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Kapanadze G, Berg J, Sun Y, Gerdin Wärnberg M. Facilitators and barriers impacting in-hospital Trauma Quality Improvement Program (TQIP) implementation across country income levels: a scoping review. BMJ Open 2023; 13:e068219. [PMID: 36806064 PMCID: PMC9944272 DOI: 10.1136/bmjopen-2022-068219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
OBJECTIVE Trauma is a leading cause of mortality and morbidity globally, disproportionately affecting low/middle-income countries (LMICs). Understanding the factors determining implementation success for in-hospital Trauma Quality Improvement Programs (TQIPs) is critical to reducing the global trauma burden. We synthesised topical literature to identify key facilitators and barriers to in-hospital TQIP implementation across country income levels. DESIGN Scoping review. DATA SOURCES PubMed, Web of Science and Global Index Medicus databases were searched from June 2009 to January 2022. ELIGIBILITY CRITERIA Published literature involving any study design, written in English and evaluating any implemented in-hospital quality improvement programme in trauma populations worldwide. Literature that was non-English, unpublished and involved non-hospital TQIPs was excluded. DATA EXTRACTION AND SYNTHESIS Two reviewers completed a three-stage screening process using Covidence, with any discrepancies resolved through a third reviewer. Content analysis using the Consolidated Framework for Implementation Research identified facilitator and barrier themes for in-hospital TQIP implementation. RESULTS Twenty-eight studies met the eligibility criteria from 3923 studies identified. The most discussed in-hospital TQIPs in included literature were trauma registries. Facilitators and barriers were similar across all country income levels. The main facilitator themes identified were the prioritisation of staff education and training, strengthening stakeholder dialogue and providing standardised best-practice guidelines. The key barrier theme identified in LMICs was poor data quality, while high-income countries (HICs) had reduced communication across professional hierarchies. CONCLUSIONS Stakeholder prioritisation of in-hospital TQIPs, along with increased knowledge and consensus of trauma care best practices, are essential efforts to reduce the global trauma burden. The primary focus of future studies on in-hospital TQIPs in LMICs should target improving registry data quality, while interventions in HICs should target strengthening communication channels between healthcare professionals.
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Affiliation(s)
- George Kapanadze
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Johanna Berg
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Emergency and Internal Medicine, Skånes universitetssjukhus Malmö, Malmo, Sweden
| | - Yue Sun
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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Radan B, Ogendi J, Charyk Stewart T, Shkrum M. Implementation of a road traffic crash injury surveillance tool in a trauma referral hospital in Kisumu City, Western Kenya: Lessons learned from the pilot study. TRAFFIC INJURY PREVENTION 2022; 23:S155-S160. [PMID: 36095146 DOI: 10.1080/15389588.2022.2115295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Road traffic injury (RTI) is a major public health concern in Kenya with more than 13,000 deaths estimated annually. The primary objective of this study was to design and implement an injury surveillance tool for the collection of injury data, and assess the tool's feasibility for the development of a hospital-based trauma registry in a leading Kenyan referral hospital. Secondarily, an epidemiologic profile was created to characterize RTI in the region. METHODS An injury surveillance tool was developed and implemented, on a pilot basis, in a level 5 trauma hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), in Kisumu City, Western Kenya, for a 4-week period from 2019-07-15 to 2019-08-11. A descriptive statistical analysis summarized injury frequency counts and percentages. RESULTS Over the pilot phase, 371 patients had forms completed, but 488 official injury-related hospital registrations, indicating that 117 injury patients (24%) were missed. A process evaluation of the tool implementation revealed issues in the collection protocol that required revisions, resulting in improved data form completeness rates. For the 368 cases with cause documented, the most common mechanisms of injury were RTI (46.5%; n = 171), assaults (23.9%; n = 88), and falls (14.9%; n = 55). For RTI patients, the median age was 28 years (IQR = 16) and 77% (n = 132) were males, with motorbike collision injuries (n = 91; 53.2%) the leading RTI mechanism. There were 348 injuries for 171 patients. The most common anatomical regions for RTI were the lower limb 32.8% (n = 114), upper limb (15.2%; n = 53), followed by head lacerations 8.6% (n = 30) and concussions 7.2% (n = 25). Two-thirds of patients (n = 113; 66.1%) were discharged from ED, just over a quarter (n = 46; 26.9%) were admitted to hospital and 9 patients succumbed to RTI (5.3%). CONCLUSIONS This injury surveillance pilot study produced the first injury dataset in Kisumu City, demonstrating the significant magnitude of RTI in Western Kenya, the leading cause of injury for the region. This dataset can be replicated in other hospitals to create an injury surveillance system for the collection of trauma data, needed for the development of countermeasures for the reduction of trauma, as well as for quality initiatives to improve patient outcomes.
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Affiliation(s)
- Bojana Radan
- Department of Community and Family Medicine, University of Toronto, Toronto, Canada
| | - Japheths Ogendi
- School of Health Sciences, Mount Kenya University, Kigali, Rwanda
| | - Tanya Charyk Stewart
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Canada
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Michael Shkrum
- Department of Pathology and Laboratory Medicine, London Health Sciences Centre, London, Canada
- Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, Western University, London, Canada
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Alayande B, Chu KM, Jumbam DT, Kimto OE, Musa Danladi G, Niyukuri A, Anderson GA, El-Gabri D, Miranda E, Taye M, Tertong N, Yempabe T, Ntirenganya F, Byiringiro JC, Sule AZ, Kobusingye OC, Bekele A, Riviello RR. Disparities in Access to Trauma Care in Sub-Saharan Africa: a Narrative Review. CURRENT TRAUMA REPORTS 2022; 8:66-94. [PMID: 35692507 PMCID: PMC9168359 DOI: 10.1007/s40719-022-00229-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 02/02/2023]
Abstract
Purpose of Review Sub-Saharan Africa is a diverse context with a large burden of injury and trauma-related deaths. Relative to high-income contexts, most of the region is less mature in prehospital and facility-based trauma care, education and training, and trauma care quality assurance. The 2030 Agenda for Sustainable Development recognizes rising inequalities, both within and between countries as a deterrent to growth and development. While disparities in access to trauma care between the region and HICs are more commonly described, internal disparities are equally concerning. We performed a narrative review of internal disparities in trauma care access using a previously described conceptual model. Recent Findings A broad PubMed and EMBASE search from 2010 to 2021 restricted to 48 sub-Saharan African countries was performed. Records focused on disparities in access to trauma care were identified and mapped to de Jager’s four component framework. Search findings, input from contextual experts, comparisons based on other related research, and disaggregation of data helped inform the narrative. Only 21 studies were identified by formal search, with most focused on urban versus rural disparities in geographical access to trauma care. An additional 6 records were identified through citation searches and experts. Disparity in access to trauma care providers, detection of indications for trauma surgery, progression to trauma surgery, and quality care provision were thematically analyzed. No specific data on disparities in access to injury care for all four domains was available for more than half of the countries. From available data, socioeconomic status, geographical location, insurance, gender, and age were recognized disparity domains. South Africa has the most mature trauma systems. Across the region, high quality trauma care access is skewed towards the urban, insured, higher socioeconomic class adult. District hospitals are more poorly equipped and manned, and dedicated trauma centers, blood banks, and intensive care facilities are largely located within cities and in southern Africa. The largest geographical gaps in trauma care are presumably in central Africa, francophone West Africa, and conflict regions of East Africa. Disparities in trauma training opportunities, public–private disparities in provider availability, injury care provider migration, and several other factors contribute to this inequity. National trauma registries will play a role in internal inequity monitoring, and deliberate development implementation of National Surgical, Obstetrics, and Anesthesia plans will help address disparities. Human, systemic, and historical factors supporting these disparities including implicit and explicit bias must be clearly identified and addressed. Systems approaches, strategic trauma policy frameworks, and global and regional coalitions, as modelled by the Global Alliance for Care of the Injured and the Bellagio group, are key. Inequity in access can be reduced by prehospital initiatives, as used in Ghana, and community-based insurance, as modelled by Rwanda. Summary Sub-Saharan African countries have underdeveloped trauma systems. Consistent in the narrative is the rural-urban disparity in trauma care access and the disadvantage of the poor. Further research is needed in view of data disparity. Recognition of these disparities should drive creative equitable solutions and focused interventions, partnerships, accompaniment, and action. Supplementary Information The online version contains supplementary material available at 10.1007/s40719-022-00229-1.
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Affiliation(s)
- Barnabas Alayande
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Kathryn M. Chu
- Centre for Global Surgery, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University, Cape Town, South Africa
| | | | | | | | - Alliance Niyukuri
- Hope Africa University, Bujumbura, Burundi
- Mercy Surgeons-Burundi, Research Department, Bujumbura, Burundi
- Mercy James Center for Paediatric Surgery and Intensive Care-Blantyre, Blantyre, Malawi
| | - Geoffrey A. Anderson
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
| | - Deena El-Gabri
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Elizabeth Miranda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
| | - Mulat Taye
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ngyal Tertong
- International Fellow, Paediatric Orthopaedic Surgery Department of Orthopaedics, Sheffield Children’s Hospital, Sheffield, UK
| | - Tolgou Yempabe
- Orthopaedic and Trauma Unit, Department of Surgery, Tamale Teaching Hospital, Tamale, Ghana
| | - Faustin Ntirenganya
- University Teaching Hospital of Kigali, Kigali, Rwanda
- Department of Surgery, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
| | - Jean Claude Byiringiro
- University Teaching Hospital of Kigali, Kigali, Rwanda
- NIHR Research Hub On Global Surgery, University of Rwanda, Kigali, Rwanda
- School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | | | - Olive C. Kobusingye
- Makerere University School of Public Health, Kampala, Uganda
- George Institute for Global Health, Sydney, Australia
| | - Abebe Bekele
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Robert R. Riviello
- Center for Equity in Global Surgery, University of Global Health Equity, Kigali, Rwanda
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA USA
- Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA USA
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
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Abstract
ABSTRACT Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.
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Mobinizadeh M, Berenjian F, Mohamadi E, Habibi F, Olyaeemanesh A, Zendedel K, Sharif-Alhoseini M. Trauma Registry Data as a Policy-Making Tool: A Systematic Review on the Research Dimensions. Bull Emerg Trauma 2022; 10:49-58. [PMID: 35434165 PMCID: PMC9008338 DOI: 10.30476/beat.2021.91755.1286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/18/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: To review the research dimensions of trauma registry data on health policy making. Methods: PubMed and EMBASE were searched until July 2020. Keywords were used on the search process included Trauma, Injury, Registry and Research, which were searched by using appropriate search strategies. The included articles had to: 1. be extracted from data related to trauma registries; 2- be written in English; 3- define a time period and a patient population; 4- preferably have more details and policy recommendations; and 5- preferably have a discussion on how to improve diagnosis and treatment. The results obtained from the included studies were qualitatively analyzed using thematic synthesis and comparative tables. Results: In the primary round of search, 19559 studies were retrieved. According to PRISMA statement and also performing quality appraisal process, 30 studies were included in the final phase of analysis. In the final papers’ synthesis, 14 main research domains were extracted and classified in terms of the policy implication and research priority. The domains with the highest frequency were “The relationship between trauma registry data and hospital care protocols for trauma patients” and “The causes of Disability Adjusted Life Years (DALYs) due to trauma”. Conclusion: Using trauma registry data as a tool for policy-making could be helpful in several ways, namely increasing the quality of patient care, preventing injuries and decreasing their number, figuring out the details of socioeconomic status effects, and improving the quality of researches in practical ways. Also, follow-up of patients after trauma surgery as one of the positive effects of the trauma registry can be the focus of attention of policy-making bodies.
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Affiliation(s)
| | - Farzan Berenjian
- Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Efat Mohamadi
- Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran
| | - Farhad Habibi
- Department of Health Economics and Management, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Olyaeemanesh
- National Institute for Health Research and Health Equity Research Center (HERC), Tehran University of Medical Sciences, Tehran, Iran
| | - Kazem Zendedel
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
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Tanoli O, Ahmad H, Khan H, Khattak FA, Khan A, Mikhail A, Deckelbaum D, Razek T. A pilot trauma registry in Peshawar, Pakistan - A roadmap to decreasing the burden of injury - Quality improvement study. Ann Med Surg (Lond) 2021; 72:103137. [PMID: 34934485 PMCID: PMC8654792 DOI: 10.1016/j.amsu.2021.103137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND/LOCAL PROBLEM In Pakistan, trauma is a significant public health issue accounting for the second leading cause of disability and fifth for healthy years of life lost. Well-developed trauma systems, utilizing trauma registries, have been proven to decrease morbidity and mortality from injuries, and helped to reduce the number of injured patients. In Pakistan, most data on injury are acquired through methods that are retrospective, incomplete, and open to recall bias. To that end, a trauma registry was piloted at the Lady Reading Hospital (LRH) in Peshawar, Pakistan to elucidate the importance of trauma registries in designing healthcare targeted quality improvement initiatives. INTERVENTION Upon receiving ethics approval, a twenty-five-point registry was piloted at the Lady Reading Hospital. METHODS The pilot implementation was carried out from May 9th to May 13th, 2018. RESULTS A total of 267 patients were included in the pilot registry. Motor vehicle collisions were the most prevalent cause of injury (46%). The other causes of injury included falls (24%), blunt assaults (9%), stabs/cuts (8%), gunshots (6%), crush injuries (3%), burns (2%), and blasts/landmines (2%). Most patients were treated in the trauma bay and required no further acute intervention (51%). CONCLUSION This 5-day pilot trauma registry was the first of its kind in Peshawar, Pakistan, and despite its short course, an immense amount of data was garnered on the epidemiology of injury in the region. Significantly, the data collected can already be used to develop evidence-based changes, which will effectively minimize the impact of trauma.
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Affiliation(s)
- Omaid Tanoli
- McGill University Health Centre, Centre for Global Surgery, Montreal, Qc, Canada
- University of Toronto, Department of General Surgery, Toronto, On, Canada
| | - Hamza Ahmad
- McGill University Health Centre, Centre for Global Surgery, Montreal, Qc, Canada
| | - Haider Khan
- Bacha Khan Medical College, Mardan, Khyber Pakhtunkhwa, Pakistan
| | | | - Awais Khan
- Khyber Medical College, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Alexandre Mikhail
- University of Toronto, Department of General Surgery, Toronto, On, Canada
| | - Dan Deckelbaum
- McGill University Health Centre, Centre for Global Surgery, Montreal, Qc, Canada
| | - Tarek Razek
- McGill University Health Centre, Centre for Global Surgery, Montreal, Qc, Canada
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7
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Laytin AD, Seyoum N, Kassa S, Juillard CJ, Dicker RA. Patterns of injury at an Ethiopian referral hospital: Using an institutional trauma registry to inform injury prevention and systems strengthening. Afr J Emerg Med 2020; 10:58-63. [PMID: 32612909 PMCID: PMC7320203 DOI: 10.1016/j.afjem.2020.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 12/18/2019] [Accepted: 01/02/2020] [Indexed: 12/31/2022] Open
Abstract
Background Data about injury patterns and clinical outcomes are essential to address the burden of injury in low- and middle-income countries. Institutional trauma registries (ITRs) are a key tool for collecting epidemiologic data about injury. This study uses ITR data to describe the demographics and patterns of injury of trauma patients in Addis Ababa, Ethiopia in order to identify opportunities for injury prevention, systems strengthening and further research. Methods This is an analysis of prospectively collected data from a sustainable ITR at Menelik II Specialized Hospital, a public teaching hospital with trauma expertise. All patients presenting to the hospital with serious injuries requiring intervention or admission over a 13 month period were included. Univariable and bivariable analyses were performed for patient demographics and injury characteristics. Results A total of 854 patients with serious injuries were treated during the study period. Median age was 33 years and 74% were male. The most common mechanisms of injury were road traffic injuries (RTI) (37%), falls (30%) and blunt assault (17%). Over half of RTI victims were pedestrians. Median delay in presentation was 2 h; 17% of patients presented over 6 h after injury. 58% of patients were referred from another hospital or a clinic, and referrals accounted for 84% of patients arriving by ambulance. Median emergency center length of stay was 2 h and 62% of patients were discharged from the emergency center. Conclusion This study highlights the utility of institutional trauma registries in collecting crucial injury surveillance data. In Addis Ababa, road safety is an important target for injury prevention. Our findings suggest that the most severely injured patients may not be making it to the referral centers with the capacity to treat their injuries, thus efforts to improve prehospital care and triage are needed. African relevance Injury is a public health priority in Africa. Institutional trauma registries play a crucial role in efforts to improve trauma care by describing injury epidemiology to identify targets for injury prevention and systems strengthening efforts. In our context, pedestrian safety is a key target for injury prevention. Improving prehospital care and developing referral networks are goals for systems strengthening.
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Prakash I, Neves O, Cumbe E, Hamadani F, Razek T, Fata P, Beckett A, Khwaja K, Grushka J, Wong EG, Jacobe M, de Costa A, Deckelbaum DL, Yohannan P. The Financial Burden of Road Traffic Injuries in Mozambique: A Hospital-Related Cost-of-Illness Study of Maputo Central Hospital. World J Surg 2019; 43:2959-2966. [PMID: 31506715 DOI: 10.1007/s00268-019-05152-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Road traffic injuries (RTIs) are increasingly being recognized for their significant economic impact. Mozambique, like other low-income countries, suffers staggering rates of road traffic collisions. To our knowledge, this is the first study to estimate direct hospital costs of RTIs using a bottom-up, micro-costing approach in the Mozambican context. This study aims to calculate the direct, inpatient costs of RTIs in Mozambique and compare it to the financial capacity of the Mozambican public health care system. METHODS This was a retrospective, single-centre study. Charts of all patients with RTIs admitted to Maputo Central Hospital over a period of 2 months were reviewed. The costs were recorded and analysed based on direct costs, human resource costs, and overhead costs. Costs were calculated using a micro-costing approach. RESULTS In total, 114 patients were admitted and treated for RTIs at Maputo Central Hospital during June-July 2015. On average, the hospital cost per patient was US$ 604.28 (IQR 1033.58). Of this, 44% was related to procedural costs, 23% to diagnostic imaging costs, 17% to length-of-stay costs, 9% to medication costs, and 7% to laboratory test costs. The average annual inpatient cost of RTIs in Mozambique was almost US$ 116 million (0.8% of GDP). CONCLUSION The financial burden of RTIs in Mozambique represents approximately 40% of the annual public health care budget. These results help highlight the economic impact of trauma in Mozambique and the importance of an organized trauma system to reduce such costs.
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Affiliation(s)
- Ipshita Prakash
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.,Centre for Global Surgery, McGill University, Montreal, QC, Canada
| | | | - Eduardo Cumbe
- Department of Surgery, Maputo Central Hospital, Maputo, Mozambique
| | - Fadi Hamadani
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.,Centre for Global Surgery, McGill University, Montreal, QC, Canada
| | - Tarek Razek
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.,Centre for Global Surgery, McGill University, Montreal, QC, Canada
| | - Paola Fata
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Andrew Beckett
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Kosar Khwaja
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Jeremy Grushka
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
| | - Evan G Wong
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada.,Centre for Global Surgery, McGill University, Montreal, QC, Canada
| | - Mario Jacobe
- Department of Surgery, Maputo Central Hospital, Maputo, Mozambique
| | - Assis de Costa
- Department of Surgery, Maputo Central Hospital, Maputo, Mozambique
| | - Dan L Deckelbaum
- Department of Surgery, Montreal General Hospital, McGill University, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada. .,Centre for Global Surgery, McGill University, Montreal, QC, Canada.
| | - Prem Yohannan
- Department of Surgery, Maputo Central Hospital, Maputo, Mozambique
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