leading to delays for the remainder of cases, and lack of preoperative patient preparation. In a setting with a high unmet burden of surgical disease, OR efficiency must be maximized with improved patient evaluation workflows, adequate OR staffing and commitment to punctual start times. We recommend future quality improvement projects focusing on these areas to increase OR efficiency.
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Affiliation(s)
- Samuel Negash
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia.
| | - Endale Anberber
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
| | - Blen Ayele
- Department of Anesthesia, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zeweter Ashebir
- Department of Anesthesia, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ananya Abate
- Department of Anesthesia, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Miliard Derbew
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
- Lifebox Foundation, London, UK
| | - Thomas G Weiser
- Lifebox Foundation, London, UK
- Department of Surgery, University of Edinburgh, Edinburgh, UK
- Department of Surgery, Stanford University, Stanford, USA
| | - Nichole Starr
- Lifebox Foundation, London, UK
- Department of Surgery, University of California San Francisco, San Francisco, USA
| | - Tihitena Negussie Mammo
- Department of Surgery, Addis Ababa University, Addis Ababa, Ethiopia
- Lifebox Foundation, London, UK
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Bakker J, van Duinen AJ, Nolet WWE, Mboma P, Sam T, van den Broek A, Flinkenflögel M, Gjøra A, Lindheim-Minde B, Kamanda S, Koroma AP, Bolkan HA. Barriers to increase surgical productivity in Sierra Leone: a qualitative study. BMJ Open 2021; 11:e056784. [PMID: 34933865 PMCID: PMC8693091 DOI: 10.1136/bmjopen-2021-056784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To explore factors influencing surgical provider productivity and identify barriers against and opportunities to increase individual surgical productivity in Sierra Leone, in order to explain the observed increase in unmet surgical need from 92.2% to 92.7% and the decrease in surgical productivity to 1.7 surgical procedures per provider per week between 2012 and 2017. DESIGN AND METHODS This explanatory qualitative study consisted of in-depth interviews about factors influencing surgical productivity in Sierra Leone. Interviews were analysed with a thematic network analysis and used to develop a conceptual framework. PARTICIPANTS AND SETTING 21 surgical providers and hospital managers working in 12 public and private non-profit hospitals in all regions in Sierra Leone. RESULTS Surgical providers in Sierra Leone experience a broad range of factors within and outside the health system that influence their productivity. The main barriers involve both patient and facility financial constraints, lack of equipment and supplies, weak regulation of providers and facilities and a small surgical workforce, which experiences a lack of recognition. Initiation of a Free Health Care Initiative for obstetric and paediatric care, collaborations with partners or non-governmental organisations, and increased training opportunities for highly motivated surgical providers are identified as opportunities to increase productivity. DISCUSSION Broader nationwide health system strengthening is required to facilitate an increase in surgical productivity and meet surgical needs in Sierra Leone. Development of a national strategy for surgery, obstetrics and anaesthesia, including methods to reduce financial barriers for patients, improve supply-mechanisms and expand training opportunities for new and established surgical providers can increase surgical capacity. Establishment of legal frameworks and appropriate remuneration are crucial for sustainability and retention of surgical health workers.
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Affiliation(s)
- Juul Bakker
- Royal Tropical Institute, Amsterdam, The Netherlands
- CapaCare, Trondheim, Norway
| | - A J van Duinen
- CapaCare, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olavs Hospital University Hospital, Trondheim, Norway
| | | | - Peter Mboma
- Pujehun Government Hospital, Pujehun, Sierra Leone
| | - Tamba Sam
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | | | | | - Andreas Gjøra
- CapaCare, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Barbro Lindheim-Minde
- CapaCare, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Samuel Kamanda
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - Alimamy P Koroma
- Department of Obstetrics and Gynaecology, Princess Christian Maternity Hospital, Freetown, Sierra Leone
| | - H A Bolkan
- CapaCare, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Surgery, St Olavs Hospital University Hospital, Trondheim, Norway
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Assessing the Rates and Reasons of Elective Surgical Cancellations on the Day of Surgery: A Multicentre Study from Urban Indian Hospitals. World J Surg 2021; 46:382-390. [PMID: 34787712 PMCID: PMC8724145 DOI: 10.1007/s00268-021-06364-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2021] [Indexed: 12/05/2022]
Abstract
Background Cancellations of elective surgeries on the day of surgery (DOS) can lead to added financial burden and wastage of resources for healthcare facilities; as well as social and emotional problems to patients. These cancellations act as barriers to delivering efficient surgical services. Optimal utilisation of the available resources is necessary for resource-constrained low-and-middle-income countries (LMIC). This study investigates the rate and causes of cancellations of elective surgeries on the DOS in various surgical departments across ten hospitals in India. Methods A research consortium ‘IndSurg’ led by World Health Organisation Collaboration Centre (WHOCC) for Research in Surgical Care Delivery in LMICs, India conducted this multicentre retrospective cross-sectional study to analyse the cancellations of elective/planned surgical operations on DOS across urban secondary and tertiary level hospitals. We audited surgical records of a pre-decided period of six weeks for cancellations, documented relevant demographic information and reasons for cancellations. Results We analysed records from the participating hospitals, with an overall cancellation rate of 9.7% (508/5231) on the DOS for elective surgical operations. Of these, 74% were avoidable cancellations. A majority (30%) of these 508 cancellations were attributed to insufficient resources, 28% due to patient's refusal or failure to show-up, and 22% due to change in patient's medical status. Conclusion We saw a preponderance of avoidable reasons for elective surgery cancellations. A multidisciplinary approach with adequate preoperative patient counselling, timely communication between the patients and caregivers, adequate preoperative anaesthetic assessment, and planning by the surgical team may help reduce the cancellation rate.
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Gallaher J, Kayange L, Purcell LN, Reid T, Charles A. Are Surgeons Enough? The Relationship between Increasing Surgical Demand and Access to Surgery in a Resource-Limited Environment. J Surg Res 2021; 267:569-576. [PMID: 34265600 DOI: 10.1016/j.jss.2021.06.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/25/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The relationship between increasing surgical demand and access to operative intervention remains unclear in delivering general surgical care in resource-limited settings, where demand often exceeds capacity. We sought to characterize the association between general surgery patient volume and operative intervention at a tertiary hospital in Malawi, which has an adequate surgical workforce. METHODS We analyzed patients admitted to Kamuzu Central Hospital Lilongwe, Malawi, with a general surgery complaint from 2018-2020. We examined the relationship between the census at the time of admission, the use of operative intervention, and the time to operative intervention. The patient census was defined as low (≤30 patients), medium (31-49 patients), and high (≥50 patients), based on historical patterns. RESULTS 2,701 patients were included. The mean daily census was 46 patients (SD 10). For the medium and high census, the adjusted risk ratio of undergoing surgery was 0.86 (95% CI 0.78, 0.95) and 0.81 (95% CI 0.73, 0.90), respectively, adjusted for admission diagnosis. For patients requiring urgent abdominal exploration, at a census of 25, the adjusted mean time to operation was 0.8 days (95% CI 0.1, 1.5) compared to 2.8 days (95% CI 2.1, 3.5) at a census of 65 patients. CONCLUSIONS Despite an adequate surgical workforce, an increasing mean daily census significantly reduced the use of operative intervention and increased time to operation for patients who needed urgent abdominal exploration. Additional improvements in the surgical ecosystem beyond surgeons are necessary to improve surgical access.
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Affiliation(s)
- Jared Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Linda Kayange
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Laura N Purcell
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Trista Reid
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA; Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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Blaise Pascal FN, Malisawa A, Barratt-Due A, Namboya F, Pollach G. General anaesthesia related mortality in a limited resource settings region: a retrospective study in two teaching hospitals of Butembo. BMC Anesthesiol 2021; 21:60. [PMID: 33622245 PMCID: PMC7901086 DOI: 10.1186/s12871-021-01280-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 02/15/2021] [Indexed: 12/05/2022] Open
Abstract
Background General anaesthesia (GA) in developing countries is still a high-risk practice, especially in Africa, accompanied with high morbidity and mortality. No study has yet been conducted in Butembo in the Democratic Republic of the Congo to determine the mortality related to GA practice. The main objective of this study was to assess mortality related to GA in Butembo. Methods This was a retrospective descriptive and analytic study of patients who underwent surgery under GA in the 2 main teaching hospitals of Butembo from January 2011 to December 2015. Data were collected from patients files, anaesthesia registries and were analysed with SPSS 26. Results From a total of 921 patients, 539 (58.5%) were male and 382 (41.5%) female patients. A total of 83 (9.0%) patients died representing an overall perioperative mortality rate of 90 per 1000. Out of the 83 deaths, 38 occurred within 24 h representing GA related mortality of 41 per 1000. There was a global drop in mortality from 2011 to 2015. The risk factors of death were: being a neonate or a senior adult, emergency operation, ASA physical status > 2 and a single deranged vital sign preoperatively, presenting any complication during GA, anaesthesia duration > 120 minutes as well as visceral surgeries/laparotomies. Ketamine was the most employed anaesthetic. Conclusion GA related mortality is very high in Butembo. Improved GA services and outcomes can be obtained by training more anaesthesia providers, proper patients monitoring, improved infrastructure, better equipment and drugs procurement and considering regional anaesthesia whenever possible.
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Affiliation(s)
- Furaha Nzanzu Blaise Pascal
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi. .,Faculty of Medicine, Université Catholique du Graben, Butembo, Democratic Republic of the Congo.
| | - Agnes Malisawa
- Matanda Hospital of Butembo, Butembo, Democratic Republic of the Congo
| | - Andreas Barratt-Due
- Division of Emergencies and Critical Care, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Felix Namboya
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gregor Pollach
- Department of Anaesthesia and Intensive Care, College of Medicine, University of Malawi, Blantyre, Malawi
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Birhanu Y, Endalamaw A, Adu A. Root causes of elective surgical case cancellation in Ethiopia: a systematic review and meta-analysis. Patient Saf Surg 2020; 14:46. [PMID: 33298136 PMCID: PMC7727239 DOI: 10.1186/s13037-020-00271-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 11/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cancellation of elective surgical operation recognized as a major cause of emotional trauma to patients as well as their families. In Ethiopia, prevalence and root causes for elective surgical case cancellation varies from time to time in different settings. This systematic review and meta-analysis aimed to find the pooled prevalence and root causes for elective surgical case cancellation in Ethiopia. METHODS The databases for the search were Web of Science, PubMed, and Google Scholar. The last literature search was performed on February 8, 2020. To assess publication bias Egger's regression analysis was applied. The pooled estimation was estimated using random-effects model meta-analysis. Subgroup analysis was also done based on the root causes of surgical case cancellation. RESULTS This meta-analysis included a total of 5 studies with 5591 study participants. The pooled prevalence of elective surgical case cancellation was 21.41% (95% CI: 12.75 to 30.06%). Administration-related reason (34.50%) was the most common identified root cause, followed by surgeon (25.29%), medical (13.90%), and patient-related reasons (13.34%). CONCLUSION The prevalence of elective surgical case cancellation was considerable. The most common root cause for elective surgical case cancellation was administration-related reasons, followed by the surgeon, medical and patient-related reasons. The causes for the surgical cancellations are potentially preventable. Thus, efforts should be made to prevent unnecessary cancellations through careful planning.
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Affiliation(s)
- Yeneabat Birhanu
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Aklilu Endalamaw
- Department of Pediatrics and Child Health Nursing, School of Health Sciences, College of Medicine and Health Sciences, Bahir Dar University, Bahir Dar, Ethiopia
| | - Aynalem Adu
- Department of Surgical Nursing, School of Nursing, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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12
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Postoperative Complications and Risk of Mortality after Laparotomy in a Resource-Limited Setting. J Surg Res 2020; 260:428-435. [PMID: 33272596 DOI: 10.1016/j.jss.2020.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 09/09/2020] [Accepted: 11/01/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Despite increases in surgical capacity in Malawi, minimal data exist on postoperative complications. Identifying surgical management gaps and targeting quality improvement requires detailed, longitudinal complications, and outcome data that assess surgical safety and efficacy. METHODS We conducted a 6-mo prospective, observational study of patients >12 y after laparotomy at a tertiary hospital in Lilongwe, Malawi. Outcomes included postoperative complications and mortality. The seniormost rounding physician determined complication diagnoses. Bivariate and Poisson regression analyses identified predictors of mortality. RESULTS Only patients undergoing emergent laparotomy (77.8%) died before discharge, so analysis excluded elective cases. Of 189 patients included, the median age was 33.5 y (IQR 22-50.5), 22 (12.2%) had prior abdominal surgery, and 11 (12.1%) were human immunodeficiency virus-positive. Gastrointestinal perforation was the most common diagnosis (35.5%). The most common procedures were primary gastrointestinal repair (24.9%), diverting ostomy (21.2%), and bowel resection with anastomosis (16.4%). Overall postoperative mortality was 14.8%. Intra-abdominal complication occurred in 17 (9.0%) patients, of whom 8 (47.1%) died. Older age (RR 1.05, 95% CI 1.02-1.08, P < 0.001) and intra-abdominal complication (RR 2.88, 95% CI 1.28-6.46, P = 0.01) increased the relative risk of mortality. Preoperative diagnosis, surgical intervention type, and symptom-to-surgery time did not increase the relative risk of mortality. CONCLUSIONS The incidence of complications and mortality after laparotomy at a large referral hospital in Malawi is high. Older age and intra-abdominal complications increase the risk of death. Strategies to improve operative mortality in Malawi should prioritize postoperative surveillance and management and continued outcomes reporting.
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13
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Bobrowski A, Nayan M, Heimrath O, Goche D, Ludzu E, Singal RK. Supply the demand: Assessment of the feasibility of local nonurologists in relieving the burden of chronic indwelling catheters in a low-income country. Can Urol Assoc J 2020; 15:E261-E266. [PMID: 33939602 DOI: 10.5489/cuaj.6576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Despite the high prevalence rates of urinary retention in sub-Saharan Africa, regional deficiencies in urological care have culminated in inadequate medical management and a backlog of urology cases. Our study examined the efficacy and safety of a surgical camp enlisting local non-urologists performing simple open prostatectomy on the rate of chronic catheter usage secondary to urinary retention. METHODS We reported on a prospective case series of patients with chronic indwelling catheters who underwent open simple prostatectomy during a one-week urology camp in the Machinga District of Malawi. All operations were performed by a locally trained general surgeon and a clinical officer. RESULTS Twenty-three (47.9%) of 48 male patients with urinary retention assessed for eligibility for open simple prostatectomy were deemed eligible and underwent the procedure. Of the patients who underwent an open simple prostatectomy, histopathological findings demonstrated benign prostatic hyperplasia in 19 patients (82.6%), while six patients (26.1%) had coincidental malignancy. At postoperative followup, the entire cohort was catheter-free and reported regular sexual activity and the ability to return to work, while 87.0% noted improvements in social integration and 34.8% cited higher self-esteem. Two patients required treatment for infection and one patient experienced fascial dehiscence. Two months following prostatectomy, all patients were catheter-free and able to void independently. CONCLUSIONS Local surgical practitioners without formal urology training can successfully perform open simple prostatectomy to relieve patients of chronic indwelling catheters and assist in addressing the disease burden in a low-resource setting.
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Affiliation(s)
- Adam Bobrowski
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Madhur Nayan
- Division of Urology, Department of Surgery, University of Toronto, ON, Canada
| | - Olivier Heimrath
- Division of Urology, Department of Surgery, University of Toronto, ON, Canada.,Division of Urology, Michael Garron Hospital, Toronto, ON, Canada
| | - Duncan Goche
- Department of Surgery, Zomba Central Hospital, Zomba, Southeastern Region, Malawi
| | - Enok Ludzu
- Department of Surgery, Zomba Central Hospital, Zomba, Southeastern Region, Malawi
| | - Rajiv K Singal
- Division of Urology, Department of Surgery, University of Toronto, ON, Canada.,Division of Urology, Michael Garron Hospital, Toronto, ON, Canada
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14
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Sommer JL, Noh E, Jacobsohn E, Christodoulou C, El-Gabalawy R. An examination of difficulties accessing surgical care in Canada from 2005-2014: Results from the Canadian Community Health Survey. PLoS One 2020; 15:e0240083. [PMID: 33085681 PMCID: PMC7577481 DOI: 10.1371/journal.pone.0240083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 09/19/2020] [Indexed: 12/04/2022] Open
Abstract
Background Difficulties accessing surgical care (e.g., related to wait times, cancellations, cost, receiving a diagnosis) are understudied in Canada. Using population-based data, we studied difficulty accessing non-emergency surgical care, including (1) the incidence and annual changes in incidence, (2) types of difficulties, and (3) associated factors (e.g., sociodemographics, surgery characteristics). Methods Cross-sectional data from the Canadian Community Health Survey annual components were analyzed from 2005–2014. Weighted frequencies established the annual incidence of difficulty accessing surgical care, and total incidence of types of difficulties. Chi-square analyses, independent samples t-tests, and a multivariable logistic regression examined sociodemographic and surgery-related characteristics associated with difficulty accessing surgical care. Results Among individuals who required past-year non-emergency surgery between 2005–2014 (weighted n = 3,052,072), 15.6% experienced difficulty accessing surgical care. The most common difficulty was “waited too long for surgery” (58.5%). There were significant differences in the incidence of difficulty according to year (Χ2 = 83.50, p < .001) from 2005–2014. The incidence of difficulty accessing surgery varied according to sex (Χ2 = 4.02, p < .05), surgery type (Χ2 = 96.09, p < .001), party responsible for cancellation/postponement (Χ2 range: 4.36–19.01, p < .05), and waiting time (t = 10.59, p < .001). In particular, males, orthopedic surgery, and surgery cancelled by the surgeon or hospital had the highest rates of difficulty. Conclusion Results provide insight into the difficulties experienced by patients accessing elective surgery, and the associated factors. These results may inform targeted healthcare interventions and resource reallocation to reduce these occurrences.
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Affiliation(s)
- Jordana Liyat Sommer
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Edward Noh
- Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric Jacobsohn
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Chris Christodoulou
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Renée El-Gabalawy
- Department of Anesthesiology, Perioperative and Pain Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Health Psychology, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Psychiatry, University of Manitoba, Winnipeg, Manitoba, Canada
- * E-mail:
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15
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Sommer JL, Jacobsohn E, El-Gabalawy R. Impacts of elective surgical cancellations and postponements in Canada. Can J Anaesth 2020; 68:315-323. [PMID: 33085061 PMCID: PMC7575861 DOI: 10.1007/s12630-020-01824-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/25/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022] Open
Abstract
Purpose Worldwide, patients experience difficulties accessing elective surgical care. This study examined the perceived health, social, and functional impacts of elective surgical cancellations and postponements in Canada. Methods We analyzed a subset of aggregate data from the Canadian Community Health Survey (CCHS) annual components from 2005 to 2014. Multivariable logistic regressions examined associations between past-year non-emergency surgical cancellations/postponements and perceived impacts of waiting for surgery (e.g., worry/stress/anxiety, pain, loss of work, loss of income, deterioration of health, relationships suffered). Results Among those who experienced a cancellation or postponement of a past-year non-emergency surgery (weighted n = 256,836; 11.8%), 23.5% (weighted n = 60,345) indicated their life was affected by waiting for surgery. After adjusting for type of surgery, year, and sociodemographics, those who experienced a surgical cancellation or postponement had increased odds of reporting their life was affected by waiting for surgery (adjusted odds ratio [aOR], 2.67; 99% confidence interval [CI], 1.41 to 5.1); in particular, they reported greater deterioration of their health (aOR, 3.47; 99% CI, 1.05 to 11.4) and increased dependence on relatives/friends (aOR, 2.53; 99% CI, 1.01 to 6.3) than those who did not have a cancellation or postponement. Conclusion Results highlight the multifaceted perceived impacts of surgical cancellations/postponements. These findings suggest there is a need for improvements in reducing elective surgical cancellations and postponements. Results may also inform the development of targeted interventions to improve patients’ health and quality of life while waiting for surgery.
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Affiliation(s)
- Jordana L Sommer
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, AE211, Harry Medovy House, 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, Canada
| | - Eric Jacobsohn
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, AE211, Harry Medovy House, 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada
| | - Renée El-Gabalawy
- Department of Anesthesiology, Perioperative and Pain Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, AE211, Harry Medovy House, 671 William Avenue, Winnipeg, MB, R3E 0Z2, Canada.
- Department of Psychology, Faculty of Arts, University of Manitoba, Winnipeg, Canada.
- Department of Clinical Health Psychology, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Psychiatry, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
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16
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Zhu LF, Qian WY, Zhou G, Yang M, Lin JJ, Jin JL, Dong SJ, Zhu LH, Chen HX. Applying Lean Six Sigma to Reduce the Incidence of Unplanned Surgery Cancellation at a Large Comprehensive Tertiary Hospital in China. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020953997. [PMID: 32880500 PMCID: PMC7649947 DOI: 10.1177/0046958020953997] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Unplanned surgery cancellation (USC) was an important quality management issue in the course of medical care for surgical patients, which caused inappropriate use of hospital resources and had negative impacts on quality and safety. This study used Lean Six Sigma to reduce the incidence of USC. Following the Lean Six Sigma DMAIC (Define, Measure, Analyze, Improve, and Control) process, the main factors influencing the USC were identified, such as the time of informing patient admission, the time of submitting operation notice, and the management of test report follow-up. A series of measures were implemented including improving the health education content of virtual bed patients, standardizing the way of communication between the Admission Management Center and the patients, improving the timing of anesthesia evaluation, optimizing the process of operation notice with an information system, and implementing the regulations of virtual bed management. The incidence of USC reduced from 10.21% in Jan. 2016 to 3.8% in Dec. 2016, and the Z-score increased from 1.25 to 1.68, which improved patient safety and demonstrated that Lean Six Sigma was an effective method to solve cross-department issues in hospital.
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Affiliation(s)
- Ling-Feng Zhu
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Wei-Yang Qian
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Gang Zhou
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Min Yang
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Jing-Jing Lin
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Jing-Ling Jin
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Shu-Jing Dong
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Lin-Hong Zhu
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
| | - Hai-Xiao Chen
- Taizhou Hospital of Zhejiang Province affiliated to Wenzhou Medical University, Linhai, China
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Purcell LN, Robinson B, Msosa V, Gallaher J, Charles A. District General Hospital Surgical Capacity and Mortality Trends in Patients with Acute Abdomen in Malawi. World J Surg 2020; 44:2108-2115. [PMID: 32166470 PMCID: PMC7292121 DOI: 10.1007/s00268-020-05468-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The burden of emergency general surgery conditions is high in sub-Saharan Africa, and poor access to surgical care leads to poor patient outcomes. We examined the trends in mortality in patients presenting with an acute abdomen to a referral hospital. METHODS A retrospective analysis of the prospectively collected Kamuzu Central Hospital Acute Care Surgery database was performed (January 2014 to July 2019). Bivariate analysis was conducted by year of admission. A multivariate Poisson regression was performed to identify predictors of mortality. RESULTS During the study, 2509 patients with acute abdomen presented. The majority of patients presenting were transferred from outside hospitals (n = 2097, 83.9%). Mortality was highest in patients with preoperative diagnosis of peritonitis (n = 119, 22.2%), bowel obstruction (n = 214, 18.7%), and volvuli (n = 51, 18.6%). There was no difference in mortality by year, p = 0.1. On multivariate Poisson regression, there was an increased relative risk of mortality with being transferred (RR 1.31, 95% CI 1.12-1.55, p = 0.002), as well as undergoing an operation within 1-2 days (RR 1.48, 95% CI 1.16-1.87, p < 0.001) and >2 days (RR 1.46, 95% CI 1.17-1.82, p = 0.001) after presentation. CONCLUSION The majority of patients in our study who presented with an acute abdomen were transferred from district hospitals, which resulted in high mortality due to delays in surgical care. Therefore, the WHO's recommendation that the majority of district hospitals perform the Bellwether procedures does not occur in district hospitals in central Malawi. District hospitals require significant resource investment to reduce transfers needs and patient mortality.
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Affiliation(s)
- Laura N Purcell
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | - Brittany Robinson
- School of Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Jared Gallaher
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA
| | - Anthony Charles
- Department of Surgery, UNC School of Medicine, University of North Carolina at Chapel Hill, 4008 Burnett Womack Building, CB 7228, Chapel Hill, USA.
- Kamuzu Central Hospital, Lilongwe, Malawi.
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18
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Gallaher JR, Varela C, Purcell LN, Maine R, Charles A. Diurnal variation in trauma mortality in sub-Saharan Africa: A proxy for health care system maturity. Injury 2020; 51:97-102. [PMID: 31761427 PMCID: PMC6939627 DOI: 10.1016/j.injury.2019.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 10/22/2019] [Accepted: 11/08/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. However, trauma centers in these environments have limited resources to manage complex trauma with minimal staffing and diagnostic tools. These limitations may be exacerbated at night. We hypothesized that there is an increase in trauma-associated mortality for patients presenting during nighttime hours. METHODS We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma registry in Lilongwe, Malawi from January 2012 through December 2016. Nighttime was defined as 18:00 until 5:59. Patients brought in dead were excluded. A modified Poisson regression model was used to calculate the relationship between presentation at night and mortality, adjusted for significant confounders. RESULTS 74,500 patients were included. During the day, crude mortality was 0.8% compared to 1.4% at night (p < 0.001). The risk ratio of mortality following night time presentation compared to day was 1.90 (95% CI 1.48, 2.42) when adjusted for injury severity, assessed by the Malawi Trauma Score (MTS), and transfer status. When stratified by the year of traumatic injury, the risk ratio of death decreased each year from 2012-2014 but increased in 2015. There was no difference in 2016. CONCLUSIONS We report the first description of diurnal variation in trauma-associated mortality in sub-Saharan Africa. Injured patients who presented at night had nearly twice the adjusted risk ratio of death compared to patients that presented during the daytime although there were yearly differences. Diurnal variation in trauma-associated mortality is a simple but important indicator of the maturity of a trauma system and should be tracked for health care system improvement.
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Affiliation(s)
- Jared R Gallaher
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carlos Varela
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Laura N Purcell
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Rebecca Maine
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA,Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Anthony Charles
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA,Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
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Bath M, Bashford T, Fitzgerald JE. What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health. BMJ Glob Health 2019; 4:e001808. [PMID: 31749997 PMCID: PMC6830053 DOI: 10.1136/bmjgh-2019-001808] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/20/2019] [Accepted: 09/28/2019] [Indexed: 12/11/2022] Open
Abstract
'Global surgery' is the term adopted to describe a rapidly developing multidisciplinary field aiming to provide improved and equitable surgical care across international health systems. Sitting at the interface between numerous clinical and non-clinical specialisms, it encompasses multiple aspects that surround the treatment of surgical disease and its equitable provision across health systems globally. From defining the role of, and need for, optimal surgical care through to identifying barriers and implementing improvement, global surgery has an expansive remit. Advocacy, education, research and clinical components can all involve surgeons, anaesthetists, nurses and allied healthcare professionals working together with non-clinicians, including policy makers, epidemiologists and economists. Long neglected as a topic within the global and public health arenas, an increasing awareness of the extreme disparities internationally has driven greater engagement. Not necessarily restricted to specific diseases, populations or geographical regions, these disparities have led to a particular focus on surgical care in low-income and middle-income countries with the greatest burden and needs. This review considers the major factors defining the interface between surgery, anaesthesia and public health in these settings.
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Affiliation(s)
- Michael Bath
- Centre for Neuroscience, Surgery, and Trauma, Queen Mary University of London, London, UK
| | - Tom Bashford
- NIHR Global Health Research Group on Neurotrauma, Division of Anaesthesia, University of Cambridge, Cambridge, UK
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20
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Rajaguru PP, Jusabani MA, Massawe H, Temu R, Sheth NP. Understanding surgical care delivery in Sub-Saharan Africa: a cross-sectional analysis of surgical volume, operations, and financing at a tertiary referral hospital in rural Tanzania. Glob Health Res Policy 2019; 4:30. [PMID: 31673630 PMCID: PMC6816166 DOI: 10.1186/s41256-019-0122-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 10/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Access to surgical care in Low- and Middle-Income Countries (LMICs) such as Tanzania is extremely limited. Northern Tanzania is served by a single tertiary referral hospital, Kilimanjaro Christian Medical Centre (KCMC). The surgical volumes, workflow, and payment mechanisms in this region have not been characterized. Understanding these factors is critical in expanding access to healthcare. The authors sought to evaluate the operations and financing of the main operating theaters at KCMC in Sub-Saharan Africa. Methods The 2018 case volume and specialty distribution (general, orthopaedic, and gynecology) in the main operating theaters at KCMC was retrieved through retrospective review of operating report books. Detailed workflow (i.e. planned and cancelled cases, lengths of procedures, lengths of operating days) and financing data (patient payment methods) from the five KCMC operating theater logs were retrospectively reviewed for the available five-month period of March 2018 to July 2018. Descriptive statistics and statistical analysis were performed. Results In 2018, the main operating theaters at KCMC performed 3817 total procedures, with elective procedures (2385) outnumbering emergency procedures (1432). General surgery (1927) was the most operated specialty, followed by orthopaedics (1371) and gynecology (519). In the five-month subset analysis period, just 54.6% of planned operating days were fully completed. There were 238 cancellations (20.8% of planned operations). Time constraints (31.1%, 74 cases) was the largest reason; lack of patient payment accounted for as many cancellations as unavailable equipment (6.3%, 15 cases each). Financing for elective theater cases included insurance 45.5% (418 patients), and cash 48.4% (445 patients). Conclusion While surgical volume is high, there are non-physical inefficiencies in the system that can be addressed to reduce cancellations and improve capacity. Improving physical resources is not enough to improve access to care in this region, and likely in many LMIC settings. Patient financing and workflow will be critical considerations to truly improve access to surgical care.
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Affiliation(s)
- Praveen Paul Rajaguru
- 1Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA USA
| | | | - Honest Massawe
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Rogers Temu
- Department of Orthopaedic Surgery, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Neil Perry Sheth
- 3Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA USA
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Abstract
BACKGROUND Surgical care is essential to improving population health, but metrics to monitor and evaluate the continuum of surgical care delivery have rarely been applied in low-resource settings, and improved efforts at benchmarking progress are needed. The objective of this study was to measure the intraoperative mortality at a Central Referral Hospital in Malawi, evaluate whether there have been changes in intraoperative mortality between 2 time periods, and assess factors associated with intraoperative mortality. METHODS This was a retrospective cohort study of patients undergoing surgery at Kamuzu Central Hospital in Lilongwe, Malawi. Data describing daily consecutive operative cases were collected prospectively during 2 time periods: 2004-2006 (early cohort) and 2015-2016 (late cohort). The primary outcome was intraoperative mortality. Inverse probability of treatment weighting was used to analyze the association of intraoperative mortality with time using logistic regression models. Multivariable logistic models were performed to evaluate factors associated with intraoperative mortality. RESULTS There were 21,090 surgeries performed during the 2 time periods, with 15,846 (75%) and 5244 (25%) completed from 2004 to 2006 and 2015 to 2016, respectively. Intraoperative mortality in the early cohort was 57 deaths per 100,000 surgeries (95% confidence interval [CI], 26-108) and in the late cohort was 133 per 100,000 surgeries (95% CI, 56-286), with 76 per 100,000 surgeries (95% CI, 44-124) overall. After applying inverse probability of treatment weighting, there was no evidence of an association between time periods and intraoperative mortality (odds ratio [OR], 1.6; 95% CI, 0.9-2.8; P = .08). Factors associated with intraoperative mortality, adjusting for demographics, included American Society of Anesthesiology physical status III or IV versus I or II (OR, 4.4; 95% CI, 1.5-12.5; P = .006) and emergency versus elective surgery (OR, 7.7; 95% CI, 2.5-23.6; P < .001). CONCLUSIONS Intraoperative mortality in the study hospital in Malawi is high and has not improved over time. These data demonstrate an urgent need to improve the safety and quality of perioperative care in developing countries and integrate perioperative care into global health efforts.
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Affiliation(s)
- Meghan Prin
- From the Department of Anesthesiology and Critical Care, Columbia University College of Physicians and Surgeons, New York, New York
| | - Stephanie Pan
- Department of Biostatistics, Icahn School of Medicine at Mt Sinai, New York, New York
| | - Janey Phelps
- Department of Anesthesiology and Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Godfrey Phiri
- Department of Anesthesiology, Kamuzu Central Hospital, Lilongwe, Malawi
| | - Guohua Li
- Department of Anesthesiology, Columbia University College of Physicians and Surgeons, New York, New York
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, New York
| | - Anthony Charles
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Desta M, Manaye A, Tefera A, Worku A, Wale A, Mebrat A, Gobena N. Incidence and causes of cancellations of elective operation on the intended day of surgery at a tertiary referral academic medical center in Ethiopia. Patient Saf Surg 2018; 12:25. [PMID: 30154916 PMCID: PMC6109985 DOI: 10.1186/s13037-018-0171-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/20/2018] [Indexed: 11/10/2022] Open
Abstract
Background Elective surgical case cancellation refers to any elective surgical case that is the list on the day prior to surgery but not operated upon as scheduled. Case cancellation has a major cause of psychological trauma to patients and their families. Despite little is known in Ethiopia. Therefore, this study aimed to assess incidence and reasons of cancellations of elective operation on the intended day of surgery at tertiary referral academic medical center in Ethiopia. Methods A prospective hospital-based cross-sectional study design was conducted in a tertiary referral academic medical center in Ethiopia among 146 participants. A self-administered questionnaire with an observatory checklist was used for collecting data from the anesthetist, nurse, and surgeons. Result In this study, 462 patients were scheduled for elective surgical operations. Among those, nearly almost one-third 146 (31.6%) of the operations were cancelled and 316 (68.4%) patients were operated on their planned date. The most common reason for cancellation were surgeon related (35.8%), patient related (28.7%), management related (21.2%) and anesthesia related factors (14. 4%). The cancellation was mainly due to improper scheduling (20.5%%), unavailability of surgeons (8.9%), unavailability of oxygen and blood (8%) and equipment (5.5%). Orthopedic (28.8%) and general surgery (17.1%) were the commonest cancelled cases. Conclusion The cancellation rate in our academic medical center remains high. Improper scheduling, unavailability of surgeons, medical illness, and unavailability of operating room equipment were the commonest reason for the cancellation of elective operation. Most cancellations were preventable. For this, proper preoperative assessment, proper scheduling, fulfilling necessary operating room equipment's and cross-matched blood by the hospital and other stakeholders, early clear communication with operating room team like surgeons was recommended.
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Affiliation(s)
- Melaku Desta
- 1College of Health Science, Department of midwifery, Debre Markos University, PO. Box: 269, Debre Markos, Ethiopia
| | - Addissu Manaye
- 2College of medicine and Health Science, Department of Anesthesia, Hawassa University, Hawassa, Ethiopia
| | - Abiot Tefera
- 2College of medicine and Health Science, Department of Anesthesia, Hawassa University, Hawassa, Ethiopia
| | - Atalay Worku
- 2College of medicine and Health Science, Department of Anesthesia, Hawassa University, Hawassa, Ethiopia
| | - Alemitu Wale
- 2College of medicine and Health Science, Department of Anesthesia, Hawassa University, Hawassa, Ethiopia
| | - Alemlanchi Mebrat
- 2College of medicine and Health Science, Department of Anesthesia, Hawassa University, Hawassa, Ethiopia
| | - Negesso Gobena
- 3College of Medicine and Health Sciences, Lecturer and Senior Anesthetist, Hawassa University, Hawassa, Ethiopia
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