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Ordoobadi AJ, Wickard A, Heindel P, Raykar N, Masiakos PT, Anderson GA. Quantifying Pediatric Gun Violence by Location, Time of Day, and Day of Week. J Pediatr Surg 2024; 59:1003-1008. [PMID: 38030529 DOI: 10.1016/j.jpedsurg.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 10/25/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Firearm injuries are the leading cause of pediatric deaths. The objective of this study was to describe the location and timing of pediatric firearm injuries and to determine the proportion of these injuries that occur within schools in the United States. METHODS In this retrospective cohort study, we used national emergency medical services (EMS) data from 2019 to evaluate dispatches to firearm injuries involving school-aged children (age 5-18). We extracted incident location type, patient demographics, number of patients on scene, and injury intent. RESULTS We identified 4764 EMS dispatches for firearm injuries in school-aged children during 2019. Assault was the most common cause of injury (53.9 %), followed by unintentional shootings (12.1 %) and self-inflicted injuries (6.1 %). Most incidents involved a single patient (91.4 %). Private residence (51.5 %) was the most common location, followed by street/road (23.8 %). 81 firearm injuries (1.7 %) occurred in a school. Private residence was the most common location of injury across all injury intents. During school hours, most firearm injuries occurred in a private residence (51.6 %) or on a street/road (19.9 %). A total of 63 dispatches (1.3 %) were considered a mass casualty incident, of which 9 (14 %) occurred in a school. CONCLUSIONS Regardless of injury intent or time of day, the most common location for pediatric firearm injuries was a private home. Firearm injuries within schools were far less frequent. In designing prevention strategies, our data calls for renewed focus on preventing children from accessing firearms in the home and instituting comprehensive, community-based after school programs. TYPE OF STUDY Retrospective cohort. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexander J Ordoobadi
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Aaron Wickard
- Department of Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134, USA
| | - Patrick Heindel
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Nakul Raykar
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Peter T Masiakos
- Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Massachusetts General Hospital Center for Gun Violence Prevention, 55 Fruit Street, Boston, MA 02114, USA
| | - Geoffrey A Anderson
- Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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2
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Raguveer V, Sawhney R, Roy N, Raykar N. The rural surgeon: a practice to strive for. BMJ Glob Health 2024; 9:e013449. [PMID: 38724077 PMCID: PMC11029196 DOI: 10.1136/bmjgh-2023-013449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/30/2023] [Indexed: 05/12/2024] Open
Affiliation(s)
- Vanitha Raguveer
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Riya Sawhney
- WHO Collaborating Centre for Research in Surgical Care Delivery in Low- and Middle-Income Countries, Mumbai, India
| | - Nobhojit Roy
- WHO Collaborating Centre for Research in Surgical Care Delivery in Low- and Middle-Income Countries, Mumbai, India
- Public Health Sciences, Karolinska Institute, Stockholm, Sweden
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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3
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Jhunjhunwala R, Monzon J, Faria I, Escalona G, Zinco A, Ottolino P, Reyna F, Raykar N, Asturias S. A low-cost, DIY tourniquet simulator with built-in self-assessment for prehospital providers in Guatemala city. World J Surg 2024. [PMID: 38526473 DOI: 10.1002/wjs.12158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/10/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Hemorrhage is the leading cause of preventable death after trauma. In high-income countries first responders are trained in hemorrhage control techniques but this is not the case for developing countries like Guatemala. We present a low-cost training model for tourniquet application using a combination of virtual and physical components. METHODS The training program includes a mobile application with didactic materials, videos and a gamified virtual reality environment for learning. Additionally, a physical training model of a bleeding lower extremity is developed allowing learners to practice tourniquet application using inexpensive and accessible materials. Validation of the simulator occurred through content and construct validation. Content validation involved subjective assessments by novices and experts, construct validation compared pre-training novices with experts. Training validation compared pre and post training novices for improvement. RESULTS Our findings indicate that users found the simulator useful, realistic, and satisfactory. We found significant differences in tourniquet application skills between pre-training novices and experts. When comparing pre- and post-training novices, we found a significantly lower bleeding control time between the groups. CONCLUSION This study suggests that this training approach can enhance access to life-saving skills for prehospital personnel. The inclusion of self-assessment components enables self-regulated learning and reduces the need for continuous instructor presence. Future improvements involve refining the tourniquet model, validating it with first-responder end users, and expanding the training program to include other skills.
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Affiliation(s)
- Rashi Jhunjhunwala
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Jose Monzon
- Rafael Landivar University Guatemala City, Guatemala City, Guatemala
| | - Isabella Faria
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Gabriel Escalona
- Faculty of Medicine, Experimental Surgery and Simulation Center, Pontificia Universidad Católica de Chile, Santiago, Chile
- Hospital Sotero del Rio, Puente Alto, Chile
| | | | | | - Favio Reyna
- Francisco Marroquin University, Guatemala City, Guatemala
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
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Kumar N, Sawhney R, Roy N, Raykar N. Rapid diagnostic testing: the key to ensuring sufficient supply and safe access to blood in emergencies. BMJ Glob Health 2024; 9:e014613. [PMID: 38382978 PMCID: PMC10882364 DOI: 10.1136/bmjgh-2023-014613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 02/04/2024] [Indexed: 02/23/2024] Open
Affiliation(s)
- Nikathan Kumar
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Blood DESERT Coalition, Boston, Massachusetts, USA
| | - Riya Sawhney
- Blood DESERT Coalition, Boston, Massachusetts, USA
| | - Nobhojit Roy
- Blood DESERT Coalition, Boston, Massachusetts, USA
- The George Institute for Global Health India, New Delhi, India
| | - Nakul Raykar
- Blood DESERT Coalition, Boston, Massachusetts, USA
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Faria I, Thivalapill N, Makin J, Puyana JC, Raykar N. Bleeding, Hemorrhagic Shock, and the Global Blood Supply. Crit Care Clin 2022; 38:775-793. [PMID: 36162910 DOI: 10.1016/j.ccc.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hemorrhage is responsible for at least 40% of deaths after trauma and 27% of maternal deaths worldwide. Patients with hemorrhagic shock require attentive critical care and transfusion of blood products. Access to a safe and affordable blood supply is critical to providing safe surgical care. Traumatic injury, obstetric hemorrhage, and upper gastrointestinal bleed are the main causes of severe bleeding requiring transfusion. This article discusses the presentation and management of these causes across the world and provides a brief overview of the current challenges in maintaining a global blood supply.
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Affiliation(s)
- Isabella Faria
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Hungtington Avenue, Boston, MA 02115, USA; Faculdade de Medicina da Universidade Federal de Minas Gerais, 190 Avenida Professor Alfredo Balena, Belo Horizonte, MG 31130450, Brazil
| | - Neil Thivalapill
- Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 420 East Superior Street, Chicago IL 60611, USA
| | - Jennifer Makin
- Department of Obstetrics, Gynecology and Reproductive Science, The University of Pittsburgh Medical Center Magee - Women's Hospital, 300 Halket Street, Pittsburgh, PA 15213, USA
| | - Juan Carlos Puyana
- Critical Care Medicine, and Clinical Translational Science, Pittsburgh, PA 15213, USA; University of Pittsburgh, UPMC Presbyterian, F1263, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Hungtington Avenue, Boston, MA 02115, USA; Division of Trauma & Emergency Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02215, USA.
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6
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Pendleton AA, Sarang B, Mohan M, Raykar N, Wärnberg MG, Khajanchi M, Dharap S, Fitzgerald M, Sharma N, Soni KD, O'Reilly G, Bhandarkar P, Misra M, Mathew J, Jarwani B, Howard T, Gupta A, Cameron P, Bhoi S, Roy N. A cohort study of differences in trauma outcomes between females and males at four Indian Urban Trauma Centers. Injury 2022; 53:3052-3058. [PMID: 35906117 DOI: 10.1016/j.injury.2022.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 06/21/2022] [Accepted: 07/12/2022] [Indexed: 02/02/2023]
Abstract
Background Studies from high income countries suggest improved survival for females as compared to males following trauma. However, data regarding differences in trauma outcomes between females and males is severely lacking from low- and middle-income countries. The objective of this study was to determine the association between sex and clinical outcomes amongst Indian trauma patients using the Australia-India Trauma Systems Collaboration database. Methods A prospective multicentre cohort study was performed across four urban public hospitals in India April 2016 through February 2018. Bivariate analyses compared admission physiological parameters and mechanism of injury. Logistic regression assessed association of sex with the primary outcomes of 30-day and 24-hour in-hospital mortality. Secondary outcomes included ICU admission, ICU length of stay, ventilator requirement, and time on a ventilator. Results Of 8,605 patients, 1,574 (18.3%) were females. The most common mechanism of injury was falls for females (52.0%) and road traffic injury for males (49.5%). On unadjusted analysis, there was no difference in 30-day in-hospital mortality between females (11.6%) and males (12.6%, p = 0.323). However, females demonstrated a lower mortality at 24-hours (1.1% vs males 2.1%, p = 0.011) on unadjusted analysis. Females were also less likely to require a ventilator (17.3% vs 21.0% males, p = 0.001) or ICU admission (34.4% vs 37.5%, p = 0.028). Stratification by age or by ISS demonstrated no difference in 30-day in-hospital mortality for males vs females across age and ISS categories. On multivariable regression analysis, sex was not associated significantly with 30-day or 24-hour in-hospital mortality. Conclusion This study did not demonstrate a significant difference in the 30-day trauma mortality or 24-hour trauma mortality between female and male trauma patients in India on adjusted analyses. A more granular data is needed to understand the interplay of injury severity, immediate post-traumatic hormonal and immunological alterations, and the impact of gender-based disparities in acute care settings.
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Affiliation(s)
- Anna Alaska Pendleton
- Harvard Program for Global Surgery and Social Change, Harvard Medical School, Boston, United States
| | - Bhakti Sarang
- Trauma Research Group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Monali Mohan
- Trauma Research Group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Nakul Raykar
- Trauma and Emergency General Surgery, Brigham and Women's Hospital, Boston, United States
| | | | - Monty Khajanchi
- Harvard Program for Global Surgery and Social Change, Harvard Medical School, Boston, United States
| | - Satish Dharap
- Department of General Surgery, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | | | - Naveen Sharma
- Department of Surgery, All India Institute of Medical Sciences (AIIMS), Jodhpur, India
| | - Kapil Dev Soni
- Critical and Intensive Care, JPN Apex Trauma Centre, AIIMS, New Delhi, India
| | - Gerard O'Reilly
- Department of Epidemiology and Biostatistics, National Trauma Research Institute, The Alfred, Melbourne, Australia
| | - Prashant Bhandarkar
- Department of Statistics, Bhabha Atomic Research Centre Hospital, Mumbai, India
| | - Mahesh Misra
- JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Joseph Mathew
- The Alfred Hospital, Emergency and Trauma Centre, Melbourne, Australia
| | | | | | - Amit Gupta
- Division of Trauma Surgery & Critical Care, JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Peter Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne Australia
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Nobhojit Roy
- Harvard Program for Global Surgery and Social Change, Harvard Medical School, Boston, United States; Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden SE-171 77; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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7
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Affiliation(s)
- Eric K Kim
- University of California San Francisco School of Medicine, San Francisco, California, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Rohini Dutta
- Christian Medical College and Hospital, Ludhiana, India.,World Health Organization Collaborating Centre for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Nobhojit Roy
- World Health Organization Collaborating Centre for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA .,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Trauma, Emergency Surgery, Surgical Critical Care, Brigham and Women's Hospital, Boston, MA, 02215
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8
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Joseph A, Uribe-Leitz T, Dey T, Havens J, Cooper Z, Raykar N. Racial and neighborhood disparities in mortality among hospitalized COVID-19 patients in the United States: An analysis of the CDC case surveillance database. PLOS Glob Public Health 2022; 2:e0000701. [PMID: 36962563 PMCID: PMC10022015 DOI: 10.1371/journal.pgph.0000701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Black and Hispanic populations have higher overall COVID-19 infection and mortality odds compared to Whites. Some state-wide studies conducted in the early months of the pandemic found no in-hospital racial disparities in mortality. METHODS We performed chi-square and logistic regression analyses on the CDC COVID-19 Case Surveillance Restricted Database. The primary outcome of the study was all-cause in-hospital mortality. The primary exposures were racial group (White, Black, Hispanic and Others) and neighborhood type (low vulnerability, moderate vulnerability, high vulnerability, very high vulnerability). FINDINGS The overall unadjusted mortality rate was 33% and was lowest among Hispanics. In the fully adjusted models, Blacks and Hispanics had higher overall odds of dying [OR of 1.20 (95% CI 1.15, 1.25) and 1.23 (95% CI 1.17, 1.28) respectively] compared with White patients, and patients from neighborhoods with very high vulnerability had the highest mortality odds in the Northeast, Midwest and overall [Adjusted OR 2.08 (95% CI 1.91, 2.26)]. In the Midwest, Blacks and Hispanics had higher odds of mortality compared with Whites, but this was not observed in other regions. INTERPRETATION Among hospitalized COVID-19 patients, Blacks and Hispanics were more likely to die compared to Whites in the Midwest. Patients from highly vulnerable neighborhoods also had the highest likelihood of death in the Northeast and Midwest. These results raise important questions on our efforts to curb healthcare disparities and structural racism in the healthcare setting.
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Affiliation(s)
- Atarere Joseph
- Department of Biostatistics and Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Department of Internal Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, United States of America
| | - Tarsicio Uribe-Leitz
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston Massachusetts, United States of America
- Division of Sport and Health Sciences, Department of Epidemiology, Technical University of Munich, Munich, Germany
| | - Tanujit Dey
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Joaquim Havens
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Zara Cooper
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Nakul Raykar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Program in Global Surgery and Social Change, Harvard Medical School, Boston Massachusetts, United States of America
- Division of Trauma, Burns, and Surgical Critical Care, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
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Sarang B, Raykar N, Gadgil A, Mishra G, Wärnberg MG, Rattan A, Khajanchi M, Soni KD, Mohan M, Sharma N, Kumar V, Kv D, Roy N. Outcomes of Renal Trauma in Indian Urban Tertiary Healthcare Centres: A Multicentre Cohort Study. World J Surg 2021; 45:3567-3574. [PMID: 34420094 PMCID: PMC8572839 DOI: 10.1007/s00268-021-06293-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Renal trauma is present in 0.5-5% of patients admitted for trauma. Advancements in radiologic imaging and minimal-invasive techniques have led to decreased need for surgical intervention. We used a large trauma cohort to characterise renal trauma patients, their management and outcomes. METHODS We analysed "Towards Improved Trauma Care Outcomes in India" cohort from four urban tertiary public hospitals in India between 1st September 2013 and 31st December 2015. The data of patients with renal trauma were extracted using International Classification of Diseases 10 codes and analysed for demographic and clinical details. RESULTS A total of 16,047 trauma patients were included in this cohort. Abdominal trauma comprised 1119 (7%) cases, of which 144 (13%) had renal trauma. Renal trauma was present in 1% of all the patients admitted for trauma. The mean age was 28 years (SD-14.7). A total of 119 (83%) patients were male. Majority (93%) were due to blunt injuries. Road traffic injuries were the most common mechanism (53%) followed by falls (29%). Most renal injuries (89%) were associated with other organ injuries. Seven of the 144 (5%) patients required nephrectomy. Three patients had grade V trauma; all underwent nephrectomy. The 30-day in-hospital mortality, in patients with renal trauma, was 17% (24/144). CONCLUSION Most renal trauma patients were managed nonoperatively. 89% of patients with renal trauma had concomitant injuries. The renal trauma profile from this large cohort may be generalisable to urban contexts in India and other low- and middle-income countries.
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Affiliation(s)
- Bhakti Sarang
- Department of Surgery, Terna Medical College and Hospital, New Mumbai, India
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMIC, Mumbai, India
| | - Nakul Raykar
- Trauma and Emergency Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Anita Gadgil
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMIC, Mumbai, India
- Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India
| | - Gunjan Mishra
- Department of Surgery, Mahatma Gandhi Mission Medical College and Hospital, New Mumbai, India
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Amulya Rattan
- Department of Trauma Surgery and Critical Care, All India Institute of Medical Sciences, Rishikesh, India
| | - Monty Khajanchi
- Department of Surgery, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Kapil Dev Soni
- Critical and Intensive Care, JPN Apex Trauma Hospital, AIIMS, New Delhi, India
| | - Monali Mohan
- Health Systems Strengthening, Muzaffarpur Field Health Laboratory, CARE-India, Patna, Bihar, India
| | - Naveen Sharma
- Department of General Surgery, All India Institute of Medical Sciences, Jodhpur, India
| | - Vineet Kumar
- Department of Surgery, Lokmanya Tilak Municipal Medical College and Hospital, Mumbai, India
| | - Deepa Kv
- Department of Surgery, Manipal Hospital, Dwarka, Delhi, India
| | - Nobhojit Roy
- WHO Collaborating Centre for Research in Surgical Care Delivery in LMIC, Mumbai, India.
- Department of Global Public Health, Karolinska Institutet, 171 77, Stockholm, Sweden.
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Himmler A, Galarza Armijos ME, Naranjo JR, Patiño SGP, Sarmiento Altamirano D, Lazo NF, Pino Andrade R, Aguilar HS, Fernández de Córdova L, Augurto CC, Raykar N, Puyana JC, Salamea JC. Is the whole greater than the sum of its parts? The implementation and outcomes of a whole blood program in Ecuador. Trauma Surg Acute Care Open 2021; 6:e000758. [PMID: 34869909 PMCID: PMC8603278 DOI: 10.1136/tsaco-2021-000758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/21/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Hemorrhagic shock is a major cause of mortality in low-income and middle-income countries (LMICs). Many institutions in LMICs lack the resources to adequately prescribe balanced resuscitation. This study aims to describe the implementation of a whole blood (WB) program in Latin America and to discuss the outcomes of the patients who received WB. METHODS We conducted a retrospective review of patients resuscitated with WB from 2013 to 2019. Five units of O+ WB were made available on a consistent basis for patients presenting in hemorrhagic shock. Variables collected included gender, age, service treating the patient, units of WB administered, units of components administered, admission vital signs, admission hemoglobin, shock index, Revised Trauma Score in trauma patients, intraoperative crystalloid (lactated Ringer's or normal saline) and colloid (5% human albumin) administration, symptoms of transfusion reaction, length of stay, and in-hospital mortality. RESULTS The sample includes a total of 101 patients, 57 of which were trauma and acute care surgery patients and 44 of which were obstetrics and gynecology patients. No patients developed symptoms consistent with a transfusion reaction. The average shock index was 1.16 (±0.55). On average, patients received 1.66 (±0.80) units of WB. Overall mortality was 13.86% (14 of 101) in the first 24 hours and 5.94% (6 of 101) after 24 hours. DISCUSSION Implementing a WB protocol is achievable in LMICs. WB allows for more efficient delivery of hemostatic resuscitation and is ideal for resource-restrained settings. To our knowledge, this is the first description of a WB program implemented in a civilian hospital in Latin America. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Amber Himmler
- Department of Surgery, MedStar Georgetown University Hospital, Washington DC, District of Columbia, USA
| | - Monica Eulalia Galarza Armijos
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Jeovanni Reinoso Naranjo
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | | | - Doris Sarmiento Altamirano
- College of Medicine, University of Azuay, Cuenca, Ecuador
- Department of Surgery, Hospital Jose Carrasco Arteaga, Cuenca, Ecuador
| | - Nube Flores Lazo
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Raul Pino Andrade
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Hernán Sacoto Aguilar
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Azuay, Cuenca, Ecuador
| | - Lenin Fernández de Córdova
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad Católica de Cuenca, Cuenca, Ecuador
| | - Cecibel Cevallos Augurto
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Cuenca, Cuenca, Ecuador
| | - Nakul Raykar
- Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Juan Carlos Puyana
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Juan Carlos Salamea
- Department of Surgery, Hospital Vicente Corral Moscoso Cuenca, Cuenca, Ecuador
- College of Medicine, Universidad de Azuay, Cuenca, Ecuador
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11
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Sarang B, Bhandarkar P, Raykar N, O'Reilly GM, Soni KD, Wärnberg MG, Khajanchi M, Dharap S, Cameron P, Howard T, Gadgil A, Jarwani B, Mohan M, Bhoi S, Roy N. Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study. Injury 2021; 52:1158-1163. [PMID: 33685640 DOI: 10.1016/j.injury.2021.02.075] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/20/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India. METHODS We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality. RESULTS A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP<90mm Hg), tachycardia (HR>100bpm) and bradycardia (HR<60bpm), hypoxia (SpO2<90%), Tachypnoea (RR>20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality. CONCLUSION The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.
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Affiliation(s)
- Bhakti Sarang
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Associate Professor, Terna Medical College & Hospital, Nerul, New Mumbai, India
| | - Prashant Bhandarkar
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; School of Health System Studies, Tata Institute of Social Sciences, Mumbai, India
| | - Nakul Raykar
- Trauma Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, USA; Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA
| | - Gerard M O'Reilly
- NHMRC Research Fellow & Head of Epidemiology & Biostatistics, National Trauma Research Institute, The Alfred, Melbourne, Australia; Adjunct Clinical Associate Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia; Emergency Physician & Head of Global programs, Emergency & Trauma Centre, The Alfred, Melbourne, Australia
| | - Kapil Dev Soni
- Additional Professor, Critical & Intensive Care, JPN Apex Trauma Centre, AIIMS, New Delhi
| | | | - Monty Khajanchi
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Associate Professor, Seth.G.S. Medical College & K.E.M. Hospital, Parel, Mumbai, India
| | - Satish Dharap
- Professor & Head of General Surgery, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | - Peter Cameron
- Academic Director, Emergency & Trauma Centre, The Alfred Hospital, Melbourne Australia; Professor, School of Public Health & Preventive Medicine, Monash University, Melbourne, Australia
| | - Teresa Howard
- Central Clinical School, Monash University, Melbourne, Australia; Burnet Institute, Melbourne, Australia; National Trauma Research Institute, Alfred Hospital and Monash University, Melbourne, Australia
| | - Anita Gadgil
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Bhavesh Jarwani
- Associate Professor, Emergency Medicine Department, Vadilal Sarabhai General Hospital, Ahmedabad, Gujarat, India
| | - Monali Mohan
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Sanjeev Bhoi
- Department of Emergency Medicine, JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Nobhojit Roy
- Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Affiliate, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Adjunct Professor (Research), School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia.
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Soni KD, Khajanchi M, Raykar N, Sarang B, O'Reilly GM, Dharap S, Cameron P, Sharma N, Howard T, Farrow N, Roy N. Does in-hospital trauma mortality in urban Indian academic centres differ between "office-hours" and "after-hours"? J Crit Care 2020; 62:31-37. [PMID: 33242732 DOI: 10.1016/j.jcrc.2020.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 10/07/2020] [Accepted: 11/13/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Trauma services within hospitals may vary considerably at different times across a 24 h period. The variable services may negatively affect the outcome of trauma victims. The current investigation aims to study the effect of arrival time of major trauma patients on mortality and morbidity. METHOD Retrospective analysis of the Australia-India Trauma Systems Collaboration (AITSC) registry established in four public university teaching centres in India Based on hospital arrival time, patients were grouped into "Office-hours" and "After-hours". Outcome parameters were compared between the above groups. RESULTS 5536 (68.4%) patients presented "after-hours" (AO) and 2561 (31.6%) during "office-hours" (OH). The in-hospital mortality for "after-hours" and "office-hours" presentations were 12.1% and 11.6% respectively. On unadjusted analysis, there was no statistical difference in the odds of survival for OH versus AH presentations. (OR,1.05, 95% CI 0.9-1.2). Adjusting for potential prognostic factors (injury severity, presence of shock on arrival, referral status, sex, or extremes of age), there was no statistically significant odds of survival for OH versus AH presentations (OR,1.02, 95%CI 0.9-1.2).ICU length of stay and duration of mechanical ventilation was longer in the AH group. CONCLUSION The in-hospital mortality did not differ between trauma patients who arrived during "after-hours" compared to '"office-hours".
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Affiliation(s)
- Kapil Dev Soni
- Critical and Intensive Care, JPN Apex Trauma Centre, AIIMS, New Delhi, India
| | - Monty Khajanchi
- Seth. G. S. Medical College & K.E.M. HospitalParel, Mumbai, India
| | - Nakul Raykar
- Division of Trauma and Emergency Surgery, Brigham and Women's Hospital, Boston, USA
| | - Bhakti Sarang
- Trauma Research Group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India
| | - Gerard M O'Reilly
- NHMRC Research, Head of Epidemiology and Biostatistics, National Trauma Research Institute, The Alfred, Melbourne, Australia
| | - Satish Dharap
- Dept of General Surgery, Topiwala National Medical College & B.Y.L. Nair Ch. Hospital, Mumbai, India
| | - Peter Cameron
- The Alfred Hospital, Emergency and Trauma Centre, Prehospital Emergency and Trauma Research, Health Services Research, Australia
| | | | - Teresa Howard
- Central Clinical School, Monash University, Melbourne, Australia-The Burnet Institute, Melbourne, Australia
| | - Nathan Farrow
- Monash University-Alfred Health, National Trauma Research Institute, Patient Safety Review, Safer Care Victoria, Australia
| | - Nobhojit Roy
- Trauma Research Group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Dept of Global Public Health, Karolinska Institutet, Stockholm, Sweden; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia.
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Sansosti AA, Munoz-Valencia A, Bonilla-Escobar FJ, Raykar N, Puyana JC. Blood Unit Availability and its Association with Fatal Hemorrhagic Shock in Trauma Patients in a Middle-Income Country. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Raykar N, Mukhopadhyay S, Saluja S, Amte S, David S, Gnanaraj J, Kataria R, Jadhav B, Johnson W, Meara J, Menon N, Prabhu RD, Shetty D, Singh R, Tongaonkar R, Vora R, Roy N. Implementation of The Lancet Commission on Global Surgery in India. Healthcare (Basel) 2019; 7:4-6. [DOI: 10.1016/j.hjdsi.2018.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/04/2018] [Indexed: 11/28/2022] Open
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Raykar N, Meara J, Gawande A, Farmer P, Roy N. Moving forward the Lancet Commission on Global Surgery: The Karad Consensus Statement. Healthc (Amst) 2018; 7:3. [PMID: 30497933 DOI: 10.1016/j.hjdsi.2018.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/04/2018] [Indexed: 11/25/2022]
Affiliation(s)
- Nakul Raykar
- Department of Surgery, Beth Israel Deaconess Medical Center, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States.
| | - John Meara
- Department of Oral and Plastic Surgery, Boston Children's Hospital, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States.
| | - Atul Gawande
- Department of Surgery, Brigham & Women's Hospital, Ariadne Laboratories, Harvard Medical School, Boston, MA, United States.
| | - Paul Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, Department of Infectious Diseases, Brigham & Women's Hospital, Partners-in-Health, Boston, MA, United States.
| | - Nobhojit Roy
- Advisor, Indian Ministry of Health and Family Welfare, Department of Surgery, BARC Hospital, Association of Rural Surgeons of India, Mumbai, India.
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Gupta S, Khajanchi M, Kumar V, Raykar N, Alkire B, Roy N, Park KB. 188 Third Delay in Traumatic Brain Injury. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
The current system of blood banks in India is such that rural patients are deprived of timely access to an adequate volume of life-saving blood, adding to preventable mortality. On the basis of an academic framework for a blood transfusion system, we describe an alternative approach in which rural practitioners utilise unbanked blood transfusions from a voluntary pool of pre-screened donors. This system would provide safe blood - as evidenced by international experience and limited projected increase in transfusion-transmissible infection in India - at a fraction of the financial cost imposed by the current system. Given the failing status quo and the undue burden placed on rural clinicians and patients to procure blood, it is imperative that policy-makers further explore the use of unbanked, direct blood transfusion for patients facing emergent, life-threatening haemorrhage.
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Affiliation(s)
- Rachita Sood
- University of Miami, Miller School of Medicine, Miami, FL 33136, USA and Program in Global Surgery and Social Change, Harvard Medical School, Boston MA 02115 USA.,
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA 02115, USA and Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02115, USA.,
| | - Brian Till
- Program in Global Surgery and Social Change, Harvard Medical School, Boston MA 02115, USA and University of Vermont, Larner College of Medicine, Burlington, VT 05405, USA.,
| | - Hemant Shah
- CARE India - Bihar, 14 Patliputra Colony, Patna, Bihar, 800 013 India.,
| | - Nobhojit Roy
- WHO Collaborating Centre for Research on Surgical Care Delivery in LMICs; Surgical Unit, BARC Hospital (Govt. of India), Mumbai - 400 094, India.,
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Scott JW, Havens JM, Raykar N, Rose JA, Salim A, Haider AH, Meara JG, Shrime MG. High Risk of Catastrophic Health Expenditure among Uninsured Emergency Surgery Patients in the United States. J Am Coll Surg 2017. [DOI: 10.1016/j.jamcollsurg.2017.07.262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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19
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Saluja S, Silverstein A, Mukhopadhyay S, Lin Y, Raykar N, Keshavjee S, Samad L, Meara JG. Using the Consolidated Framework for Implementation Research to implement and evaluate national surgical planning. BMJ Glob Health 2017; 2:e000269. [PMID: 29225930 PMCID: PMC5717928 DOI: 10.1136/bmjgh-2016-000269] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 04/22/2017] [Accepted: 04/24/2017] [Indexed: 11/28/2022] Open
Abstract
The Lancet Commission on Global Surgery defined six surgical indicators and a framework for a national surgical plan that aimed to incorporate surgical care as a part of global public health. Multiple countries have since begun national surgical planning; each faces unique challenges in doing so. Implementation science can be used to more systematically explain this heterogeneous process, guide implementation efforts and ultimately evaluate progress. We describe our intervention using the Consolidated Framework for Implementation Research. This framework requires identifying characteristics of the intervention, the individuals involved, the inner and outer setting of the intervention, and finally describing implementation processes. By hosting a consultative symposium with clinicians and policy makers from around the world, we are able to specify key aspects of each element of this framework. We define our intervention as the incorporation of surgical care into public health planning, identify local champions as the key individuals involved, and describe elements of the inner and outer settings. Ultimately we describe top-down and bottom-up models that are distinct implementation processes. With the Consolidated Framework for Implementation Research, we are able to identify specific strategic models that can be used by implementers in various settings. While the integration of surgical care into public health throughout the world may seem like an insurmountable challenge, this work adds to a growing effort that seeks to find a way forward.
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Affiliation(s)
- Saurabh Saluja
- Department of Surgery, Weill Cornell Medicine, New York, USA.,Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE
| | - Allison Silverstein
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Medical Education, University of Miami, Miami, USA
| | - Swagoto Mukhopadhyay
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE.,Department of Surgery, University of Connecticut, Hartford, USA
| | - Yihan Lin
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Surgery, University of Colorado, Denver, USA
| | - Nakul Raykar
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, USA
| | - Salmaan Keshavjee
- Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE
| | - Lubna Samad
- Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE.,Department of Surgery, Indus Hospital, Karachi, Pakistan
| | - John G Meara
- Department of Global Health and Social Medicine, Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Center for Global Health Delivery - Dubai, Harvard Medical School, Dubai, UAE.,Department of Plastic Surgery, Boston Children's Hospital, Boston, USA
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20
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Bruno E, White MC, Baxter LS, Ravelojaona VA, Rakotoarison HN, Andriamanjato HH, Close KL, Herbert A, Raykar N, Saluja S, Shrime MG. An Evaluation of Preparedness, Delivery and Impact of Surgical and Anesthesia Care in Madagascar: A Framework for a National Surgical Plan. World J Surg 2017; 41:1218-1224. [PMID: 27905017 DOI: 10.1007/s00268-016-3847-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The Lancet Commission on Global Surgery (LCoGS) described the lack of access to safe, affordable, timely surgical, and anesthesia care. It proposed a series of 6 indicators to measure surgery, accompanied by time-bound targets and a template for national surgical planning. To date, no sub-Saharan African country has completed and published a nationwide evaluation of its surgical system within this framework. METHOD Mercy Ships, in partnership with Harvard Medical School and the Madagascar Ministry of Health, collected data on the 6 indicators from 22 referral hospitals in 16 out of 22 regions of Madagascar. Data collection was by semi-structured interviews with ministerial, medical, laboratory, pharmacy, and administrative representatives in each region. Microsimulation modeling was used to calculate values for financial indicators. RESULTS In Madagascar, 29% of the population can access a surgical facility within 2 h. Surgical workforce density is 0.78 providers per 100,000 and annual surgical volume is 135-191 procedures per 100,000 with a perioperative mortality rate of 2.5-3.3%. Patients requiring surgery have a 77.4-86.3 and 78.8-95.1% risk of incurring impoverishing and catastrophic expenditure, respectively. Of the six LCoGS indicator targets, Madagascar meets one, the reporting of perioperative mortality rate. CONCLUSION Compared to the LCoGS targets, Madagascar has deficits in surgical access, workforce, volume, and the ability to offer financial risk protection to surgical patients. Its perioperative mortality rate, however, appears better than in comparable countries. The government is committed to improvement, and key stakeholder meetings to create a national surgical plan have begun.
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Affiliation(s)
- Emily Bruno
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.,University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA.,Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Michelle C White
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar. .,M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin.
| | - Linden S Baxter
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar
| | | | | | | | - Kristin L Close
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar.,M/V Africa Mercy, Mercy Ships, Port of Cotonou, Benin
| | - Alison Herbert
- M/V Africa Mercy, Mercy Ships, Port of Toamasina, Madagascar
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Saurabh Saluja
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Mark G Shrime
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA.,Department of Otolaryngology, Harvard Medical School, Boston, MA, USA.,Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
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21
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Jenny HE, Saluja S, Sood R, Raykar N, Kataria R, Tongaonkar R, Roy N. Access to safe blood in low-income and middle-income countries: lessons from India. BMJ Glob Health 2017; 2:e000167. [PMID: 30206488 PMCID: PMC5584485 DOI: 10.1136/bmjgh-2016-000167] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 02/13/2017] [Accepted: 02/16/2017] [Indexed: 01/07/2023] Open
Abstract
Timely, affordable access to screened blood is essential to the provision of safe surgical care and depends on three key aspects: adequate volume of blood supply, safe protocols for blood donation and transfusion, and appropriate regulation to ensure safe, equitable and sustainable distribution. Many low-income and middle-income countries experience a deficit in these categories, particularly in rural areas. We draw on the experience of rural surgical practitioners in India and summarise the existing literature to evaluate India's blood banking system and discuss its major barriers to the safe and equitable provision of blood. Many low-income and middle-income countries struggle with accruing a sufficient voluntary, unpaid blood donation base to meet the need. Efforts to increase blood supply through mandatory family replacement donations can lead to dangerous delays in care provision. Additionally, prohibition of unbanked, directed blood transfusion restricts the options of health practitioners, particularly in rural areas. Blood safety is also a significant concern, and efforts must be taken to decrease the risk of transfusion-transmitted infections and inform and treat donors who test positive. Lastly, blood banking systems need a centralised governing body to ensure fair prices for blood, promote comprehensive transfusion reporting and increase system-wide transparency and accountability.
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Affiliation(s)
- Hillary E Jenny
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, USA.,Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA
| | - Saurabh Saluja
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA.,Department of Surgery, Weill Cornell Medicine, New York, USA
| | - Rachita Sood
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA.,Department of Medical Education, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Nakul Raykar
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, USA.,Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Raman Kataria
- Department of Surgery, Jan Swasthya Sahyog, Beltookri, Chhattisgarh, India
| | | | - Nobhojit Roy
- Department of Surgery, BARC Hospital, Mumbai, Maharashtra, India
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Raykar N, Mukhopadhyay S, Ng-Kamstra JS, Lin Y, Saluja S, Scott JW, Anderson G, Meara JG, Tefera G, Bickler SW. Progress in achieving universal access to surgical care: An update and a path forward. Bull Am Coll Surg 2016; 101:12-18. [PMID: 27405180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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23
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Coffron M, Raykar N, Selzer DJ, Meara JG. New resources from the College offer alternative approaches to medical liability reform. Bull Am Coll Surg 2015; 100:14-17. [PMID: 25842603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Raykar N, Mandigo M, Nagengast E, Coffron M, Hanks JB, Meara JG, Tracci MC. Medicaid expansion likely to affect the delivery of surgical care. Bull Am Coll Surg 2014; 99:10-21. [PMID: 24665777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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