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Yager PH, Samost-Williams A, Bonilla JA, Guzman L, Hasbun SCA, Rodríguez AEA, Cárdena A, Núñez AML, Jayawardena ADL, Zablah EJ, Callans KM, Hartnick CJ. Sustainable improvement in upstream and downstream outcomes for intubated patients three years after an airway-based educational intervention in a low-resource pediatric intensive care unit. Int J Pediatr Otorhinolaryngol 2024; 182:112011. [PMID: 38865866 DOI: 10.1016/j.ijporl.2024.112011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 05/22/2024] [Accepted: 06/07/2024] [Indexed: 06/14/2024]
Abstract
OBJECTIVE To determine whether implementation of an education-based intervention can sustainably improve upstream and downstream outcomes in intubated patients in a pediatric intensive care unit (PICU) in a low-resource country. DESIGN Quality improvement study comparing airway-related morbidity in two previously studied patient cohorts pre-intervention (Epoch 1) and immediately post-intervention (Epoch 2) with a third cohort thirty-six months post-intervention (Epoch 3). SETTING PICU of the largest public children's hospital in El Salvador. PATIENTS 147 patients under 18 years requiring intubation and mechanical ventilation (MV) met inclusion criteria in the long-term follow-up period and were consecutively sampled without exclusion (Epoch 3) (compared to 98 previously studied patients in the short-term follow-up period (Epoch 2)). INTERVENTION A low-cost, education-based intervention to close knowledge gaps, improve communication among PICU doctors, nurses, and respiratory therapists, and optimize patient outcomes. MEASUREMENTS AND MAIN RESULTS The primary outcome measure was change in unplanned extubation (UE) between Epochs 2 and 3. Other outcomes included use of cuffed endotracheal tubes (ETT), rate of elective ETT change and days of MV. The 17 % decrease in UE previously reported for Epoch 2 was sustained in Epoch 3. There was a statistically significant increase in use of cuffed ETT from 35.7 % in Epoch 2-55.1 % in Epoch 3 (p = 0.003, z-score -2.99). There was also a statistically significant mean difference in rate of elective ETT change per 100 MV days from Epoch 2 to Epoch 3 of 1.7 (p = 0.007; 95 % CI 0.15-0.84). There was no change in MV days from Epoch 2 to Epoch 3 (p-value 0.764; 95 % CI -1.48-2.02). Beyond these quantifiable results, many unanticipated practice changes were observed three years after the initial intervention. CONCLUSIONS Sustained improvement in upstream and downstream outcomes (UE, cuffed ETT use, elective ETT change) for intubated patients in a low-resource PICU were observed three years after a low-cost, low-touch, education-based intervention.
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Affiliation(s)
- Phoebe H Yager
- Massachusetts General Hospital, Department of Pediatrics, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Aubrey Samost-Williams
- University of Texas Health Science Center at Houston, Department of Anesthesia, Critical Care, and Pain Medicine, MSB 5.020, 6431 Fannin St., Houston, TX, 77030, USA.
| | - Jose A Bonilla
- Hospital de Niños y Adolescentes Centro Pediatrico, Department of Pediatric Otolaryngology, Primera Planta Clinica #25, Colonia Medica, San Salvador, El Salvador.
| | - Luis Guzman
- Hospital Centro Pediátrico, Department of Pediatric Critical Care Medicine, Final Diagonal Dr. Luis Edmundo Vásquez, N°222, local N° 32 Colonia Medica, San Salvador, El Salvador.
| | - Susana C A Hasbun
- Hospital Centro Pediátrico, Department of Anesthesiology, Final Diagonal Dr. Luis Edmundo Vásquez, N°222, local N° 32 Colonia Medica, San Salvador, El Salvador.
| | - Angel E A Rodríguez
- Hospital Centro Pediátrico, Department of Pediatrics, Final Diagonal Dr. Luis Edmundo Vásquez, N°222, local N° 32 Colonia Medica, San Salvador, El Salvador
| | - Alejandra Cárdena
- Hospital Centro Pediátrico, Department of Pediatrics, Final Diagonal Dr. Luis Edmundo Vásquez, N°222, local N° 32 Colonia Medica, San Salvador, El Salvador.
| | - Alexia M L Núñez
- Instituto Tecnológico y de Estudios Superiores de Monterrey in Guadalajara, México. Avenida Aviacion 4304, El Real 65-M-1, Zapopan, Jalisco, Mexico
| | - Asitha D L Jayawardena
- Children's Minnesota, ENT & Facial Plastic Clinic, 2530 Chicago Avenue, Suite 450, Minneapolis, MN, 55404, USA.
| | - Evelyn J Zablah
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, 243 Charles Street, Boston, MA, 02114, USA.
| | - Kevin Mary Callans
- Massachusetts General Hospital, Department of Pediatrics, 55 Fruit Street, Boston, MA, 02114, USA; Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, 243 Charles Street, Boston, MA, 02114, USA.
| | - Christopher J Hartnick
- Massachusetts Eye and Ear Infirmary, Department of Otolaryngology, 243 Charles Street, Boston, MA, 02114, USA.
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Yager PH, Callans KM, Samost-Williams A, Bonilla JA, Flores LJG, Hasbun SCA, Rodríguez AEA, Cárdenas ABA, Núñez AML, Jayawardena ADL, Zablah EJ, Hartnick CJ. Practical quality improvement changes for a low-resourced pediatric unit. Front Public Health 2024; 12:1411681. [PMID: 38932785 PMCID: PMC11199403 DOI: 10.3389/fpubh.2024.1411681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 05/07/2024] [Indexed: 06/28/2024] Open
Abstract
Background This work describes a sustainable and replicable initiative to optimize multi-disciplinary care and uptake of clinical best practices for patients in a pediatric intensive care unit in Low/Middle Income Countries and to understand the various factors that may play a role in the reduction in child mortality seen after implementation of the Quality Improvement Initiative. Methods This was a longitudinal assessment of a quality improvement program with the primary outcome of intubated pediatric patient mortality. The program was assessed 36 months following implementation of the quality improvement intervention using a t-test with linear regression to control for co-variates. An Impact Pathway model was developed to describe potential pathways for improvement, and context was added with an exploratory analysis of adoption of the intervention and locally initiated interventions. Results 147 patients were included in the sustainability cohort. Comparing the initial post-implementation cohort to the sustainability cohort, the overall PICU unexpected extubations per 100 days mechanical ventilation decreased significantly from baseline (6.98) to the first year post intervention (3.52; p < 0.008) but plateaued without further significant decrease in the final cohort (3.0; p = 0.73), whereas the mortality decreased from 22.4 (std 0.42) to 9.5% (std 0.29): p value: 0.002 (confidence intervals: 0.05;0.21). The regression model that examined age, sex, diagnosis and severity of illness (via aggregate Pediatric Risk of Mortality (PRISM) scores between epochs) yielded an adjusted R-squared (adjusting for the number of predictors) value of 0.046, indicating that approximately 4.6% of the variance in mortality was explained by the predictors included in the model. The overall significance of the regression model was supported by an F-statistic of 3.198 (p = 0.00828). age, weight, diagnosis, and severity of illness. 15 new and locally driven quality practices were observed in the PICU compared to the initial post-implementation time period. The Impact Pathway model suggested multiple unique potential pathways connecting the improved patient outcomes with the intervention components. Conclusion Sustained improvements were seen in the care of intubated pediatric patients. While some of this improvement may be attributable to the intervention, it appears likely that the change is multifactorial, as evidenced by a significant number of new quality improvement projects initiated by the local clinical team. Although currently limited by available data, the use of Driver Diagram and Impact Pathway models demonstrates several proposed causal pathways and holds potential for further elucidating the complex dynamics underlying such improvements.
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Affiliation(s)
| | | | - Aubrey Samost-Williams
- Department of Anesthesiology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Jose A. Bonilla
- Department of Pediatric Otolaryngology, Hospital de Niños y Adolescentes Centro Pediatrico, San Salvador, El Salvador
| | - Luis J. G. Flores
- Department of Pediatric Critical Care Medicine, Hospital Centro Pediátrico, San Salvador, El Salvador
| | - Susana C. A. Hasbun
- Department of Anesthesiology, Hospital Centro Pediátrico, San Salvador, El Salvador
| | | | - Alejandra B. A. Cárdenas
- Department of Pediatric Critical Care Medicine, Hospital Centro Pediátrico, San Salvador, El Salvador
| | - Alexia M. L. Núñez
- Instituto Tecnológico y de Estudios Superiores de Monterrey in Guadalajara, Zapopan, Mexico
| | | | - Evelyn J. Zablah
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
| | - Christopher J. Hartnick
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA, United States
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Madhuri V, Stewart RJ, Lakhoo K. Developing and transferring a children's surgical training program from India to Africa a south-to-south global initiative. Pediatr Surg Int 2024; 40:155. [PMID: 38856770 DOI: 10.1007/s00383-024-05720-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE The availability of children's surgical care in lower middle-income countries is lacking. The authors describe a hub and spoke global training initiative in children's surgery for adult teams from district hospitals (spokes) comprising general and orthopaedic surgeons, anaesthetists, and nurses and specialist children's surgical trainers from tertiary centres (hubs) in delivering the course. METHODS The training course developed in Vellore, trained several sets of district hospital adult teams and trainer teams in India. Six specialist children's surgical trainer teams were invited from African countries to the course delivered in Vellore, India. The aim was to train them to deliver the course in their countries. RESULTS Participants underwent a precourse 'train the trainer' program, observed and assessed the suitability of the district hospital training course. The program received positive feedback, government supported planning of similar courses in some of the countries and discussions in others. CONCLUSION The availability of children's surgical care is similarly limited in the Asian and African continent, and the regions have shared challenges of disease burden, lack of access, poverty, deficient infrastructure, and trained human resources. They would benefit from this 'South to South' collaboration to impart training skills and modules to the children's surgical trainers.
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Affiliation(s)
- Vrisha Madhuri
- Christian Medical College, Vellore, India.
- Amara Hospital, Tirupati, India.
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Bandyopadhyay S, Philipo GS, Bokhary ZM, Lakhoo K. A review of twenty-first century developments in paediatric surgery in Africa. Pediatr Surg Int 2024; 40:137. [PMID: 38780635 DOI: 10.1007/s00383-024-05718-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 05/25/2024]
Abstract
This review explores the significant advancements in paediatric surgery in Africa during the twenty-first century, with a particular focus on capacity-building, education, infrastructural development, and research. Historically, paediatric surgery has been an overlooked sector, especially in low-and-middle-income countries in Africa. However, recent years have seen considerable progress. Collaborative efforts such as the Global Initiative for Children's Surgery, and the formation of the Pan African Paediatric Surgery Association, the College of Surgeons of East, Central and Southern Africa and the West African College of Surgeons have facilitated knowledge sharing, collaboration, and advocacy for enhancing surgical standards. Local training programmes, including Master of Medicine programmes and fellowships, have been instrumental in building a skilled workforce. These initiatives have been complemented by infrastructural developments through non-governmental organisations like Kids Operating Room, which have expanded access to paediatric surgical care. Technological advancements, particularly in telemedicine, have further enhanced accessibility. Task-sharing strategies, where non-specialist physicians are trained in paediatric surgical skills, have also been utilised to address the shortage of specialised surgeons. Research in paediatric surgery has experienced an upswing, with local health professionals taking the lead. Research has been crucial for understanding the epidemiology of paediatric surgical conditions, and developing prevention strategies, and is increasingly leading to the inclusion of paediatric surgery in national health plans. Despite the progress, challenges remain, including the need for sustainable funding, continued investment in infrastructure, and training and retention of healthcare professionals. The review emphasises the importance of ongoing efforts in community engagement, innovative technologies, and health systems strengthening for the sustainable development of paediatric surgical services in Africa.
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Affiliation(s)
- Soham Bandyopadhyay
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK.
| | - Godfrey Sama Philipo
- The College of Surgeons of East Central and Southern Africa, Arusha, Tanzania
- The Branch for Global Surgical Care (BGSC), University of British Columbia (UBC), Columbia, Canada
| | - Zaitun Mohamed Bokhary
- Department of Surgery, Muhimbili National Hospital, Dar Es Salaam, Tanzania
- Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
| | - Kokila Lakhoo
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, Medical Sciences Division, University of Oxford, Oxford, UK
- Department of Surgery, Muhimbili National Hospital, Dar Es Salaam, Tanzania
- Department of Surgery, Muhimbili University of Health and Allied Sciences, Dar Es Salaam, Tanzania
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Binda CJ, Adams J, Livergant R, Lam S, Panchendrabose K, Joharifard S, Haji F, Joos E. Defining a Framework and Evaluation Metrics for Sustainable Global Surgical Partnerships: A Modified Delphi Study. Ann Surg 2024; 279:549-553. [PMID: 37539584 PMCID: PMC10829902 DOI: 10.1097/sla.0000000000006058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
OBJECTIVE The aim of this study was to use expert consensus to build a concrete and realistic framework and checklist to evaluate sustainability in global surgery partnerships (GSPs). BACKGROUND Partnerships between high-resourced and low-resourced settings are often created to address the burden of unmet surgical need. Reflecting on the negative, unintended consequences of asymmetrical partnerships, global surgery community members have proposed frameworks and best practices to promote sustainable engagement between partners, though these frameworks lack consensus. This project proposes a cohesive, consensus-driven framework with accompanying evaluation metrics to guide sustainability in GSPs. METHODS A modified Delphi technique with purposive sampling was used to build consensus on the definitions and associated evaluation metrics of previously proposed pillars (Stakeholder Engagement, Multidisciplinary Collaboration, Context-Relevant Education and Training, Bilateral Authorship, Multisource Funding, Outcome Measurement) of sustainable GSPs. RESULTS Fifty global surgery experts from 34 countries with a median of 9.5 years of experience in the field of global surgery participated in 3 Delphi rounds. Consensus was achieved on the identity, definitions, and a 47-item checklist for the evaluation of the 6 pillars of sustainability in GSPs. In all, 29% of items achieved consensus in the first round, whereas 100% achieved consensus in the second and third rounds. CONCLUSIONS We present the first framework for building sustainable GSPs using the input of experts from all World Health Organization regions. We hope this tool will help the global surgery community to find noncolonial solutions to addressing the gap in access to quality surgical care in low-resource settings.
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Affiliation(s)
- Catherine J. Binda
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jayd Adams
- Faculty of Science, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rachel Livergant
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Sheila Lam
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | | | - Shahrzad Joharifard
- Department of Surgery, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Faizal Haji
- Department of Surgery, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Emilie Joos
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
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Naidoo G, Philipo GS, Bokhary Z, Lakhoo K. A roadmap for starting, growing and sustaining a comprehensive pediatric surgery service in a low resource area. Semin Pediatr Surg 2023; 32:151350. [PMID: 38007999 DOI: 10.1016/j.sempedsurg.2023.151350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
The Tanzania-Oxford Children's Surgery Partnership is a longstanding capacity building and research collaboration. Over a 21-year period, this non-hierarchical partnership has worked to develop from service delivery to children surgical system strengthening in Tanzania. This has directly impacted the children's surgery and workforce by increasing the number of pediatric surgeons in the country and upskilling nurses, anesthetists, and pediatricians. Clinical skills acquisition has been complemented by the development of leadership, mentorship, and research acumen. The partnership has also delivered critical upgrading of infrastructure which has significantly increased operative volume and allowed for the provision of minimally invasive children's surgery. A children's research network has been established, with a focus on research equity and local data ownership adhering to local ethics, leading to prolific academic output. At the core of this partnership has been the recognition that achieving sustainable change requires local leadership, long-term commitment, and 'bottom-up' change. We described the historical events and steps taken by our partners to achieve the universal provision of children's surgery in Tanzania.
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Affiliation(s)
- Gerlin Naidoo
- Nuffield Department of Surgical Sciences, University of Oxford, UK.
| | - Godfrey Sama Philipo
- Nuffield Department of Surgical Sciences, University of Oxford, UK; Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences (MUHAS), Tanzania
| | - Zaitun Bokhary
- Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences (MUHAS), Tanzania
| | - Kokila Lakhoo
- Nuffield Department of Surgical Sciences, University of Oxford, UK; Muhimbili National Hospital and Muhimbili University of Health and Allied Sciences (MUHAS), Tanzania
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Naluyimbazi R, Nimanya S, Kisa P. Anatomy and lessons of partnerships in global pediatric surgery. Semin Pediatr Surg 2023; 32:151353. [PMID: 38006694 DOI: 10.1016/j.sempedsurg.2023.151353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2023]
Abstract
Partnerships in Global Surgery have evolved over several decades and continue to do so based on reports from different experiences and collaborations. These should be characterised by their objectives, leadership and "championship," communication, ethics and equity. Partnerships take the form of academic collaborations or clinical support whose details vary with the different stakeholders involved. Over time, these have evolved based on challenges, successes, and failures. Recently, quality improvement activities have been increasingly initiated with locally derived information. This has come from local databases in low and middle income country (LMIC) settings whose maintenance and analysis have been done through academic collaborations. For many sites in LMICs, there would be very little advance in paediatric surgery without collaborations. Despite this, problems still arise from collaborations due to failure to learn from past problems, lack of local championship, poor communication, and externally driven objectives. For success and longevity, the collaboration must pay attention to unique the needs of the site, champions and equity.
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Affiliation(s)
| | | | - Phyllis Kisa
- Mulago National Referral Hospital, Kampala, Uganda; Makerere University College of Health Sciences, Kampala, Uganda.
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Flocks Monaghan C, Pittalis C, Byrne E, Hussein I, Chilunjika T, Nandi B, Borgstein E, Gajewski J. The status of pediatric surgery in Malawi: a narrative mini-review. Front Pediatr 2023; 11:1195691. [PMID: 37484773 PMCID: PMC10357470 DOI: 10.3389/fped.2023.1195691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction Pediatric surgery is essential to a well-functioning health system. Unmet surgical needs contribute to 6.7% of pediatric deaths in Malawi. Understanding the current state of pediatric surgical care in Malawi is necessary to recognize gaps and opportunities in service delivery and to develop evidence-based national planning and solutions. Methods This narrative mini review synthesized the literature on the state of pediatric surgery in Malawi through the pillars of the World Health Organization's Health System Building Blocks. A search of PubMed, Embase, and Scopus databases was executed to identify relevant studies and a thematic analysis was performed. Further, to ensure contextual accuracy, pediatric surgeons from Malawi were consulted and involved in this review. Results Twenty-six papers were identified. In Malawi's central hospitals, there are six specialist pediatric surgeons for a pediatric population of more than 8 million. There is limited pediatric surgical capacity at the district hospitals. There is little to no written evidence of the national governing and finance structures in place for pediatric surgical services. Discussion In countries like Malawi, where a significant portion of the population comprises children, it is crucial to recognize that pediatric services are currently inadequate and fall short of the required standards. It is crucial to prioritize the enhancement of services specifically designed for this age group. This review aims to shed light on the existing gaps within pediatric surgical services in Malawi, providing valuable insights that can inform the development of comprehensive national surgical planning strategies.
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Affiliation(s)
- Celina Flocks Monaghan
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Chiara Pittalis
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elaine Byrne
- Centre for Positive Health Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Israa Hussein
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Tiyamike Chilunjika
- Department of Surgery, University of Malawi College of Medicine, Zomba, Malawi
| | - Bip Nandi
- Department of Surgery, Kamuzu Central Hospital, Lilongwe, Malawi
- Michael E. Debakey Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Eric Borgstein
- Department of Surgery, University of Malawi College of Medicine, Zomba, Malawi
| | - Jakub Gajewski
- Institute of Global Surgery, School of Population Health, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Global Surgery, University of Stellenbosch, Cape Town, South Africa
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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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Laverde R, Majekodunmi O, Park P, Udeigwe-Okeke CR, Yap A, Klazura G, Ukwu N, Bryce E, Ozgediz D, Ameh EA. Impact of new dedicated pediatric operating rooms on surgical volume in Africa: Evidence from Nigeria. J Pediatr Surg 2023; 58:161-166. [PMID: 36289035 DOI: 10.1016/j.jpedsurg.2022.09.021] [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: 08/31/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND There is a large unmet children's surgical need in low- and middle-income countries (LMICs). This study examines the impact of installing dedicated pediatric operating rooms (ORs) on surgical volume at National Hospital Abuja, a hospital in Abuja, Nigeria. METHODS A Non-Governmental Organization installed two pediatric ORs in August 2019. We assessed changes in volume from July 2018 to September 2021 using interrupted time series analysis. RESULTS Total surgical volume increased by 13 cases (p = 0.01) in 1-month post-installation, with elective operations making up 85% (p = 0.02) of cases. There was an increase in elective volume by about 1 case per month (p = 0.01) post-installation and the difference between pre-and post-trends was 1.23 cases per month (p = 0.009). The baseline volume of neonatal surgeries increased by 9 cases per month (p < 0.001) post-installation and this difference between pre- and post-trends was statistically significant (p = 0.001). Similarly, one-month post-installation, the cases classified as ASA class >2 increased by 14 (p < 0.001). There was no significant difference between pre-and post-installation mortality rate at about 2% per month. CONCLUSIONS There were significant changes in surgical volume after OR installation, primarily composed of elective operations, reflecting an increased capacity to address surgical backlogs and/or perform more specialized surgeries. Despite a significant increase in volume and higher ASA class, there was no significant difference in mortality. This study supports the installation of surgical infrastructure in LMICs to strengthen capacity without increasing postoperative mortality.
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Affiliation(s)
- Ruth Laverde
- School of Medicine, University of California, 513 Parnassus Ave, Suite S-224, San Francisco, CA 94143, USA; Center for Health Equity in Surgery and Anesthesia, University of California, 550 16th St, 3rd Floor, Box 1224, San Francisco, CA 94158, USA.
| | - Olubumni Majekodunmi
- Division of Paediatric Surgery, National Hospital, PO Box 187, FCT, Abuja, Garki, Nigeria
| | - Paul Park
- School of Medicine, University of California, 513 Parnassus Ave, Suite S-224, San Francisco, CA 94143, USA; Center for Health Equity in Surgery and Anesthesia, University of California, 550 16th St, 3rd Floor, Box 1224, San Francisco, CA 94158, USA
| | - Chisom R Udeigwe-Okeke
- Division of Paediatric Surgery, National Hospital, PO Box 187, FCT, Abuja, Garki, Nigeria
| | - Ava Yap
- Center for Health Equity in Surgery and Anesthesia, University of California, 550 16th St, 3rd Floor, Box 1224, San Francisco, CA 94158, USA; Department of Surgery, University of California, 513 Parnassus Avenue, S-321, San Francisco, CA 94143, USA
| | - Greg Klazura
- Center for Health Equity in Surgery and Anesthesia, University of California, 550 16th St, 3rd Floor, Box 1224, San Francisco, CA 94158, USA; Department of Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Nancy Ukwu
- Division of Paediatric Surgery, National Hospital, PO Box 187, FCT, Abuja, Garki, Nigeria
| | - Emma Bryce
- Kids Operating Room, Edinburgh, Scotland, United Kingdom
| | - Doruk Ozgediz
- Center for Health Equity in Surgery and Anesthesia, University of California, 550 16th St, 3rd Floor, Box 1224, San Francisco, CA 94158, USA; Division of Paediatric Surgery, National Hospital, PO Box 187, FCT, Abuja, Garki, Nigeria
| | - Emmanuel A Ameh
- Division of Paediatric Surgery, National Hospital, PO Box 187, FCT, Abuja, Garki, Nigeria
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Coyle D, Nidaw E, Getachew H, Payne SR, Subramaniam R. Paediatric Urology in
Sub‐Saharan
Africa: Challenges and Opportunities. BJU Int 2022; 130:277-284. [DOI: 10.1111/bju.15852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David Coyle
- The Leeds Teaching Hospitals NHS Trust Leeds UK
| | - Ephrem Nidaw
- Department of Surgery Addis Ababa University School of Medicine Addis Ababa Ethiopia
| | - Hanna Getachew
- Department of Surgery Addis Ababa University School of Medicine Addis Ababa Ethiopia
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Vu MT, Shalkow J, Naik-Mathuria B, Qureshi SS, Ozgediz D, Lakhoo K, Abdelhafeez H. Wilms’ tumor in low- and middle-income countries: survey of current practices, challenges, and priorities. ANNALS OF PEDIATRIC SURGERY 2022. [DOI: 10.1186/s43159-022-00163-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
To identify the current practices and priorities in Wilms’ tumor management for surgeons in low- and middle-income countries (LMICs).
Methods
One hundred thirty-seven pediatric surgeons from 44 countries completed surveys on Wilms’ tumor surgical strategy in LMIC. This survey was distributed through the Global Initiative for Children’s Surgery, Pan-African Pediatric Surgical Association, and Latin American Pediatric Surgical Oncology Group.
Results
Ninety-two respondents (67.2%) participated from 19 lower middle-income countries (43.2%). Twenty-one respondents (15.3%) participated from nine lower income countries (20.5%). Nineteen respondents (13.9%) participated from 13 upper middle-income countries (29.5%). Most providers do not obtain biopsy for suspected Wilms’ tumor (79%). Delayed resection after preoperative chemotherapy is the preferred approach (70%), which providers chose due to protocol (45%), to decrease tumor rupture (22%), and to decrease complications (8%). The providers’ goal was to prevent tumor spillage and upstaging (46%) or to prevent bleeding, complication, or other organ resections (21%). Most surgeons believed that upfront resection increased the risk of tumor spillage (72%).
Conclusion
Providers in LMICs prefer delayed resection after preoperative chemotherapy to reduce the incidence of tumor spillage and upstaging of Wilms’ tumor. An evidence-based guideline tailored to the LMIC context can be developed from these findings.
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A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study. World J Surg 2022; 46:1643-1659. [PMID: 35412059 PMCID: PMC9174323 DOI: 10.1007/s00268-022-06530-z] [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: 03/04/2022] [Indexed: 10/25/2022]
Abstract
BACKGROUND A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children's journey to surgical care. We aimed to explore children's journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania. METHODS A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann-Whitney, Kruskal-Wallis and Fisher's exact tests were used for data analysis. RESULT We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died. CONCLUSION Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children's surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.
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Current status and future perspectives of collaboration in surgical research: A scoping review of the evidence. Surgery 2021; 170:748-755. [PMID: 34112518 DOI: 10.1016/j.surg.2021.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgery is rapidly changing in terms of techniques, education, and methods of conducting research. To keep up with this pace, surgeons have recently focused on collaborative research projects. The aim of this review was to investigate practices for collaborations in surgical research. METHODS A scoping review was conducted according to the guidelines proposed by Peters et al. Publications on patterns of collaboration in surgical research between January 2000 and December 2020, irrespective of the study design or language of publication, which were indexed in PubMed, the Cochrane Library, and Google Scholar, were included. A research librarian assisted in choosing the search terms and conducting the search. The very broad nature of the subject necessitated a pragmatic search strategy, with primary focus on reviews about collaboration. A new form of crowd science was used that explored collaborations using social media and online shared documents. RESULTS The search identified 38 studies that covered different aspects of collaboration in surgical research. Global, specialist, trainee-/student-led, and patient-led collaboratives are growing in number and size. Implementation of information technologies in surgical collaboration is still limited. The review identified attempts to include researchers from low- and middle-income countries in these collaborations, but these were at the early stages. CONCLUSION There are many patterns of collaboration in surgical research. Involvement of low- and middle-income countries will lead to capacity building in these countries, fast recruitment for surgical trials, and more generalizability of trial results. Due to the complex nature of surgical research, implementation of information technologies might improve the quality of research.
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Turcotte-Tremblay AM, Fregonese F, Kadio K, Alam N, Merry L. Global health is more than just 'Public Health Somewhere Else'. BMJ Glob Health 2020; 5:bmjgh-2020-002545. [PMID: 32381653 PMCID: PMC7228490 DOI: 10.1136/bmjgh-2020-002545] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/06/2020] [Indexed: 01/19/2023] Open
Affiliation(s)
| | - Federica Fregonese
- Research Institute of McGill University Health Center, Montreal, Quebec, Canada
| | - Kadidiatou Kadio
- Institut de Recherche en Science de la Santé (IRSS), Centre National de la Recherche Scientifique et Technologique (CNRST), Ouagadougou, Burkina Faso.,Institut de Recherche pour le Développement, Ouagadougou, Burkina Faso
| | - Nazmul Alam
- Department of Public Health, Asian University for Women, Chittagong, Bangladesh
| | - Lisa Merry
- Faculty of Nursing, Université de Montréal, Montreal, Quebec, Canada
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Calisti A, Andriani M, Mlawa A, Zara GP. The start-up phase of a non-specialist paediatric surgical service by outreach focused on capacity building at the Consolata Hospital Ikonda, Makete District, Tanzania. Afr J Prim Health Care Fam Med 2020; 12:e1-e4. [PMID: 33181876 PMCID: PMC7669999 DOI: 10.4102/phcfm.v12i1.2428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 02/02/2023] Open
Abstract
age) are far lower than the recommended workforce size. Complex conditions require a significant increase in the number of paediatric surgeons. In contrast, children with minor diseases, living in rural areas, could be managed even at the district level by trained general surgeons. AIM The aim of this study was to develop capacity for general paediatric surgical services in a district hospital by outreach with a focus on mentorship. METHODS Capacity building priorities for non-specialist paediatric surgery were identified and addressed using evidence-based guidelines. Local general surgeons were involved in supervised clinical decision-making and in all surgical procedures. The visiting team provided daily meetings, weekly lectures, and on-job training. Electronic copies of recent surgical textbooks were provided together with video-conferencing distant specialist consultations. RESULTS A total of 715 children were handled by the visiting team during the 27-week period. Four hundred and fifty diseases were diagnosed amongst 406 children. Awareness of paediatric surgical needs, improved management of most common conditions like congenital hernias, undescended testis, hypospadias and anorectal malformations needing temporary colostomy occurred. Local general surgeons were assisted in treating 358 cases of general paediatric surgical conditions. Updated early management protocols were introduced for more complex diseases needing referral to specialist centres like solid tumours and neonatal abnormalities. The visiting team operated major paediatric surgical cases at the Consolata Hospital Ikonda. LESSONS LEARNT Surgical outreach and capacity building at the district hospital level could be a possible answer to the unmet paediatric surgical needs of children living in rural areas. Apprenticeship training for general surgeons may help to fill the gap provided that they are strongly motivated and supported on acquiring and implementing their paediatric surgical skills.
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