Accountability in global surgery missions

Coordination and Pilot Implementation of a Standardized Data Collection for Touching Hands

PURPOSE

Touching Hands is an American Society for Surgery of the Hand program that provides hand surgeries to the world's underserved communities. The purpose of this study was to develop and implement a systematic data collection method for Touching Hands to assess patient outcomes, volunteer impact, alleviated disease burden, and cost-effectiveness.

METHODS

Research electronic data capture (REDCap) was used as the secure software platform to facilitate data collection. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire was used to assess pre-and postoperative patient-reported outcomes. The Maslach Burnout Inventory-Human Services (Medical Personnel) survey was administered to volunteers before and after the mission to measure impact on volunteers. Case information was collected to calculate disability-adjusted life years and cost-effectiveness.

RESULTS

The data collection system was implemented in some capacity in 4 domestic and 3 international mission sites during 2020 and 2021.

CONCLUSIONS

Substantial limitations exist for the implementation of a systematic data collection framework for Touching Hands and warrant further modification and optimization.

CLINICAL RELEVANCE

A REDCap database can be used for standardized and centralized patient and volunteer data collection for Touching Hands missions.

Factors Associated With Lack of Long-Term Follow-Up Data After Global Cardiac Surgery Missions

Background: Humanitarian medical missions attempt to lessen the burden of limited access to cardiac surgery in low- and middle-income countries. While organizations express difficulties obtaining follow-up information, there is currently little evidence to support the various assumptions for lack of data. This study examines the factors influencing long-term patient follow-ups on repeated short-term cardiac surgery missions across nine countries. Methods: A retrospective analysis of CardioStart International's database (RedCap) was conducted to investigate demographic, socioeconomic, and surgical factors associated with follow-ups. Results: A total of 550 pediatric (50%) and adult (50%) cardiac surgery patients displayed a follow-up rate of 14.7%, with no significant difference between populations (P = 1). Mean follow-up time was 1.5 years postoperative. Countries were highly variable, with Dominican Republic and Vietnam showing follow-up rates of 30.4% and 43.2%, respectively, while Brazil, Nepal, and Tanzania had no follow-ups (P < 0.0001). The 11 surrogate factors for socioeconomic status, including home amenities and technology access, were predominantly insignificant, with the exception of phone access showing an unexpectedly decreased follow-up rate (11.6%, P = 0.006). Surgical intervention was a significant factor (P = 0.009). No adult cardiac surgery trends were noted; however, congenital cases demonstrated increased follow-ups in patients with higher Risk Adjusted Congenital Heart Surgery scores, with ventricular septal defects (32.5%) exceeding atrial septal defects (7.3%). Conclusions: Follow-ups correlate with mission factors, including location and types of intervention, more so than previously assumed socioeconomic and technological factors. Thus, certain missions may require more allocation of resources and adapted organizational policies to overcome site-specific barriers to follow-up.

Global Neurosurgery Advances From Trenches to Bedside: Lessons From Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response

INTRODUCTION

War has influenced the evolution of global neurosurgery throughout the past century. Armed conflict and mass casualty disasters (MCDs), including Humanitarian Assistance Disaster Relief missions, require military surgeons to innovate to meet extreme demands. However, the military medical apparatus is seldom integrated into the civilian health care sector. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses. In this paper, we explore how wars and MCD have influenced innovations of growing interest in the resource-limited settings of global neurosurgery.

METHODS

We performed a narrative review of the literature examining the influence of wars and MCD on contemporary global neurosurgery practices.

RESULTS

Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, the implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, the use of combat body armor, and the rise of damage control neurosurgery. In addition to promoting task-shifting and task-sharing, workforce shortages during wars and disasters contributed to the establishment of the physician assistant/physician associate profession in the USA. Low- and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges-ubiquitous in low-resource settings-have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk.

CONCLUSION

War and MCDs have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military and subsequently spread to the civilian sector as military neurosurgeons and reservist civilian neurosurgeons returned from the battlefront or other low-resource locations. Military neurosurgeons have utilized their experience in low-resource settings to make volunteer global neurosurgery efforts in LMICs successful. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.

Pediatric Otolaryngology Short-Term Mission Outcomes at a Surgical Mission Hospital in Guatemala

OBJECTIVE

The frequency of humanitarian surgical mission trips has grown over recent decades. Unfortunately, research on patient outcomes from these trips has not increased proportionately. We aim to analyze the safety and efficacy of surgeries in a low- and middle-income country missions-based surgery center in Guatemala City, Guatemala, and identify factors that influence surgical outcomes.

STUDY DESIGN

Retrospective cohort study.

SETTING

Guatemalan surgery center is called the Moore Center.

METHODS

Pediatric patients underwent otolaryngology surgery between 2017 and 2019. All patients required follow up. We analyzed the effect of patient, surgical, and geographic factors on follow up and complications with univariate and multivariate analyses.

RESULTS

 A total of 1094 otolaryngologic surgeries were performed between 2017 to 2019, which comprised 37.4% adenotonsillectomies, 26.8% cleft lip (CL)/cleft palate (CP) repairs, 13.6% otologic, and 20% "other" surgeries. Patients traveled on average 88 km to the center (±164 km). Eighty-nine percent attended their first follow up and 55% attended their second. The 11% who missed their first follow up lived farther from the center (p < .001) and had a higher ASA classification (p < .001) than the 89% who did attend. Sixty-nine (6.3%) patients had 1 or more complications. CL/CP surgery was associated with more complications than other procedures (p < .001). Of 416 tonsillectomies, 4 patients (1%) had a bleeding episode with 2 requiring reoperation.

CONCLUSION

This surgical center models effective surgical care in low-resource areas. Complications and follow-up length vary by diagnosis. Areas to improve include retaining complex patients for follow up and reducing complications for CL/CP repair.

Unmet Surgical Needs and Trust Deficit in Marginalized Communities in India: A Comparative Cross-Sectional Survey

INTRODUCTION

We carried out a household study of surgical unmet needs and trust in the physician and perception of quality in the health system in a rural Tribal area and an urban slum in India.

METHODS

A community-based, cross-sectional study was carried out in a Tribal and in an urban slum in Gujarat, India. We surveyed 7914 people in 2066 households in urban slum and 5180 people of 1036 households in rural Tribal area. The Surgeons Overseas Assessment of Surgical need was used to identify surgical met and unmet needs. Two instruments for trust deficit 'the Socio-culturally Competent Trust in Physician Scale for a Developing Country Setting' and 'Patient perceptions of quality' were also administered to understand perception about healthcare. Frequencies and proportions (categorical variable) summarized utilization of surgical services and surgical needs. P < 0.05 was statistically significant.

RESULTS

Slums and Tribal areas were significantly different in sociodemographic indicators. Unmet surgical needs in Tribal area were less than 5% versus 39% in the urban slum. Major need of surgery in Tribal area was for eye conditions in older population, while surgical conditions in extremities and abdomen were predominant in the urban area. Trust level was high for physicians in both areas.

CONCLUSIONS

Surgical unmet needs were significantly lower in Tribal versus urban area, possibly due to high priority given by the Indian government to alleviate poverty, social deprivation and participation of NGOs. Our study will give impetus to study unmet surgical needs and formulation of health policies in India and low-and-middle- income countries.

Rates, Barriers, and Facilitators of Outcome Collection on Hand Surgery Outreach to Low- and Middle-Income Countries

BACKGROUND

Global outreach to low- and middle-income countries (LMICs) continues to grow in an effort to improve global health. The practice of quality measurement is empirically lacking from surgical outreach trips to LMICs, which may limit the safety and quality of care provided. Using convergent mixed-methods, we aimed to: (1) identify and evaluate barriers and facilitators to outcome measure collection; and (2) report the sample rate of such collection on hand surgery outreach trips to LMICs.

METHODS

Surgeons and administrators involved in hand surgery outreach trips completed a survey regarding rates of outcome measure collection and a semi-structured interview to explore barriers and facilitators of outcome collection. Survey data were reported descriptively. Interviews were recorded and transcribed, and excerpts were categorized according to the Pettigrew framework for strategic change (content, process, and context). Results were combined through convergent mixed-methods analysis.

RESULTS

Thirty-three participants completed the survey, and 21 participated in interviews. Rates of collection were the most common for total case number (83%) and patient mortality (65%). Longitudinal outcomes (eg, patient follow-up or time away from work) were less frequently recorded (9% and 4%, respectively). Content analysis revealed barriers related to each domain of the Pettigrew framework.

CONCLUSIONS

This analysis demonstrates low levels of outcome collection on outreach trips and identifies priority areas for improvement. Developing context-specific solutions aimed at addressing barriers (eg, resource/database availability) and promoting facilitators (eg, collaborative relationships) may encourage higher rates of collection, which stands to improve patient safety, quality of care, and accountability when conducting outreach trips to LMICs.

International Collaboration Trends in Facial Plastic and Reconstructive Surgery: A Systematic Bibliometric Scoping Review

Importance

Research in facial plastic and reconstructive surgery (FPRS) in the global health setting, especially in low- and middle-income countries (LMICs), is increasing year by year. As this work progresses, it will be crucial to include voices and perspectives of individuals living in the LMICs being studied.

Objective

To characterize and understand international collaborations in published literature on FPRS care in a global health setting and report patterns in whether these articles included authors from the LMICs in which the studies took place.

Evidence Review

A systematic bibliometric scoping review of articles in Scopus from 1971 to 2022 was performed using a set list of search terms; studies were included using predetermined inclusion and exclusion criteria. Studies met criteria for inclusion if the abstract or text contained information regarding surgeons from a different country performing surgery or conducting research in an LMIC within the domain of FPRS. Exclusion criteria were studies that did not mention a facial plastic or reconstructive surgery and studies where both an HIC and LMIC were not mentioned.

Findings

A total of 286 studies met criteria for inclusion. The highest percentage of studies (n = 72, 25.2%) were conducted across multiple countries. A total of 120 studies (41.9%) discussed cleft lip/palate. Overall, 141 studies (49.5%) included at least 1 author from the host LMIC; 89 (31.1%) had first authors from LMICs, and 72 (25.2%) had senior authors from LMICs. A total of 79 studies (27.6%) described humanitarian clinical service trips without mentioning research or education in the text. The remaining studies described research, education projects, or a combination. The published literature on humanitarian service trips had the lowest rate of inclusion of a first or senior author from the host LMICs.

Conclusions and Relevance

In this systematic bibliometric scoping review, findings showed a general trend of increased international work in the field of FPRS. However, there continues to be a paucity of inclusive authorship trends, with the majority of studies not including first or senior authors from LMICs. The findings presented here encourage new collaborations worldwide, as well as the improvement of existing efforts.

Patient Follow-up After Orthopaedic Outreach Trips - Do We Know Whether Patients are Improving?

Background

The burden of traumatic musculoskeletal injuries falls greatest on low- and middle-income countries (LMICs). To help address this burden, organizations host over 6,000 outreach trips annually, 20% of which are orthopaedic. Monitoring post-surgical outcomes is critical to ensuring care quality; however, the implementation of such monitoring is unknown. The purpose of this review is to identify published follow-up practices of short-term orthopaedic surgery outreach trips to LMICs.

Methods

We completed a systematic review of Pubmed, Web of Science, EMBASE, and ProQuest following PRISMA guidelines. Follow-up method, rate, duration, and types of outcomes measured along with barriers to follow-up were collected and reported.

Results

The initial search yielded 1,452 articles, 18 of which were eligible. The mean follow-up time was 5.4 months (range: 15 days-7 years). The mean follow-up rate was 65.8% (range: 22%-100%), the weighted rate was 57.5%. Fifteen studies reported follow-up at or after 3 months while eight studies reported follow-up at or after 9 months. Fifteen studies reported follow-up in person, three reported follow-up via phone call or SMS. Outcome reporting varied among mortality, complications, and patient-reported outcomes. The majority (75%) outlined barriers to follow-up, most commonly noting transportation and costs of follow-up to the patient.

Conclusions

There is minimal and heterogeneous public reporting of patient outcomes and follow-up after outreach trips to LMICs, limiting quality assessment and improvement. Future work should address the design and implementation of tools and guidelines to improve follow-up as well as outcome measurement to ensure provision of high-quality care.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00268-022-06630-w.

Reimagining diaspora diplomacy during the COVID-19 crisis in India

Diasporas are organized groups motivated by common cultural, ideological, political and religious values and common concerns for their countries of origin. Diaspora diplomacy has gained prominence worldwide, particularly in India, spurred by harrowing images of deaths and devastation due to the COVID-19 pandemic. A new generation of diaspora professionals modeled as social entrepreneurs uses collaborative and non-profit models to establish relationships with their counterparts to facilitate medical services and research. Teleradiology and telepsychiatry facilitate communication between diaspora members and their counterparts. We propose a common telehealth platform to standardize advice given by the Indian diaspora in the Global North as protocols change rapidly in acute pandemics. Consideration should be given to the well-known digital divide in India and other low- and middle-income countries. We advocate for diaspora members to train themselves in the art of global health diplomacy, to promote transparency and accountability in the collection of funds and a mandatory provision of outcome measurement by independent monitors rather than through social media. In the long run, Indian-Americans should play an active role in strengthening the domain of public health, which has historically been neglected in India, by focusing on the country's long-term infrastructure needs. The lessons learned from various diaspora efforts should be independently evaluated and recorded as best practice for future pandemics and humanitarian crises.

The Impact of the COVID-19 Pandemic on the Functionality of International Surgical Volunteer Organizations

Background

Surgical volunteer organizations have been severely limited during the ongoing coronavirus disease pandemic. Our purpose was to identify obstacles to surgical volunteer organizations secondary to COVID-19 and their responses.

Methods

Forty-one surgical volunteer organizations participated in a web-based survey (156 invited, 26% response rate). Respondents were separated into two groups: low donations surgical volunteer organizations (≤50% donations of previous year; n = 17) and high donations surgical volunteer organizations (≥75%; n = 24). Univariate analyses were used to compare the two cohorts.

Results

Of responding surgical volunteer organizations, 34 (83%) were unable to maintain full functionality due to COVID-19; 27% of high donations vs. 0% of low donations surgical volunteer organizations (p = 0.02). The three leading obstacles were finances/donations (78%), fewer volunteers (38%), and inadequate personal protective equipment (30%). In response, 39% of surgical volunteer organizations developed novel E-volunteering opportunities. For support, 85% of surgical volunteer organizations suggested monetary donations, 78% promotion through social media platforms, and 54% donation of personal protective equipment.

Conclusion

The majority of surgical volunteer organizations were unable to maintain full functionality due to stressors caused by COVID-19, including limitations on finances, volunteers, and personal protective equipment.

Epidemiology of Craniofacial Pathology in Northern Vietnam Using Digital Platforms: Utilization of Electronic Medical Records and an SMS-Based Reporting System in a Low-Middle Income Country

INTRODUCTION

Current disease surveillance in Vietnam relies on underdeveloped electronic medical record (EMR) systems, which are insufficient for timely standardized data collection about craniofacial and cleft pathologies. Concurrently, the World Bank reports Vietnamese mobile cellular subscription rates (per 100 people) of 128, some of the highest in the world. Herein, we discuss the development of a short messaging service (SMS)-based surveillance system based in Hanoi, Vietnam, and its utility in contrast to an EMR-based approach to craniofacial epidemiology study.

METHODS

Vietnam National Children's Hospital (VNCH) is a pediatric tertiary care center serving approximately 12 million children. Four plastic surgeons were trained in SMS data entry. The SMS database was designed using FrontlineSMS, a 2-way mobile gateway software application with automated messaging capabilities. The VNCH EMR database was queried for individual demographic data for patients seen by the department from 2010 to 2019.

RESULTS

A corrected prevalence for cleft lip and palate of 0.098% (1 in 1020 live births) was calculated based on EMR data. Six rural provinces greater than 150 km from Hanoi were found to be significantly (P < 0.01) underserved surgically by the VNCH. A significantly (P < 0.01) higher rate of Pierre Robin in Lang Son province and facial clefts in Ha Tinh province were identified. The prospective data collection system received 7 patient data sets over 4 months, resulting in a capture rate of 2.9%.

CONCLUSIONS

This feasibility study offers valuable insight into the true cleft and craniofacial prevalence in Vietnam and alternative methods to study in low- and middle-income countries.

Surveying unmet pediatric urological needs in low- and middle-income countries

INTRODUCTION

Access to pediatric urological surgery is low in low-and-middle income countries (LMICs). Pediatric Urological missions have often been undertaken without best practice guidelines. Many strides have been made in pediatric general surgery and other surgery but little in pediatric urology as a component of global surgery.

STUDY AIMS

The purpose of this study was to identify challenges to delivery of pediatric urological care in LMICs and make recommendations for its advancement.

STUDY DESIGN

An internet search for reports and websites was undertaken. Published surveys from Global Initiative for Children Surgery (GICS) and American Pediatric Surgical Association (APSA) were evaluated. We developed and administered an additional questionnaire. Respondents included LMIC pediatric surgeons, HIC pediatric surgeons and HIC pediatric urologists and LMIC urologists and general surgeons.

RESULTS

Most global surgical visits were short one-time visit, and respondents citing complex pediatric urologic patients as most neglected in LMICs with the main challenge reported as a lack of specialist surgeons, poor communication between groups and poor infrastructure. Local specialist training was universally recommended as the most effective way to address unmet needs, although the form of training was not clear.

DISCUSSION

Most published work has looked at global general surgery or pediatric general surgery ^{[1][2][3][6][8][11][13]} but little on pediatric urology. Most of the information provided was blog posts of social engagements but rarely did these websites provide information on the surgical experience, challenges and solutions gleaned overtime^{[41][43][44][45][56]} It is recognised by pediatric urologists, general urologists and pediatric surgeons that complex urologic anomalies are the most neglected among children's surgical conditions with a higher disability weight attributed to urologic conditions compared to anorectal conditions. ^{[6][8][14][27][31][36][46]}, yet there's little expertise on ground and many challenges to its advancement. This study was limited by the number of questions we could explore due to the need to make questions fewer and more concise.

CONCLUSIONS

Pediatric urological conditions remain among the most neglected in global surgery. Current missions face significant challenges that may result in suboptimal outcomes. A comprehensive effort to establish guidelines for these missions is imperative.

Outcomes Measurement in Global Hand Surgery

The global burden of musculoskeletal trauma is high. There is a need to improve access to safe, high-quality surgery in many low- and middle-income countries (LMICs). Numerous initiatives have taken aim at solving this underlying shortage in surgical care, including mission trips, academic programs, and international collaborations. However, much work remains to be done in LMICs compared with high-income countries (HICs). In HICs, the field of hand surgery has grown partially owing to the rigorous application of clinical research to examine outcomes and determine best practices. Patient-reported outcome measures (PROMs) have a key role as a valid patient-centered method of capturing symptoms and well-being. They have substantial promise in LMICs to understand patient symptom severity and quality of life better, monitor treatment success or failure, determine cost-effectiveness of procedures, and guide capacity building. Contextually appropriate PROMs can improve routine follow-up in LMICs and advance the practice and study of hand surgery worldwide.

Improving capacity and access to neurosurgery in sub-Saharan Africa using a twinning paradigm pioneered by the Swedish African Neurosurgical Collaboration

BACKGROUND

The unmet need for neurosurgery in sub-Saharan Africa is staggering. Resolving this requires strategies that synergize salient local resources with tailored foreign help. This study is a trial of a twinning model adopted by the Swedish African Neurosurgical Collaboration (SANC).

METHODS

A multi-step neurosurgical twinning technique, International Neurosurgical Twinning Modeled for Africa (INTIMA), developed through a collaboration between African and Swedish neurosurgical teams was adopted for a neurosurgical mission in March 2019. The pioneering steps are evaluated together with data of treated patients prospectively acquired using SPSS Chicago Inc., Version 23. Associations were analyzed using chi-square tests, while inferences were evaluated at 95% level of significance.

RESULTS

The SANC global neurosurgery mission targeted microsurgical brain tumor resection. Fifty-five patients were operated on during the mission and subsequent 3 months. Patients' ages ranged from 3 months to 69 years with a mean of 30.6 ± 2.1 years 95% CL. Seven cases were performed during the first mission, while 48 were performed after the mission. Compared to 3 months before SANC when only 9 brain tumors were resected, more tumors were resected (n = 25) within the 3 consecutive months from the mission (X² = 14.2, DF = 1, P = 0.000). Thirty-day mortality following tumor resection was also lower, X² = 4.8, DF = 1, P = 0.028.

CONCLUSION

Improvements in capacity and short-term outcome define our initial pioneering application of a neurosurgical twinning paradigm pioneered by SANC.

A prospective observational study of postoperative follow-ups and outcomes at a nonprofit, internationally supported pediatric surgery center in Guatemala

BACKGROUND

Global surgical access is unequally distributed, with the greatest surgical burden in low- and middle-income countries, where surgical care is often supplemented by nongovernmental organizations. Quality data from organizations providing this care are rarely collected or reported. The Moore Pediatric Surgery Center in Guatemala City, Guatemala, is unique in that it offers a permanently staffed, freestanding pediatric surgical center. Visiting surgical teams supplement the local permanent staff by providing a broad range of pediatric subspecialty surgical and anesthesia care.

AIM

The aim of this study was to collect and report the incidence of completed postoperative follow-up visits and outcome measures at this nonprofit, internationally supported surgery center.

METHODS

De-identified demographic and postoperative outcome data were collected from each routinely scheduled, one-week pediatric surgical mission trip and incorporated into an electronic data collection system. Emphasis was placed on identification of completed postoperative visits and associated perioperative complications. After 27 months of data collection, results were analyzed to identify and quantify trends in patient follow-ups and postoperative outcomes.

RESULTS

Over 27 months, 1639 pediatric surgical procedures were performed and included in data analysis. The percentage of completed postoperative day-1 follow-up visits was 99.1%, and seven complications were identified out of these 1624 cases (postoperative complication rate of 0.4%). The percentage of completed first postoperative visits after discharge was 93.3%, and 67 complications were identified out of these 1530 cases (postoperative complication rate of 4.4%).

CONCLUSION

Our data show a high rate of postoperative follow-up visits completed and low perioperative complication rates similar to those of high-income countries. Our data suggest that The Moore Surgery Center model of care offers an alternative to the short-term visiting surgical model by incorporating the local system and allows for improved follow-up, outcomes analysis, and high quality of care.

Anaesthesia care providers employed in humanitarian settings by Médecins Sans Frontières: a retrospective observational study of 173 084 surgical cases over 10 years

OBJECTIVE

To describe the extent to which different categories of anaesthesia provider are used in humanitarian surgical projects and to explore the volume and nature of their surgical workload.

DESIGN

Descriptive analysis using 10 years (2008-2017) of routine case-level data linked with routine programme-level data from surgical projects run exclusively by Médecins Sans Frontières-Operational Centre Brussels (MSF-OCB).

SETTING

Projects were in contexts of natural disaster (ND, entire expatriate team deployed by MSF-OCB), active conflict (AC) and stable healthcare gaps (HG). In AC and HG settings, MSF-OCB support pre-existing local facilities. Hospital facilities ranged from basic health centres with surgical capabilities to tertiary referral centres.

PARTICIPANTS

The full dataset included 178 814 surgical cases. These were categorised by most senior anaesthetic provider for the project, according to qualification: specialist physician anaesthesiologists, qualified nurse anaesthetists and uncertified anaesthesia providers.

PRIMARY OUTCOME MEASURE

Volume and nature of surgical workload of different anaesthesia providers.

RESULTS

Full routine data were available for 173 084 cases (96.8%): 2518 in ND, 42 225 in AC, 126 936 in HG. Anaesthesia was predominantly led by physician anaesthesiologists (100% in ND, 66% in AC and HG), then nurse anaesthetists (19% in AC and HG) or uncertified anaesthesia providers (15% in AC and HG). Across all settings and provider groups, patients were mostly healthy young adults (median age range 24-27 years), with predominantly females in HG contexts, and males in AC contexts. Overall intra-operative mortality was 0.2%.

CONCLUSION

Our findings contribute to existing knowledge of the nature of anaesthetic provision in humanitarian settings, while demonstrating the value of high-quality, routine data collection at scale in this sector. Further evaluation of perioperative outcomes associated with different models of humanitarian anaesthetic provision is required.

Patient Experience and Outcomes of the Locally Organized ApriDec Medical Outreach Group

BACKGROUND

Access to safe and effective surgery is limited in low and middle-income countries. Short-term surgical missions are a common platform to provide care, but the few published outcomes suggest unacceptable morbidity and mortality. We sought to study the safety and effectiveness of the ApriDec Medical Outreach Group (AMOG).

METHODS

Data from the December 2017 and April 2018 outreaches were prospectively collected. Patient demographics, characteristics of surgery, complications of surgery, and patient quality of life were collected preoperatively and on postoperative days 15 and 30. Data were analyzed to determine complication rates and trends in quality of life.

RESULTS

260/278 (93.5%) of patients completed a 30-day follow-up. Of these, surgical site infection was the most common complication (8.0%), followed by hematoma (4.1%). Rates of urinary tract infection were 1.2% while all other complications occurred in less than 1% of patients. There were no mortalities. With increasing time after surgery (0 to 15 days to 30 days), there was a significant improvement across each of the dimensions of quality of life (p < 0.001). All patients reported satisfaction with their procedure.

CONCLUSION

This study demonstrated that the care provided by AMOG group to the underserved populations of northern Ghana, yielded complication rates similar to others in low-resourced communities, leading to improved quality of life.

Reducing Surgical Site Infections During Otolaryngology Surgical Missions

OBJECTIVES

To determine what measures an otolaryngology-head and neck surgery team might adopt to decrease the incidence of surgical site infection (SSI) on a short-term surgical mission. Despite concerns about safety and efficacy, short-term surgical missions remain the predominant structure for humanitarian surgical care in low- and middle-income countries (LMIC). Hospitals in high-income countries strive to improve surgical outcomes through implementation of World Health Organization (WHO) safe surgery guidelines. Reduction of SSI risk is a key part of this effort.

METHODS

Literature review and practical experience.

RESULTS

WHO recommendations for reducing SSI are based largely on research done in the North America and Europe. LMIC populations are younger; comorbidities are fewer; infectious disease and trauma are prevalent; and delays in access to care are common. SSI are much more frequent in resource-limited settings. Recommendations regarding preoperative assessment, operating room environment, instrument sterilization, surgical antibiotic prophylaxis, surgical site preparation, gloving, draping, and postsurgical care are reviewed in the context of a surgical mission at a typical LMIC government hospital.

CONCLUSION

Many of the WHO guidelines on reduction of SSI are logical and applicable to the short-term surgical missions; others may need to be modified. Careful prospective data collection and clinical trials are needed to learn which interventions are valid and which should be changed.

LEVEL OF EVIDENCE

5 Laryngoscope, 130:1388-1395, 2020.