Improving quality of surgical and anaesthesia care in sub-Saharan Africa: a systematic review of hospital-based quality improvement interventions

Interventions for improving critical care in low- and middle-income countries: a systematic review

PURPOSE

To systematically review the typology, impact, quality of evidence, barriers, and facilitators to implementation of Quality Improvement (QI) interventions for adult critical care in low- and middle-income countries (LMICs).

METHODS

MEDLINE, EMBASE, Cochrane Library and ClinicalTrials.gov were searched on 1st September 2022. The studies were included if they described the implementation of QI interventions for adult critical care in LMICs, available as full text, in English and published after 2000. The risks of bias were assessed using the ROB 2.0/ROBINS-I tools. Intervention strategies were categorised according to a Knowledge Translation framework. Interventions' effectiveness were synthesised by vote counting and assessed with a binomial test. Barriers and facilitators to implementation were narratively synthesised using the Consolidated Framework for Implementation Research.

RESULTS

78 studies were included. Risk of bias was high. The most common intervention strategies were Education, Audit & Feedback (A&F) and Protocols/Guidelines/Bundles/Checklists (PGBC). Two multifaceted strategies improved both process and outcome measures: Education and A&F (p = 0.008); and PGBC with Education and A&F (p = 0.001, p < 0.001). Facilitators to implementation were stakeholder engagement, organisational readiness for implementation, and adaptability of interventions. Barriers were lack of resources and incompatibility with clinical workflows.

CONCLUSIONS

The evidence for QI in critical care in LMICs is sparse and at high risk of bias but suggests that multifaceted interventions are most effective. Co-designing interventions with and engaging stakeholders, communicating relative advantages, employing local champions and adapting to feedback can improve implementation. Hybrid study designs, process evaluations and adherence to reporting guidelines would improve the evidence base.

Expanding surgical access in Africa through improved health insurance schemes: A review

Surgical access remains a pressing public health concern in African nations, with a substantial portion of the population facing challenges in obtaining safe, timely, and affordable surgical care. This paper delves into the impact of health insurance schemes on surgical accessibility in Africa, exploring the barriers, challenges, and future directions. It highlights how high out-of-pocket costs, reliance on traditional healing practices, and inadequate surgical infrastructure hinder surgical utilization. Financing mechanisms often need to be more effective, and health insurance programs face resistance within the informal sector. Additionally, coverage of the poor remains a fundamental challenge, with geographical and accessibility barriers compounding the issue. Government policies, often marked by inconsistency and insufficient allocation of resources, create further obstacles. However, strategic purchasing and fund integration offer avenues for improving the efficiency of health insurance programs. The paper concludes by offering policy recommendations, emphasizing the importance of inclusive policies, streamlined financing mechanisms, coverage expansion, and enhanced strategic purchasing to bridge the surgical access gap in Africa. Decoupling entitlement from the payment of contributions, broadening the scope of coverage for outpatient medicines and related expenses, and enhancing safeguards against overall costs and charges, especially for individuals with lower incomes. Ultimately, by addressing these challenges and harnessing the potential of health insurance schemes, the continent can move closer to achieving universal surgical care and improving the well-being of its people.

Surgical System Efficiency and Operative Productivity in Public and Private Health Facilities in Ethiopia: A Cross-Sectional Evaluation

BACKGROUND

Global and local health organizations track surgical system efficiency to improve surgical system performance using various efficiency metrics, such as operating room (OR) output, surgical incision start time (SIST), turnover time (TOT), cancellation rate among elective surgeries, and in-hospital surgery wait time. We evaluated the surgical system efficiency and factors affecting the efficiency in health facilities across Ethiopia.

METHODS

A cross-sectional study design with retrospective record review was used to evaluate the surgical system efficiency in 163 public and private health facilities in Ethiopia from December 2020 to June 2021. Experienced, trained surgical clinicians abstracted efficiency data from service registers and patient charts using a pretested tool. A bivariable and multivariable regression analysis was conducted.

RESULTS

In the study facilities, 84.11% of the operating tables were functional, and 68,596 major surgeries were performed. The aggregate OR output in both public and private health facilities was 2 surgeries per day per OR table. Operating productivity was shown to be affected by first-case SIST (P=.004). However, of the total 881 surgery incision times audited, 19.86% of the first-of-the-day elective surgeries started after 10:01 am. The SIST was strongly associated with an in-hospital wait time for surgery (P=.016). The elective surgery cancellation rate was 5.2%, and aggregate mean TOT was 50.25 minutes. The mean in-hospital surgery wait time was 45.40 hours, longer than the national cutoff for wait time. In a bivariable analysis, the independent variables that demonstrated association operating room productivity were then inputted into a multivariable regression analysis model. However, none of the predictor/independent variables showed significance in the multivariable regression analysis model.

CONCLUSION

The volume of surgery and overall OR productivity in Ethiopia is low. This calls for concerted action to optimize OR efficiency and improve access to timely and safe surgical care in Ethiopia and other LMICs.

Factors associated with surgical site infection in myocardial revascularization: a retrospective longitudinal study

OBJECTIVES

to analyze the influence of sociodemographic and clinical variables, as well as the surgical checklist adherence score, on the occurrence of surgical site infection among patients undergoing myocardial revascularization.

METHODS

an observational, longitudinal, retrospective study was conducted at a university hospital, involving 266 medical records of patients who underwent myocardial revascularization surgery. Instruments containing sociodemographic, clinical, and infection-related variables were used, along with the Perioperative Surgical Safety Checklist. Descriptive, bivariate, and logistic regression analyses were employed.

RESULTS

surgical site infection occurred in 89 (33.5%) patients. There was a statistically significant association between body temperature outside the range of 36 degrees Celsius to 36.5 degrees Celsius (p=0.01), the presence of invasive devices (p=0.05), surgical procedures with the anticipation of critical events (p<0.001), and the occurrence of infection.

CONCLUSIONS

body temperature, the presence of invasive devices, and surgical procedures with the anticipation of critical events were significant factors contributing to an increased risk of infection.

Perioperative medicine: challenges and solutions for global health

The emerging field of perioperative medicine has the potential to make significant contributions to global health. Perioperative medicine aims to help reduce unmet surgical need, decrease variation in quality and systematically improve patient outcomes. These aims are also applicable to key challenges in global health, such as limited access to surgical care, variable quality and workforce shortages. This article describes the areas in which perioperative medicine can contribute to global health using case studies of successful care pathways, risk prediction tools, strategies for effective grassroots research and novel workforce approaches aimed at effectively using limited resources.

Achieving global surgical excellence: an evidence-based framework to guide surgical quality improvement programs in low and middle income countries

Objectives

There is a lack of evidence-based guidelines for enhancing global surgical care delivery. We propose a set of recommendations to serve as a framework to guide surgical quality improvement and scale-up initiatives in low and middle income countries (LMICs).

Methods

From January-December 2019, we reviewed the available literature and their application toward LMIC settings. The first initiative was the establishment of Best Practices Recommendations intended to summarize best-level evidence around quality improvement processes that have shown to decrease morbidity and mortality in LMICs. The GRADE level of evidence and strength of the recommendation were assigned in accordance with the WHO handbook for guidelines development. The second initiative was the scale-up of principles and practices by establishing international expert consensus on the optimal organization of surgical services in LMICs using a modified Delphi methodology.

Results

Recommendations for three topic areas were established: reducing surgical site infections, improving quality of trauma systems, and interventions to reduce maternal and perinatal mortality. 27 studies were included in a quantitative synthesis and meta-analysis for interventions reducing surgical site infections, 27 studies for interventions improving the quality of trauma systems, and 14 studies for interventions reducing maternal and perinatal mortality. Using Delphi methodology, an international expert panel established consensus that district hospitals should place the highest priority on developing surgical services for low complexity, high volume conditions. At the national level, emergency and essential surgical care should be integrated within national Universal Health Coverage frameworks.

Conclusions

This project fills a critical cap in the rapidly developing field of global surgery: gathering evidence-based, practical, and cost-effective solutions that will serve as a guide for the efficient planning and allocation of resources necessary to promote quality and safe essential surgical services in LMICs.