Bellwether Procedures for Monitoring and Planning Essential Surgical Care in Low- and Middle-Income Countries: Caesarean Delivery, Laparotomy, and Treatment of Open Fractures

Surveying anesthesia care provision and deficiencies among the secondary public sector hospitals of rural Sindh, Pakistan

PURPOSE

Provision of anesthesia care must go hand in hand with surgical care to equitably widen surgical coverage of underserved populations, especially the rural segments of low- and middle-income countries. The aim of this study was to assess the availability of key items and infrastructure needed for anesthesia care.

METHODS

We conducted a cross-sectional survey at ten subdistrict or taluqa headquarter (THQ) hospitals and five district headquarter (DHQ) hospitals in six rural districts of the Sindh province of Pakistan using the Anesthesia Facility Assessment Tool. We assessed the domains of infrastructure, workforce, service delivery, conduct of anesthesia, equipment, and medications. We also scored these components and then compared the difference in mean scores.

RESULTS

Three hospitals did not meet the minimum bed number required for a secondary hospital. Four hospitals had nonfunctioning operating rooms and conducted procedures elsewhere. Ten had full-time, certified anesthesiologists, while 11 had a postanesthesia care unit. There were only two hospitals with critical care units providing mechanical ventilation, and only one hospital conducting telemetry. Six hospitals did not have a dedicated anesthesia provider present at all times. Thirteen hospitals did not use the World Health Organization preoperative checklist before performing procedures. There were deficiencies in drugs such as hypnotics, opioids, and vasopressors.

CONCLUSION

There are many shortcomings in anesthesia care provision among these rural hospitals. Greater attention and investment are needed to safely conduct anesthesia in this setting.

Delayed Surgery Increases the Rate of Infection in Closed Diaphyseal Tibial and Femoral Fractures

BACKGROUND

Although delays in musculoskeletal care in low- and middle-income countries (LMICs) are well documented in the open fracture literature, the impact of surgical delays on closed fractures is not well understood. This study aimed to assess the impact of surgical delay on the risk of infection in closed long-bone fractures treated with intramedullary nailing in LMICs.

METHODS

Using the SIGN (Surgical Implant Generation Network) Surgical Database, patients ≥16 years of age who were treated with intramedullary nailing for closed diaphyseal femoral and tibial fractures from January 2018 to December 2021 were identified. Infection was diagnosed based on the assessment by the treating surgeon. A logistic regression model, adjusting for potential confounders, was used to analyze the association between delays to surgery (in weeks) and infection.

RESULTS

Of the 9,477 closed fractures that were included in this study, 58% were femoral fractures and 42% were tibial fractures. The mean age was 35 years, and 76.2% of the patients were men. The mean delay to surgery was 10.5 days, and the median delay to surgery was 6 days. The overall infection rate was 3.1%. The odds of developing an infection increased by 9.2% with each week of delayed surgical treatment (odds ratio,1.092; 95% confidence interval, 1.042 to 1.145). Increasing delays were also associated with longer surgery duration and higher rates of open reduction.

CONCLUSIONS

Surgical delays in LMICs were associated with an increased risk of infection in closed long-bone fractures. This study quantified the increased risk of infection due to delays in receiving care, highlighting the importance of timely surgery for closed fractures in LMICs.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Adherence to Enhanced Recovery After Surgery (ERAS) With Bellwether Surgical Procedures in Ethiopia: A Retrospective Study

BACKGROUND

Enhanced recovery after surgery (ERAS) is a multimodal perioperative care approach that aims to improve patient outcomes by reducing physiological stress and promoting organ functional recovery. Implementing ERAS in low-resource settings faces challenges due to limited infrastructure and resources. This study examined the adherence to five ERAS recommendations with Bellwether surgical procedures in Ethiopian surgical facilities.

METHOD

A retrospective database review of the Ethiopian perioperative registry was conducted. A total of 555 patients were included in this study. Data extraction included patient demographics, American Society of Anesthesiologists' Physical Status classification, surgical variables, postoperative hospital length of stay (LOS), and ERAS guidelines components. The primary outcome was adherence to five ERAS guidelines recommendations (early mobilization, feeding initiation, postoperative nausea and vomiting prophylaxis, early catheter removal, and IV fluids discontinuation). The secondary outcomes included: (i) the association between adherence to ERAS guidelines and LOS and (ii) a total unduplicated reach and frequency analysis to determine the two recommendations with the most impact on decreasing LOS for future implementation in low-resource environments.

RESULTS

A total of 555 patients were included across the three surgical categories: CS (274, 49.4%), OBF (126, 22.7%), and laparotomy (155, 27.9%). The primary outcome showed that the overall adherence was 1810 (65.2%) of the total number of the five ERAS guidelines recommendations in the cohort (2275 recommendations). The secondary outcomes showed that adherence to all five ERAS recommendations reduced LOS by 128 h compared to nonadherence to any ERAS elements. Adherence to early mobilization, early removal of urinary catheters, and early feeding each have shown consistent reductions in LOS across all Bellwether surgical procedures.

CONCLUSION

The implementation of a limited set of ERAS recommendations in low-resource environments has the potential to decrease LOS by approximately 5 days for Bellwether surgical procedures.

Negative Pressure Dressings to Prevent Surgical Site Infection After Emergency Laparotomy: The SUNRRISE Randomized Clinical Trial

Importance

Patients undergoing unplanned abdominal surgical procedures are at increased risk of surgical site infection (SSI). It is not known if incisional negative pressure wound therapy (iNPWT) can reduce SSI rates in this setting.

Objective

To evaluate the effectiveness of iNPWT in reducing the rate of SSI in adults undergoing emergency laparotomy with primary skin closure.

Design, Setting, and Participants

SUNRRISE was an assessor-masked, pragmatic, phase 3, individual-participant, randomized clinical trial. Adult patients undergoing emergency laparotomy in 22 hospitals in the UK and 12 hospitals in Australia between December 18, 2018, and May 25, 2021, were recruited. Patients were followed up for 30 days postprocedure; database closure was on August 25, 2021.

Interventions

Participants were randomized 1:1 to receive iNPWT (n = 411), which involved a specialized dressing used to create negative pressure over the closed wound vs the surgeon's choice of wound dressing (n = 410). Randomization and dressing application occurred in the operating room at the end of the surgical procedure.

Main Outcomes and Measures

The primary outcome measure was SSI up to 30 days postprocedure, evaluated by an assessor masked to the randomized allocation and using criteria from the US Centers for Disease Control and Prevention. There were 7 secondary outcomes, including length of hospital stay, postoperative complications up to 30 days, hospital readmission for wound-related complications within 30 days, wound pain, and quality of life.

Results

A total of 840 patients were randomized (536 from the UK; 304 from Australia). Overall, 52% were female; the mean age was 63.8 (range, 18.8 to 95.3) years. After postrandomization exclusions (N = 52), 394 participants per group were included in the primary analysis. The number of participants who had an SSI in the iNPWT group was 112 of 394 (28.4%), compared with 108 of 394 (27.4%) in the surgeon's preference group (relative risk, 1.03 [95% CI, 0.83-1.28]; P = .78). This finding was consistent across the preplanned subgroup analyses, including degree of contamination, presence of a stoma, participant body mass index, and skin preparation used, and across all preplanned sensitivity analyses. Of 7 secondary outcomes, 6 showed no significant difference, including hospital readmission, quality of life, and hospital stay (median [IQR], 8 [6-14] days in the iNPWT group and 9 [6-14.5] days in the surgeon's preference group [ratio of geometric means, 0.96 (95% CI, 0.88-1.06); P = .21]).

Conclusions and Relevance

Routine application of iNPWT to the closed surgical wound after emergency laparotomy did not prevent SSI more than other dressings.

Trial Registration

isrctn.com Identifier: ISRCTN17599457; anzctr.org.au Identifier: ACTRN12619000496112.

A Cost-Effectiveness Analysis of Intramedullary Nailing Versus External Fixation for Open Tibial Fractures in Tanzania

Background

Open tibial fractures are a cause of substantial orthopaedic morbidity in low- and middle-income countries. These injuries represent a substantial cost burden to both individual patients and society because of their high propensity for complications, such as infection, nonunion, and malunion. External fixation and intramedullary (IM) nailing are both utilized for definitive treatment of open tibial fractures, but given the differences in cost and lack of clear superiority of intramedullary nailing, cost-effectiveness becomes important to consider in low- and middle-income countries. The present study aimed to examine the cost-effectiveness of IM nailing versus external fixation within Tanzania.

Methods

This study utilized data from a randomized controlled trial conducted at a single tertiary hospital in Dar es Salaam, Tanzania. Direct cost data were collected via an internal audit of operating costs and hospital staff time. Indirect costs data were collected from patients in a long-term follow-up study assessing total lost work. A Markov model was utilized to run the cost-effectiveness simulations. The primary outcome was the incremental cost-effectiveness ratio (ICER) over a lifetime time horizon. Both the payer and societal perspectives were considered. To account for uncertainty, both 1-way and probabilistic sensitivity analyses were performed.

Results

From the payer perspective, the cost of external fixation ($396 USD) was lower than that of IM nailing ($529), primarily because of shorter operative times. However, IM nailing was associated with more quality-adjusted life-years (QALYs). From the payer perspective, the ICER was $499 per QALY with a donated nail and $701 per QALY with a purchased locally available nail. From the societal perspective, the ICER was lower among patients undergoing IM nailing, at $70 per QALY, largely because of shorter recovery times.

Conclusions

From both the payer and the societal perspective, IM nailing is considered highly cost-effective on the basis of the World Health Organization willingness-to-pay thresholds. This finding was consistent whether the IM nail was donated or purchased from local suppliers. These results are likely generalizable to other tertiary referral centers in low- and middle-income countries.

Level of Evidence

Economic Level II. See Instructions for Authors for a complete description of levels of evidence.

Determinant of adverse early neonatal outcomes following emergency cesarean section in North West, Ethiopia: institutional-based case-control study

BACKGROUND

The World Health Organization recommends a cesarean delivery rate of 5-15%, which is thought to be within the range that can reduce infant morbidity and mortality. Various investigations have shown that those poor newborn outcomes are influenced by a variety of maternal and fetal factors and are more prevalent in emergencies than planned cesarean deliveries. Ethiopia is one of the five nations that account for 50% of all neonatal fatalities worldwide. Sub-Saharan African countries account for 38% of all infant deaths worldwide.

AIM

To know the determinants of adverse early neonatal outcomes after emergency cesarean delivery.

METHOD AND MATERIAL

A multicenter case-control study design would be carried out between November 2022 and January 2023. Using the consecutive method, a sample of 318 mother-newborn pairs was studied. Direct observation and face-to-face interviews were undertaken to gather the data using a semi-structured questionnaire. For both data input and analysis, Epi Data version 4.6 and Stata version 14 software were used. Both the crude and adjusted odds ratios were computed. The measure of significance was based on the adjusted odds ratio with a 95% confidence interval and a p-value of less than 0.05.

RESULTS

Maternal age over 35, the presence of danger signs during pregnancy, and non-reassuring fetal heart rate were significantly associated with increased risk of adverse fetal outcomes following emergency cesarean section. Women aged over 35 were 3.6 times more likely to experience adverse fetal outcomes compared to younger women (AOR: 3.6, 95% CI: 1.1, 9.7). Women with danger signs during pregnancy were 3.5 times more likely to have adverse fetal outcomes compared to those without (AOR = 3.5, 95% CI: 2.4, 36). Similarly, cases with non-reassuring fetal heart rate were associated with a 5.2 times higher risk of adverse newborn outcomes (AOR = 5.2, 95% CI: 1.1, 26).

CONCLUSION

This study identified advanced maternal age (over 35 years old), pregnancy complications, and non-reassuring fetal heart rate as significant risk factors for adverse neonatal outcomes following emergency cesarean section.

Geospatial Access to Emergency Obstetric Surgery in Indonesia: Is Travel Time for Access Too Long?

Background: Ensuring timely access to safe and affordable surgery within a travel time of a 2‑h drive or 30‑min walk is crucial for achieving universal health coverage, as endorsed by the Lancet Commission on Global Surgery (LCoGS). In this study, we aimed to quantify the percentage of Indonesian women of reproductive age (WRA) who can access a hospital with emergency obstetric and gynecological services within this time frame. In addition, we aimed to identify the underserved populations. Methods: We identified hospitals across 38 provinces using the database from the Indonesian Society of Obstetricians and Gynecologists (ISOG) and the Indonesian Ministry of Health database that provide emergency obstetric services. We conducted geospatial analysis using the cost of distance and service area tools in ArcGIS Pro with WRA population data derived from Facebook's high‑resolution settlement layer (HRSL) maps. Results: Of the 3,202 recorded hospitals, 2,855 (89.2%) had an obstetric gynecologist (OBGYN). The workforce of 5,305 OBGYNs consisted of 4,857 (91.6%) actively practicing OBGYNs, of which 3,405 (64.2%) practice in hospitals only. Of the WRA population, 94.5% lived within 2 h of a facility. However, eight provinces had low timely access to these hospitals. Conclusion: Indonesia provides universal health coverage; however, stark disparities exist in the geographic access to emergency obstetric surgical care in certain provinces. Geospatial mapping and survey data work together to aid in assessing the strength of the surgical system and in identifying gaps in geographic access to timely surgery.

Barriers to Performing Essential Surgery at First-Level Hospitals in Pakistan: A Mixed Methods Study

INTRODUCTION

There are numerous reasons for underutilization of the public health sector for surgery in Pakistan. This results in patients being diverted to private hospitals or tertiary care centers in urban areas. Diversions overburden the hospitals and significantly increase out-of-pocket costs for the patients. This study aims to determine the barriers to surgical care in first-level hospitals in Pakistan's Sindh province.

METHODS

We conducted a concurrent nested mixed methods study from May to June 2021 in public sector first-level hospitals in the Sindh province. Fifteen hospitals in six districts were surveyed. A consolidated hospital assessment tool adapted from the World Health Organization's Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was used for quantitative data collection. Interview guides were developed for staff interviews.

RESULTS

Availability of trained staff was found to be the biggest barrier to the provision of safe surgery. Only eight hospitals had a general surgeon, anesthesiologist, and obstetrician/gynecologist, while the remaining had 1-2 of the three disciplines. Thirteen hospitals had a functioning x-ray machine, while 14 facilities had functioning ultrasound machines with trained personnel to operate them. Only three facilities always had blood available for transfusion. The qualitative component corroborated that the biggest barrier to providing surgical care was the lack of human resources.

CONCLUSIONS

The lack of human resources is difficult to overcome. We found evidence of task-shifting to medical officers and trainee anesthesiologists, but this is without discrete regulation and monitoring. Building surgical workforce capacity must be addressed in the interest of quality care.

Predictors of quality of life, economic impact, and loss to follow-up after open tibial shaft fractures in Ghana

Objectives

Open tibia fractures are associated with substantial morbidity and impact on quality of life. Despite increasing incidence in low-resource settings, most open tibia fracture research comes from high-resource settings. This study aimed to assess the impact of socioeconomic status on treatment modality and evaluate predictors of health-related quality of life following open tibia fractures in Ghana.

Design

A single-center prospective observational study was conducted in Kumasi, Ghana, from May 2020 to April 2022. Adults with open tibial shaft fractures presenting within 2 weeks of injury were eligible. Demographics, comorbidities, socioeconomic factors, and hospital course were collected at enrollment. Follow-up was scheduled at 8, 12, 26, and 52 weeks. A telephone survey assessing reasons for loss to follow-up was initiated on enrollment completion.

Results

A total of 180 patients were enrolled. Most patients were employed before injury (79.9%), had government insurance (67.2%), and were from rural areas (59.4%). Fracture classification was primarily Gustilo-Anderson type 3A (49.1%). No relationship between socioeconomic predictors and treatment modality was identified. The largest barriers to follow-up were preference for bonesetter treatment (63.1%), treatment cost (48.8%), and travel cost (29.8%). Of the lost to follow-up patients contacted, 67 (79.8%) reported receiving traditional bonesetter care. Reasons for seeking traditional bonesetter care included ease of access (83.6%), lower cost (77.6%), and familial influence (50.7%).

Conclusion

No association was identified between socioeconomic predictors and choice of treatment. Bonesetter treatment plays a substantial role in the care of open tibia fractures in Ghana, largely because of ease of access and lower cost.

A scoping review of Enhanced Recovery After Surgery (ERAS), protocol implementation, and its impact on surgical outcomes and healthcare systems in Africa

BACKGROUND

Enhanced Recovery After Surgery (ERAS) is a patient-centered approach to surgery designed to reduce stress responses and facilitate faster recovery. ERAS protocols have been widely adopted in high-income countries, supported by robust research demonstrating improved patient outcomes. However, in Africa, there is limited evidence regarding its implementation. This review aims to identify the existing literature on the implementation of ERAS principles in Africa, the reported clinical outcomes, and the challenges and recommendations for successful implementation.

METHODS

We conducted a librarian-assisted literature search of electronic research databases between October and November 2023. Titles and abstracts were screened for eligibility, and duplicates were then removed, followed by full-text assessment of potentially eligible studies. We utilized the summative content analysis method to synthesize and group the data into fewer categories based on agreed-upon criteria. Descriptive statistics were used to describe the results.

RESULTS

The search identified 342 potential studies resulting in 15 eligible studies for inclusion in the review. The publication years ranged from 2016 to 2023. The studies originated from three countries: Egypt (n = 10), South Africa (n = 4), and Uganda (n = 1). Successful implementation was associated with reduced hospital length of stay (n = 12), lower mortality rates (n = 3), and improved pain outcomes (n = 7). Challenges included protocol adherence (n = 5) and limitations of the research design to generate strong evidence (n = 3). Recommendations included formal adoption of ERAS principles (n = 5), the need for sustained research commitment, and exploration of the applicability of ERAS in diverse surgical contexts (n = 8). Large-scale implementation beyond individual institutions was encouraged to further validate its impact on patient outcomes and healthcare costs (n = 1).

CONCLUSIONS

Despite the limited number of studies on ERAS implementation in Africa, the available evidence suggests that it reduces the length of hospital stays and mortality rates. This is crucial for the region, given its higher mortality rates, necessitating more collaborative, methodically well-designed studies to establish stronger evidence for ERAS in lower-resource environments.

How ready is the health care system in Northeast India for surgical delivery? a mixed-methods study on surgical capacity and need

BACKGROUND

Surgical services are scarce with persisting inequalities in access across populations and regions globally. As the world's most populous county, India's surgical need is high and delivery rates estimated to be sub-par to meet need. There is a dearth of evidence, particularly sub-regional data, on surgical provisioning which is needed to aid planning.

AIM AND METHOD

This mixed-methods study examines the state of surgical care in Northeast India, specifically health care system capacity and barriers to surgical delivery. It involved a facility-based census and semi-structured interviews with surgeons and patients across four states in the region.

RESULTS

Abdominal conditions constituted a large portion of the overall surgeries across public and private facilities in the region. Workloads varied among surgical providers across facilities. Task-shifting occurred, involving non-specialist nursing staff assisting doctors with surgical procedures or surgeons taking on anaesthetic tasks. Structural factors dis-incentivised facility-level investment in suitable infrastructure. Facility functionality was on average higher in private providers compared to public providers and private facilities offer a wider range of surgical procedures. Facilities in general had adequate laboratory testing capability, infrastructure and equipment. Public facilities often do not have surgeon available around the clock while both public and private facilities frequently lack adequate blood banking. Patients' care pathways were shaped by facility-level shortages as well as personal preferences influenced by cost and distance to facilities.

DISCUSSION AND CONCLUSION

Skewed workloads across facilities and regions indicate uneven surgical delivery, with potentially variable care quality and provider efficiency. The need for a more system-wide and inter-linked approach to referral coordination and human resource management is evident in the results. Existing task-shifting practices, along with incapacities induced by structural factors, signal the directions for possible policy action.

The global burden of fracture-related infection: can we do better?

Fracture-related infection is a major complication related to musculoskeletal injuries that not only has important clinical consequences, but also a substantial socioeconomic impact. Although fracture-related infection is one of the oldest disease entities known to mankind, it has only recently been defined and, therefore, its global burden is still largely unknown. In this Personal View, we describe the origin of the term fracture-related infection, present the available data on its global impact, and discuss important aspects regarding its prevention and management that could lead to improved outcomes in both high-resource and low-resource settings. We also highlight the need for health-care systems to be adequately compensated for the high cost of human resources (trained staff) and well-equipped facilities required to adequately care for these complex patients. Our aim is to increase awareness among clinicians and policy makers that fracture-related infection is a disease entity that deserves prioritisation in terms of research, with the goal to standardise treatment and improve patient outcomes on a global scale.

Evaluating patient factors, operative management and postoperative outcomes in trauma laparotomy patients worldwide: a protocol for a global observational multicentre trauma study

INTRODUCTION

Trauma contributes to the greatest loss of disability-adjusted life-years for adolescents and young adults worldwide. In the context of global abdominal trauma, the trauma laparotomy is the most commonly performed operation. Variation likely exists in how these patients are managed and their subsequent outcomes, yet very little global data on the topic currently exists. The objective of the GOAL-Trauma study is to evaluate both patient and injury factors for those undergoing trauma laparotomy, their clinical management and postoperative outcomes.

METHODS

We describe a planned prospective multicentre observational cohort study of patients undergoing trauma laparotomy. We will include patients of all ages who present to hospital with a blunt or penetrating injury and undergo a trauma laparotomy within 5 days of presentation to the treating centre. The study will collect system, patient, process and outcome data, following patients up until 30 days postoperatively (or until discharge or death, whichever is first). Our sample size calculation suggests we will need to recruit 552 patients from approximately 150 recruiting centres.

DISCUSSION

The GOAL-Trauma study will provide a global snapshot of the current management and outcomes for patients undergoing a trauma laparotomy. It will also provide insight into the variation seen in the time delays for receiving care, the disease and patient factors present, and patient outcomes. For current standards of trauma care to be improved worldwide, a greater understanding of the current state of trauma laparotomy care is paramount if appropriate interventions and targets are to be identified and implemented.

Essential surgery delivery in the Northern Kivu Province of the Democratic Republic of the Congo

INTRODUCTION

Surgical services are an essential part of a functional healthcare system, but the Lancet Commission of Global Surgery (LCoGS) indicators of surgical capacity such as perioperative workforce and surgical volume are unknown in many low- and middle-income countries (LMICs) including the Democratic Republic of Congo (DRC). We aimed to determine the surgical capacity and its associated factors within the DRC.

METHODS

Hospitals were assessed in the North Kivu province of the DRC. Hospital characteristics and surgical rates were determined using the WHO-PGSSC hospital assessment tool and operating room (OR) registries. The primary outcome of interest was the number of Bellwether operations (i.e. Caesarean sections, laparotomies, and external fixation for bone fractures) per 100,000 people. Univariate and multiple linear regressions were performed. Primary predictors were the number of trained surgeons, anaesthesiologists, and obstetricians (SAOs) and the number of perioperative providers (including clinical officers and nurse anaesthetists) per 100,000 people.

RESULTS

Twenty-eight hospitals in North Kivu were assessed over one year in 2021; 24 (86%) were first-level referral health centres while 4 (14%) were second-level referral hospitals. In total, 11,176 Bellwether procedures were performed in the region in one year. Rates per 100,000 people were 1,461 Bellwether surgical interventions, 1.05 SAOs, and 13.1 perioperative providers. In univariate linear regression analysis, each additional SAO added 239 additional cases annually (p = 0.023), while each additional perioperative provider added 110 cases annually (p < 0.001). In our multiple regression analysis adjusting for other hospital services, the association between workforce and Bellwether surgeries was no longer significant.

CONCLUSIONS

The surgical workforce in DRC did not meet the LCoGS benchmark of 20 SAOs per 100,000 people but was not an independent predictor of surgical capacity. Major investment is needed to simultaneously bolster healthcare facilities and increase surgical workforce training.

The impact of elective surgery postponement during COVID-19 on emergency bellwether procedures in a large tertiary centre in Singapore

The coronavirus disease 2019 (COVID-19) pandemic drove many healthcare systems worldwide to postpone elective surgery to increase healthcare capacity, manpower, and reduce infection risk to staff. The aim of this study was to assess the impact of an elective surgery postponement policy in response to the COVID-19 pandemic on surgical volumes and patient outcomes for three emergency bellwether procedures. A retrospective cohort study of patients who underwent any of the three emergency procedures [Caesarean section (CS), emergency laparotomy (EL), and open fracture (OF) fixation] between 1 January 2018 and 31 December 2021 was conducted using clinical and surgical data from electronic medical records. The volumes and outcomes of each surgery were compared across four time periods: pre-COVID (January 2018-January 2020), elective postponement (February-May 2020), recovery (June-November 2020), and postrecovery (December 2020-December 2021) using Kruskal-Wallis test and segmented negative binomial regression. There was a total of 3886, 1396, and 299 EL, CS, and OF, respectively. There was no change in weekly volumes of CS and OF fixations across the four time periods. However, the volume of EL increased by 47% [95% confidence interval: 26-71%, P = 9.13 × 10-7) and 52% (95% confidence interval: 25-85%, P = 3.80 × 10-5) in the recovery and postrecovery period, respectively. Outcomes did not worsen throughout the four time periods for all three procedures and some actually improved for EL from elective postponement onwards. Elective surgery postponement in the early COVID-19 pandemic did not affect volumes of emergency CS and OF fixations but led to an increase in volume for EL after the postponement without any worsening of outcomes.

Geospatial mapping of 2-hour access to timely essential surgery in the Philippines

OBJECTIVES

Timely access to safe and affordable surgery is essential for universal health coverage. To date, there are no studies evaluating 2-hour access to Bellwether procedures (caesarean section, laparotomy, open fracture management) in the Philippines. The objectives of this study were to measure the proportion of the population able to reach a Bellwether hospital within 2 hours in the Philippines and to identify areas in the country with the most surgically underserved populations.

METHODS

All public hospitals with Bellwether capacities were identified from the Philippines Ministry of Health website. The service area tool in ArcGIS Pro was used to determine the population within a 2-hour drive time of a Bellwether facility. Finally, suitability modelling was conducted to identify potential future sites for a surgical facility that targets the most underserved regions in the Philippines.

RESULTS

428 Bellwether capable hospitals were identified. 85.1% of the population lived within 2 hours of one of these facilities. However, 6 regions had less than 80% of its population living within 2 hours of a Bellwether capable facility: Bicol, Eastern Visayas, Zamboanga, Autonomous region of Muslim Mindanao, Caraga and Mimaropa. Suitability analysis identified four regions-Caraga, Mimaropa, Calabarzon and Zamboanga-as ideal locations to build a new hospital with surgical capacity to improve access rates.

CONCLUSION

85.1% of the population of the Philippines are able to reach Bellwether capable hospitals within 2 hours, with regional disparities in terms of access rates. However, other factors such as weather, traffic conditions, financial access, availability of 24-hour surgical services and access to motorised vehicles should also be taken into consideration, as they also affect actual access rates.

Defining Feasibility as a Criterion for Essential Surgery: A Qualitative Study with Global Children's Surgery Experts

BACKGROUND

The Disease Control Priorities (DCP-3) group defines surgery as essential if it addresses a significant burden, is cost-effective, and is feasible-yet the feasibility component remains largely unexplored. The aim of this study was to develop a precise definition of feasibility for essential surgical procedures for children.

METHODS

Four online focus group discussions (FGDs) were organized among 19 global children's surgery providers with experience of working in low- and lower-middle-income countries (LMICs), representing 10 countries. FGDs were transcribed verbatim, and qualitative data analysis was performed. Codes, categories, themes, and subthemes were identified.

RESULTS

Six determinants of feasibility were identified, including: adequate human resources; adequate material resources; procedure and disease complexity; team commitment and understanding of their setting; timely access to care; and the ability to monitor and achieve good outcomes. Factors unique to feasibility of children's surgery included children's right to health and their reliance on adults for accessing safe and timely care; the need for specialist workforce; and children's unique perioperative care needs. FGD participants reported a greater need for task-sharing and shifting, creativity, and adaptability in resource-limited settings. Resource availability was seen to have a direct impact on decision-making and prioritization, e.g., saving a life versus achieving the best outcome.

CONCLUSIONS

The identification of a precise definition of feasibility serves as a pivotal step in identifying a list of essential surgical procedures for children, which would serve as indicators of institutional surgical capacity for this age group.

A national perspective on exposure to essential surgical procedures among medical trainees in Nigeria: a cross-sectional survey and recommendations

BACKGROUND

In sub-Saharan Africa, recent graduates from medical school provide more direct surgical and procedural care to patients than their counterparts from the Global North. Nigeria has no nationally representative data on the procedures performed by trainees before graduation from medical school and their confidence in performing these procedures upon graduation has also not been evaluated.

METHODS

We performed an internet-based, cross-sectional survey of recent medical school graduates from 15 accredited Federal, State, and private Nigerian medical schools spanning six geopolitical zones. Essential surgical procedures, bedside interventions and three Bellwether procedures were incorporated into the survey. Self-reported confidence immediately after graduation was calculated and compared using cumulative confidence scores with subgroup analysis of results by type and location of institution. Qualitative analysis of free text recommendations by participants was performed using the constant comparative method in grounded theory.

RESULTS

Four hundred ninety-nine recent graduates from 6 geopolitical zones participated, representing 15 out of a total of 44 medical schools in Nigeria. Male to female ratio was 2:1, and most respondents (59%) graduated from Federal institutions. Students had greatest practical mean exposure to bedside procedures like intravenous access and passing urethral foley catheters and were most confident performing these. Less than 23% had performed over 10 of any of the assessed procedures. They had least exposures to chest tube insertion (0.24/person), caesarean Sect. (0.12/person), and laparotomy (0.09/person). Recent graduates from Federal institutions had less procedural exposure in urethral catheterization (p < 0.001), reduction (p = 0.035), and debridement (p < 0.035). Respondents that studied in the underserved North-East and North-West performed the highest median number of procedures prior to graduation. Cumulative confidence scores were low across all graduates (maximum 25/60), but highest in graduates from Northern Nigeria and private institutions. Graduates recommended prioritizing medical students over senior trainees, using simulation-based training and constructive individualized non-toxic feedback from faculty.

CONCLUSION

Nigerian medical students have poor exposure to procedures and low confidence in performing basic procedures after graduation. More attention should be placed on training for essential surgeries and procedures in medical schools.

Estimating access to surgical care: A community centered national household survey from Pakistan

Pakistan is a lower middle-income country in South Asia with a population of 225 million. No estimate for surgical care access exists for the country. We postulate the estimated access to surgical care is less than the minimum 80% to be achieved by 2030. We conducted a randomized, stratified two-stage cluster household survey. A sample of 770 households was selected using 2017 census frames from the Pakistan Bureau of Statistics. Data was collected on choice of hospital and travel time to the chosen hospital for C-section, laparotomy, open fracture repair (OFR), and specialized surgery. Analysis was conducted using Stata 14. Access to all Bellwether surgeries (C-section, laparotomy, and open fracture repair) in Pakistan is estimated to be 74.8%. However, estimated access in rural areas and the provinces of Balochistan, Khyber Pakhtunkhwa (KP) and Sindh is far less than in urban areas and in Punjab and Islamabad. Estimated access to C-sections is more compared to OFR, laparotomy, and specialized surgery. Health system strengthening efforts should focus on improving surgical care access in rural areas and in Balochistan, KP, and Sindh. More focus is required on standardizing the availability and quality of surgical services in secondary-level hospitals.

Determinants of Access to Essential Surgery in the Democratic Republic of Congo

INTRODUCTION

In the Democratic Republic of Congo (DRC), the determinants and barriers of essential surgical care are not well described, hindering efforts to improve national surgical programs and access.

METHODS

A cross-sectional study evaluated access to essential surgery in the Butembo and Katwa health zones in the North Kivu province of DRC. A double-clustered random sample of community members was surveyed using questions derived from the Surgeons OverSeas Surgical Needs Assessment Survey, a validated tool to determine the reasons for not seeking, reaching, or receiving a Bellwether surgery (i.e., caesarean delivery, laparotomy, and external fixation of a fracture) when needed.

RESULTS

Overall, 887 households comprising 5944 community members were surveyed from April to August 2022. Six percent (n = 363/5944) of the study population involving 35% (n = 309/887) households needed a Bellwether surgery in the previous year, 30% (n = 108/363) of whom died. Of those who needed surgery, 25% (n = 78) did not go to the hospital to seek care and were more likely to find transportation unaffordable (P = 0.042). The most common reasons for not seeking care were lack of funds for hospitalization, prior poor hospital experience, and fear of hospital care.

CONCLUSIONS

Access and delivery of essential surgery are drastically limited in the North Kivu province of the DRC, such that a quarter of households needing surgery fails to seek surgical care. Poor access was predominantly driven by households' inability to pay for surgery and community distrust of the hospital system.

Trends of surgical-care delivery during the COVID-19 pandemic: A multi-centre study in India (IndSurg Collaboration)

Context

The COVID-19 pandemic and subsequent lockdowns adversely affected global healthcare services to varying extents. To accommodate its added burden, emergency services were affected along-with elective surgeries.

Aims

To quantify and analyze the trends of essential surgeries and bellwether procedures during the waxing and waning of the pandemic, across various hospitals in India.

Settings and Design

Multi-centric retrospective study.

Methods and Material

A research consortium led by World Health Organization (WHO) Collaboration Center (WHOCC) for Research in Surgical Care Delivery in Low-and Middle-Income countries, India, conducted this study with 5 centers. All surgeries performed during April 2020 (Wave I), November 2020 (Recovery I), and April 2021 (Wave II) were compared with those performed in April 2019 (pre-pandemic period).

Statistical Analysis Used

Microsoft Excel 2019 and SPSS Version 20.

Results

The total number of surgeries reduced by 77% during Wave I, which improved to a 52% reduction in Recovery I compared to the pre-pandemic period. However, surgeries were reduced again during Wave II to 68%, but the reduction was less compared to Wave I. Emergency and essential surgeries were affected along with the elective ones but to a lesser extent.

Conclusions

The present study has quantified the effects of the pandemic on surgical-care delivery across a timeline and documented a reduction in overall surgical volumes during the peaks of the pandemic (Wave I and II) with minimal improvement as the surge of COVID-19 cases declined (Recovery II). The surgical volumes improved during the second wave compared to the first one which may be attributable to better preparedness. Cesarean sections were affected the least.

Trainee autonomy and surgical outcomes after emergency gastrointestinal surgery

BACKGROUND

Operative meaningful trainee autonomy is an essential component of surgical training. Reduced trainee autonomy is frequently attributed to patient safety concerns, but this has not been examined within Kenya. We aimed to assess whether meaningful trainee autonomy was associated with a change in patient outcomes.

METHODS

We investigated whether meaningful trainee autonomy was associated with a change in severe postoperative complications and all-cause in-hospital mortality in a previously described cohort undergoing emergency gastrointestinal operations. Each operation was reviewed to determine the presence of meaningful autonomy, defined as "supervision only" from faculty. Comparisons were made between faculty-led cases and cases with meaningful trainee autonomy. Multilevel logistic regression models were created for the outcomes of mortality and complications with the exposure of meaningful trainee autonomy, accounting for fixed effects of the Africa Surgical Outcomes Study Risk Score and random effects of discharge diagnoses.

RESULTS

After excluding laparoscopy (N = 28) and missing data (N = 3), 451 operations were studied, and 343 (76.1%) had meaningful trainee autonomy. Faculty were more involved in operations with older age, cancer, prior complications, and higher risk scores. On unadjusted analysis, meaningful trainee autonomy was associated with mortality odds of 0.32 (95% confidence interval: 0.17-0.58) compared with faculty-led operations. Similarly, the odds of developing complications were 0.52 (95% confidence interval: 0.32-0.84) with meaningful trainee autonomy compared with faculty-led operations. When adjusting for Africa Surgical Outcomes Study Score and clustering discharge diagnoses, the odds of mortality (odds ratio 0.58; 95% confidence interval: 0.27-1.2) and complication (odds ratio 0.83; 95% confidence interval: 0.47-1.5) were not significant.

CONCLUSION

Our findings support that increasing trainee autonomy does not change patient outcomes in selected emergency gastrointestinal operations. Further, trainees and faculty appropriately discern patients at higher risk of complications and mortality, and the selective granting of trainee autonomy does not affect patient safety.

Are LMICs Achieving the Lancet Commission Global Benchmark for Surgical Volumes? A Systematic Review

INTRODUCTION

The Lancet Commission on Global Surgery (LCoGS) set the benchmark of 5000 procedures per 100,000 population annually to meet surgical needs adequately. This systematic review provides an overview of the last ten years of surgical volumes in Low and Middle- Income-Countries (LMICs).

METHODOLOGY

We searched PubMed, Web of Science, Scopus, Cochrane, and EMBASE databases for studies from LMICs addressing surgical volume. The number of surgeries performed per 100,000 population was estimated. We used cesarean sections, hernia, and laparotomies as index cases for the surgical capacities of the country. Their proportions to total surgical volumes were estimated. The association of country-specific surgical volumes and the proportion of index cases with its Gross Domestic Product (GDP) per capita was analyzed.

RESULTS

A total of 26 articles were included in this review. In LMICs, on average, 877 surgeries were performed per 100,000 population. The proportion of cesarean sections was found to be high in all LMICs, with an average of 30.1% of the total surgeries, followed by hernia (16.4%) and laparotomy (5.1%). The overall surgical volumes increased as the GDP per capita increased. The proportions of cesarean section and hernia to total surgical volumes decreased with increased GDP per capita. Significant heterogeneity was found in the methodologies to assess surgical volumes, and inconsistent reporting hindered comparison between countries.

CONCLUSION

Most LMICs have surgical volumes below the LCoGS benchmark of 5000 procedures per 100,000 population, with an average of 877 surgeries. The surgical volume increased while the proportions of hernia and cesarean sections reduced with increased GDP per capita. In the future, it's essential to apply uniform and reproducible data collection methods for obtaining multinational data that can be more accurately compared.

Determining Critical Topics for Undergraduate Surgical Education in Rwanda: Results of a Modified Delphi Process and a Consensus Conference

Background Developing a contextually appropriate curriculum is critical to train physicians who can address surgical challenges in sub-Saharan Africa. An innovative modified Delphi process was used to identify contextually optimized curricular content to meet sub-Saharan Africa and Rwanda's surgical needs. Methods Participants were surgeons from East, Central, Southern, and West Africa and general practitioners with surgical experience. Delphi participants excluded or prioritized surgical topic areas generated from extensive grey and formal literature review. Surgical educators first screened and condensed identified topics. Round 1 screened and prioritized identified topics, with a 75% consensus cut-off based on the content validity index and a prioritization score. Topics that reached consensus were screened again in round 2 and re-prioritized, following controlled feedback. Frequencies for aggregate prioritization scores, experts in agreement, item-level content validity index, universal agreement and scale-level content validity index based on the average method (S-CVI/Ave) using proportion relevance, and intra-class correlation (ICC) (based on a mean-rating, consistency, two-way mixed-effects model) were performed. We also used arithmetic mean values and modal frequency. Cronbach's Alpha was also calculated to ascertain reliability. Results were validated through a multi-institution consensus conference attended by Rwanda-based surgical specialists, general practitioners, medical students, surgical educators, and surgical association representatives using an inclusive, participatory, collaborative, agreement-seeking, and cooperative, a priori consensus decision-making model. Results Two-hundred and sixty-seven broad surgical content areas were identified through the initial round and presented to experts. In round 2, a total of 247 (92%) content areas reached 75% consensus among 31 experts. Topics that did not achieve consensus consisted broadly of small intestinal malignancies, rare hepatobiliary pathologies, and transplantation. In the final round, 99.6% of content areas reached 75% consensus among 31 experts. The highest prioritization was on wound healing, fluid and electrolyte management, and appendicitis, followed by metabolic response, infection, preoperative preparation, antibiotics, small bowel obstruction and perforation, breast infection, acute urinary retention, testicular torsion, hemorrhoids, and surgical ethics. Overall, the consistency and average agreement between panel experts was strong. ICC was 0.856 (95% CI: 0.83-0.87). Cronbach's Alpha for round 2 was very strong (0.985, 95% CI: 0.976-0.991) and higher than round 1, demonstrating strong reliability. All 246 topics from round 4 were verbally accepted by 40 participants in open forum discussions during the consensus conference. Conclusions A modified Delphi process and consensus were able to identify essential topics to be included within a highly contextualized, locally driven surgical clerkship curriculum delivered in rural Rwanda. Other contexts can use similar processes to develop relevant curricula.

Delivery of essential pediatric congenital surgical care within Brazil's universal health coverage system: a national survey of pediatric surgeons

Objective

In this study, we assess the delivery of congenital pediatric surgical care under Brazil's system of universal health coverage and evaluate differences in delivery between public and private sectors.

Methods

A cross-sectional national survey of pediatric surgeons in Brazil was conducted. Participants were asked which of 23 interventions identified through the Disease Control Priorities 3 (Surgical Interventions for Congenital Anomalies) they perform and to report barriers faced while providing surgical care. Responses were weighted by state and stratified by sector (public vs private).

Results

A sample of 352 responses was obtained and weighted to represent 1378 practicing pediatric surgeons registered in Brazil during the survey time. 73% spend the majority of their time working in the public sector ('Sistema Único de Saúde' and Foundation hospitals), and most of them also work in the private sector. Generally, Brazilian pediatric surgeons have the expertise to provide thoracic, abdominal, and urologic procedures. Surgeons working mostly in the public sector were more likely to report a lack of access to essential medications (25% vs 9%, p<0.01) and a lack of access to hospital beds for surgical patients (52% vs 32%, p<0.01).

Conclusions

Brazilian pediatric surgeons routinely perform thoracic, abdominal, and urologic surgery. Those working in government-financed hospitals face barriers related to infrastructure, which may impact Brazilians who rely on Brazil's universal health coverage system. Policies that support pediatric surgeons working in the public sector may promote the workforce available to provide congenital pediatric surgical care.

GO-Tibia: a masked, randomized control trial evaluating gentamicin versus saline in open tibia fractures

BACKGROUND

The rate of open tibia fractures is rapidly increasing across the globe due to a recent rise in road traffic accidents, predominantly in low- and low-middle-income countries. These injuries are orthopedic emergencies associated with infection rates as high as 40% despite the use of systemic antibiotics and surgical debridement. The use of local antibiotics has shown some promise in reducing the burden of infection in these injuries due to increasing local tissue availability; however, no trial has yet been appropriately powered to evaluate for definitive evidence and the majority of current studies have taken place in a high-resource countries where resources and the bio-burden may be different.

METHODS

This is a prospective randomized, masked, placebo-controlled superiority trial designed to evaluate the efficacy of locally administered gentamicin versus placebo in the prevention of fracture-related infection in adults (age > 18 years) with primarily closeable Gustillo-Anderson class I, II, and IIIA open tibia fractures. Eight hundred ninety patients will be randomized to receive an injection of either gentamicin (treatment group) or saline (control group) at the site of their primarily closed open fracture. The primary outcome will be the occurrence of a fracture-related infection occurring during the course of the 12-month follow-up.

DISCUSSION

This study will definitively assess the effectiveness of local gentamicin for the prevention of fracture-related infections in adults with open tibia fractures in Tanzania. The results of this study have the potential to demonstrate a low-cost, widely available intervention for the reduction of infection in open tibia fractures.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05157126. Registered on December 14, 2021.

Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards

BACKGROUND

Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia.

METHOD

An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform.

RESULTS

Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures.

CONCLUSION

Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.

Geographical Inequalities in Access to Bellwether Procedures in Brazil

BACKGROUND

Brazil is a middle-income country that aims to provide universal health coverage, but its surgical system's efficiency has rarely been analyzed. In an effort to strengthen surgical national systems, the Lancet Commission on Global Surgery proposed bellwether procedures as quality indicators of surgical workforces. This study aims to evaluate regional inequalities in access to bellwether procedures and their associated mortality across the five Brazilian geographical regions.

METHODS

Using DATASUS, Brazil's national healthcare database, data were collected on the total amount of performed bellwether procedures-cesarean section, laparotomy, and open fracture management-and their associated mortality, by geographical region. We evaluated the years 2018-2020, both in emergent and elective conditions. Statistical analysis was performed by one-way ANOVA test and Tukey's multiple comparisons test.

RESULTS

During this period, DATASUS registered 2,687,179 cesarean sections, 1,036,841 laparotomies, and 648,961 open fracture treatments. The access and associated mortality related to these procedures were homogeneous between the regions in elective care. There were significant geographical inequalities in access and associated mortality in emergency care (p < 0.05, 95% CI) for all bellwether procedures. The Southeast, the most economically developed region of the country, was the region with the lowest amount of bellwether procedures per 100,000 inhabitants.

CONCLUSION

Brazil's public surgical system is competent at promoting elective surgical care, but more effort is needed to fortify emergency care services. Public policies should encourage equity in the geographic allocation of the surgical workforce.

Pathways to effective surgical coverage in a lower-middle-income country: A multiple methods study of the family physician-led generalist surgical team in rural Nepal

The Lancet Commission on Global Surgery (LCoGS) recommends using specialist surgical workforce density as one of 6 core indicators for monitoring universal access to safe, affordable surgical and anaesthesia care. Using Nepal as a case study, we explored the capacity of a generalist workforce (led by a family physician or MD general practitioner and non-physician anaesthetist) to enable effective surgical delivery through task-shifting. Using a multiple-methods approach, we retrospectively mapped essential surgical care and the enabling environment for surgery in 39 hospitals in 25 remote districts in Nepal and compared it with LCoGS indicators. All 25 districts performed surgery, 21 performed Caesarean section (CS), and 5 met at least 50% of district CS needs. Generalist surgical teams performed CS, the essential major operation at the district level, and very few laparotomies, but no operative orthopaedics. The density of specialist Surgeon/Anaesthesiologist/Obstetrician (SAO) was 0·4/100,000; that of Generalist teams (gSAO) led by a family physician (MD General Practitioners-MDGP) supported by non-physician anaesthetists was eight times higher at 3·1/100,000. gSAO presence was positively associated with a two-fold increase in CS availability. All surgical rates were well below LCoGS targets. 46% of hospitals had adequate enabling environments for surgery, 28% had functioning anaesthesia machines, and 75% had blood transfusion services. Despite very low SAO density, and often inadequate enabling environment, surgery can be done in remote districts. gSAO teams led by family physicians are providing essential surgery, with CS the commonest major operation. gSAO density is eight times higher than specialists and they can undertake more complex operations than just CS alone. These family physician-led functional teams are providing a pathway to effective surgical coverage in remote Nepal.

Acute care surgery in a Malawian district hospital: Epidemiology, outcomes, and assessment of operative capacity

District hospitals (DHs) care for the majority of surgical patients in Malawi, but data on district hospital surgical capacity are limited. We sought to evaluate the management and outcomes of surgical patients presenting to Salima District Hospital (SDH) in Malawi. Using the SDH surgery registry, we compared patients managed operatively and those non-operatively and performed logistic regression to identify factors associated with operative management. We then compared cases performed at SDH with procedures recommended to be performed at DHs. We included 1374 patients, of whom half were managed operatively. The most common procedures performed were abscess drainage and wound debridement. Logistic regression analysis revealed that patients with abdominal diagnoses were least likely to be treated operatively. Though SDH performs most procedures recommended for the district hospital level, patients requiring laparotomies were most likely to be transferred to a referral hospital. Future studies should assess barriers to performing laparotomies at SDH.

Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study

BACKGROUND

Provision of timely, safe, and affordable surgical care is an essential component of any high-quality health system. Increasingly, it is recognized that poor quality of care in the perioperative period (before, during, and after surgery) may contribute to significant excess mortality and morbidity. Therefore, improving access to surgical procedures alone will not address the disparities in surgical outcomes globally until the quality of perioperative care is addressed. We aimed to identify key barriers to quality perioperative care delivery for 3 "Bellwether" procedures (cesarean delivery, emergency laparotomy, and long-bone fracture fixation) in 5 low- and middle-income countries (LMICs).

METHODS

Ten hospitals representing secondary and tertiary facilities from 5 LMICs were purposefully selected: 2 upper-middle income (Colombia and South Africa); 2 lower-middle income (Sri Lanka and Tanzania); and 1 lower income (Uganda). We used a rapid appraisal design (pathway mapping, ethnography, and interviews) to map out and explore the complexities of the perioperative pathway and care delivery for the Bellwether procedures. The framework approach was used for data analysis, with triangulation across different data sources to identify barriers in the country and pattern matching to identify common barriers across the 5 LMICs.

RESULTS

We developed 25 pathway maps, undertook >30 periods of observation, and held >40 interviews with patients and clinical staff. Although the extent and impact of the barriers varied across the LMIC settings, 4 key common barriers to safe and effective perioperative care were identified: (1) the fragmented nature of the care pathways, (2) the limited human and structural resources available for the provision of care, (3) the direct and indirect costs of care for patients (even in health systems for which care is ostensibly free of charge), and (4) patients' low expectations of care.

CONCLUSIONS

We identified key barriers to effective perioperative care in LMICs. Addressing these barriers is important if LMIC health systems are to provide safe, timely, and affordable provision of the Bellwether procedures.

Aqueous skin antisepsis before surgical fixation of open fractures (Aqueous-PREP): a multiple-period, cluster-randomised, crossover trial

BACKGROUND

Chlorhexidine skin antisepsis is frequently recommended for most surgical procedures; however, it is unclear if these recommendations should apply to surgery involving traumatic contaminated wounds where povidone-iodine has previously been preferred. We aimed to compare the effect of aqueous 10% povidone-iodine versus aqueous 4% chlorhexidine gluconate on the risk of surgical site infection in patients who required surgery for an open fracture.

METHODS

We conducted a multiple-period, cluster-randomised, crossover trial (Aqueous-PREP) at 14 hospitals in Canada, Spain, and the USA. Eligible patients were adults aged 18 years or older with an open extremity fracture treated with a surgical fixation implant. For inclusion, the open fracture required formal surgical debridement within 72 h of the injury. Participating sites were randomly assigned (1:1) to use either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate immediately before surgical incision; sites then alternated between the study interventions every 2 months. Participants, health-care providers, and study personnel were aware of the treatment assignment due to the colour of the solutions. The outcome adjudicators and data analysts were masked to treatment allocation. The primary outcome was surgical site infection, guided by the 2017 US Centers for Disease Control and Prevention National Healthcare Safety Network reporting criteria, which included superficial incisional infection within 30 days or deep incisional or organ space infection within 90 days of surgery. The primary analyses followed the intention-to-treat principle and included all participants in the groups to which they were randomly assigned. This study is registered with ClinicalTrials.gov, NCT03385304.

FINDINGS

Between April 8, 2018, and June 8, 2021, 3619 patients were assessed for eligibility and 1683 were enrolled and randomly assigned to povidone-iodine (n=847) or chlorhexidine gluconate (n=836). The trial's adjudication committee determined that 45 participants were ineligible, leaving 1638 participants in the primary analysis, with 828 in the povidone-iodine group and 810 in the chlorhexidine gluconate group (mean age 44·9 years [SD 18·0]; 629 [38%] were female and 1009 [62%] were male). Among 1571 participants in whom the primary outcome was known, a surgical site infection occurred in 59 (7%) of 787 participants in the povidone-iodine group and 58 (7%) of 784 in the chlorhexidine gluconate group (odds ratio 1·11, 95% CI 0·74 to 1·65; p=0·61; risk difference 0·6%, 95% CI -1·4 to 3·4).

INTERPRETATION

For patients who require surgical fixation of an open fracture, either aqueous 10% povidone-iodine or aqueous 4% chlorhexidine gluconate can be selected for skin antisepsis on the basis of solution availability, patient contraindications, or product cost. These findings might also have implications for antisepsis of other traumatic wounds.

FUNDING

US Department of Defense, Canadian Institutes of Health Research, McMaster University Surgical Associates, PSI Foundation.

Unreamed Intramedullary Nailing Versus External Fixation for the Treatment of Open Tibial Shaft Fractures in Uganda: A Randomized Clinical Trial

OBJECTIVE

To compare unreamed intramedullary nailing versus external fixation for the treatment of Gustilo-Anderson type II and IIIA open tibial fractures admitted to a hospital in rural Uganda.

DESIGN

Randomized clinical trial.

SETTING

Regional referral hospital in Uganda.

PATIENTS

Fifty-five skeletally mature patients with a Gustilo-Anderson type II or IIIA open tibia shaft fracture treated within 24 hours of injury between May 2016 and December 2019.

INTERVENTION

Unreamed intramedullary nailing (n = 31) versus external fixation (n = 24).

MAIN OUTCOME MEASUREMENTS

The primary outcome was function within 12 months of injury, measured using the Function IndeX for Trauma (FIX-IT) score. Secondary outcomes included health-related quality of life (HRQoL) using the 3-level version of the 5-dimension EuroQol instrument (EQ-5D-3L), radiographic healing using the Radiographic Union Scale for Tibia (RUST) fractures score, and clinical complications.

RESULTS

Treatment with an intramedullary nail resulted in a 1.0-point higher [95% credible intervals (CrI), 0.1 to 1.9] FIX-IT score compared with external fixation. Results were similar for the secondary patient-reported outcomes, EQ-5D-3L and the visual analog scale component of the EuroQol instrument (EQ-VAS). RUST scores were not different between groups at any time point. Treatment with an intramedullary nail was associated with a 22.1% (95% CrI, -42.6% to 1.7%) lower rate of malunion and a 20.8% (95% CrI, -44.0% to 2.9%) lower rate of superficial infection.

CONCLUSION

In rural Uganda, treatment of open tibial shaft fractures with an unreamed intramedullary nail results in marginal clinically important improvements in functional outcomes, although there is likely an important reduction in malunion and superficial infection.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery at Primary and Secondary Hospitals in Low-Middle-Income Countries (LMIC's): Enhanced Recovery After Surgery (ERAS) Society Recommendation

BACKGROUND

This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low-middle-income countries (LMIC's) for elective abdominal and gynecologic care.

METHODS

The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC's. The group consisted of seven members from the ERAS® Society and eight members from LMIC's. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592-695, Nelson et al in Int J Gynecol Cancer 29(4):651-668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC's and LMIC's were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC's. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC's and determined through discussions and consensus.

RESULTS

In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.

CONCLUSIONS

These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC's.

Perioperative Care Pathways in Low- and Lower-Middle-Income Countries: Systematic Review and Narrative Synthesis

BACKGROUND

Safe and effective care for surgical patients requires high-quality perioperative care. In high-income countries (HICs), care pathways have been shown to be effective in standardizing clinical practice to optimize patient outcomes. Little is known about their use in low- and middle-income countries (LMICs) where perioperative mortality is substantially higher.

METHODS

Systematic review and narrative synthesis to identify and describe studies in peer-reviewed journals on the implementation or evaluation of perioperative care pathways in LMICs. Searches were conducted in MEDLINE, EMBASE, CINAHL Plus, WHO Global Index, Web of Science, Scopus, Global Health and SciELO alongside citation searching. Descriptive statistics, taxonomy classifications and framework analyses were used to summarize the setting, outcome measures, implementation strategies, and facilitators and barriers to implementation.

RESULTS

Twenty-seven studies were included. The majority of pathways were set in tertiary hospitals in lower-middle-income countries and were focused on elective surgery. Only six studies were assessed as high quality. Most pathways were adapted from international guidance and had been implemented in a single hospital. The most commonly reported barriers to implementation were cost of interventions and lack of available resources.

CONCLUSIONS

Studies from a geographically diverse set of low and lower-middle-income countries demonstrate increasing use of perioperative pathways adapted to resource-poor settings, though there is sparsity of literature from low-income countries, first-level hospitals and emergency surgery. As in HICs, addressing patient and clinician beliefs is a major challenge in improving care. Context-relevant and patient-centered research, including qualitative and implementation studies, would make a valuable contribution to existing knowledge.

Management of fracture-related infection in low resource settings: how applicable are the current consensus guidelines?

The global burden of fracture-related infection (FRI) is likely to be found in countries with limited healthcare resources and strategies are needed to ensure the best available practice is context appropriate. This study has two main aims: (i) to assess the applicability of recently published expert guidance from the FRI consensus groups on the diagnosis and management of FRI to low- and middle-income countries (LMICs); (ii) to summarise the available evidence on FRI, with consideration for strategies applicable to low resource settings.

Data related to the International Consensus Meeting Orthopaedic Trauma Work Group and the International Fracture Related Infection Consensus Group FRI guidelines were collected including panel membership, country of origin, language of publication, open access status and impact factor of the journal of publication. The recommendations and guidelines were then summarised with specific consideration for relevance and applicability to LMICs. Barriers to implementation were explored within a group of LMIC residents and experienced workers.

The authorship, evidence base and reach of the FRI consensus guidelines lack representation from low resource settings. The majority of authors (78.5–100%) are based in high-income countries and there are no low-income country collaborators listed in any of the papers. All papers are in English.

The FRI consensus guidelines give a clear set of principles for the optimum management of FRI. Many of these – including the approach to diagnosis, multidisciplinary team working and some elements of surgical management – are achievable in low resource settings. Current evidence suggests that it is important that a core set of principles is prioritised but robust evidence for this is lacking. There are major organisational and infrastructure obstacles in LMICs that will make any standardisation of FRI diagnosis or management challenging. The detail of how FRI consensus principles should be applied in low resource settings requires further work.

The important work presented in the current FRI consensus guidelines is relevant to low resource settings. However, leadership, collaboration, creativity and innovation will be needed to implement these strategies for communities who need it the most.

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania

BACKGROUND

Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania.

METHODS

We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures.

RESULTS

Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission.

CONCLUSIONS

Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

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.

Self-perceived preparedness and training needs of healthcare personnel on humanitarian mission: a pre- and post-deployment survey

Background

Humanitarian healthcare workers are indispensable for treating weapon-wounded patients in armed conflict, and the international humanitarian community should ensure adequate preparedness for this task. This study aims to assess deployed humanitarian healthcare workers’ self-perceived preparedness, training requirements and mental support needs.

Methods

Medical professionals deployed with the International Committee of the Red Cross (ICRC) between October 2018 and June 2020 were invited to participate in this longitudinal questionnaire. Two separate questionnaires were conducted pre- and post-deployment to assess respondents’ self-perceived preparedness, preparation efforts, deployment experiences and deployment influence on personal and professional development.

Results

Response rates for the pre- and post-deployment questionnaires were 52.5% (114/217) and 26.7% (58/217), respectively. Eighty-five respondents (85/114; 74.6%) reported feeling sufficiently prepared to treat adult trauma patients, reflected by predeployment ratings of 3 or higher on a scale from 1 (low) to 5 (high). Significantly lower ratings were found among nurses compared to physicians. Work experience in a high-volume trauma centre before deployment was associated with a greater feeling of preparedness (mean rank 46.98 vs. 36.89; p = 0.045). Topics most frequently requested to be included in future training were neurosurgery, maxillofacial surgery, reconstructive surgery, ultrasound, tropical diseases, triage, burns and newborn noncommunicable disease management. Moreover, 51.7% (30/58) of the respondents regarded the availability of a mental health professional during deployment as helpful to deal with stress.

Conclusion

Overall, deployed ICRC medical personnel felt sufficiently prepared for their missions, although nurses reported lower preparedness levels than physicians. Recommendations were made concerning topics to be covered in future training and additional preparation strategies to gain relevant clinical experience. Future preparatory efforts should focus on all medical professions, and their training needs should be continuously monitored to ensure the alignment of preparation strategies with preparation needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13017-022-00417-z.

Delphi Method Consensus on Priority Global Otolaryngology-Head and Neck Surgery Conditions and Procedures

OBJECTIVE

The objective of this study was to develop an international expert consensus on priority otolaryngology-head and neck surgery conditions and procedures globally for which national health systems should be capable of caring.

STUDY DESIGN

The Delphi method was employed via a multiround online survey administered to attending otolaryngologists in an international research collaborative of >180 otolaryngologists in >40 countries.

SETTING

International online survey.

METHODS

In round 1, participants listed the top 15 otolaryngologic conditions and top 15 otolaryngology procedures for their World Bank regions. In round 2, participants ranked round 1 responses in order of global importance on a 5-point Likert scale. In round 3, participants reranked conditions and procedures that did not achieve consensus, defined as 50% of the round 2 Likert responses being ranked as "important" or "very important." Descriptive statistics were calculated for each round.

RESULTS

The survey was distributed to 53 experts globally, with a response rate of 38% (n = 20). Fifty percent (n = 10) of participants were from low- and middle-income countries, with at least 1 participant from each World Bank region. Ten consensus surgical procedures and 10 consensus conditions were identified.

CONCLUSION

This study identified a list of priority otolaryngology-head and neck surgery conditions and surgical procedures for which all national health systems around the world should be capable of managing. Acute and infectious conditions with preventative and emergent procedures were highlighted. These findings can direct future research and guide international collaborations.

Gender-based disparities in burn injuries, care and outcomes: A World Health Organization (WHO) Global Burn Registry cohort study

BACKGROUND

We aimed to describe the gender-based disparities in burn injury patterns, care received, and mortality across national income levels.

METHODS

In the WHO Global Burn Registry (GBR), we compared patient demographics, injury characteristics, care and outcomes by sex using Chi-square statistics. Logistic regression was used to identify the associations of patient sex with surgical treatment and in-hospital mortality.

RESULTS

Among 6431 burn patients (38 % female; 62 % male), females less frequently received surgical treatment during index hospitalization (49 % vs 56 %, p < 0.001), and more frequently died in-hospital (26 % vs 16 %, p < 0.001) than males. Odds of in in-hospital death was 2.16 (95 % CI: 1.73-2.71) times higher among females compared to males in middle-income countries.

CONCLUSIONS

Across national income levels, there appears to be important gender-based disparities among burn injury epidemiology, treatment received and outcomes that require redress. Multinational registries can be utilized to track and to evaluate initiatives to reduce gender disparities at national, regional and global levels.

Delays to essential surgery at four faith based hospitals in rural Sub-Saharan Africa

BACKGROUND

Data regarding delays for emergency surgery in Sub-Saharan Africa is limited. We have therefore decided to undertake an evaluation of delays in patients seeking care, reaching care and receiving care for emergency surgery at four rural faith-based hospitals in this region over a 3 month period.

METHODS

This is a cross-sectional, multi-center, international study at four rural faith-based hospitals in Madagascar, Gabon, Cameroon and Burundi. All patients presenting at these hospitals between 10 February and 1 May 2020 for one of the three Bellwether procedures (caesarean delivery, emergency laparotomy, management of open fracture) were to be enrolled in this study. Data was collected in the form of a questionnaire administered to the patient or the patient's caregiver within 24 h of admission to the hospital.

RESULTS

After analysis of data for 148 patients, we found that the median [quartiles] delay in seeking care overall was 3.5 [0.5, 17.6] h, in reaching care 7.6 [2.3, 33.6] h and in receiving care 3.6 [1.7, 6.8] h. In 72% (107/148) of cases, the second delay was more than 2 h. Sixty-five percent of patients who were delayed reported that their delay was because care was sought elsewhere before arrival at one of our Bellwether-capable sites.

CONCLUSIONS

Our results suggest that the majority of patients needing emergency surgical care in the rural areas of Sub-Saharan Africa where our study was conducted are frequently delayed, with the largest delay being in reaching care. Further investigations into the reasons for these delays should be conducted.

Assessing Brazilian Medical Student Awareness About Global Surgery: A Survey-Based Study

BACKGROUND

Global surgery is an interdisciplinary field that advocates for access to equitable, affordable surgical services for all people. Engaging medical students in the field can strengthen the surgical workforce in low- and middle-income countries. We aim to investigate Brazilian medical students' acknowledgment of global surgery and their preferred learning platforms.

MATERIALS AND METHODS

We performed a cross-sectional study through an anonymous Portuguese survey on Google Forms, consisting of 30 mixed multiple-choice and five-point Likert scale questions. Students enrolled in a Brazilian medical school from the second to sixth academic year fulfilled inclusion criteria. The association between qualitative variables was assessed using Chi-square, Fisher's exact test, or binary logistic model.

RESULTS

We received 1,345 responses from 208 medical schools. Only 20.9% (282/1,345) of participants reported awareness of global surgery, who were predominantly female. 96.5% (1,298/1,345) declared interest in knowing more about global surgery and participants indicated social media (71.6%, 202/282) as the prevalent manner to gain awareness on it, followed by webinars (63.5%, 179/282). Extracurricular classes were the most preferable option among students (61.4%, 827/1,345) to get acquainted with the field, followed by internships (59.4%, 812/1,345), workshops (57%, 767/1,345), and social media (53.4%, 730/1,345). The main obstacles to pursue a global surgery career were lack of national opportunities (32%, 431/1,345) and adequate training (25.4%, 341/1,345).

CONCLUSION

We outlined the most strategic pathways to raising awareness on global surgery among Brazilian medical students, providing relevant insights on its education in similar settings.

Definitive Fixation Outcomes of Open Tibial Shaft Fractures: Systematic Review and Network Meta-analysis

OBJECTIVES

To delineate if there were differences in outcomes between definitive fixation strategies in open tibial shaft fractures.

DATA SOURCES

MEDLINE, EMBASE, CENTRAL, and OpenGrey.

STUDY SELECTION

Randomized and Quasi-randomized studies analyzing adult patients (>18 years) with open tibial shaft fractures (AO-42), undergoing definitive fixation treatment of any type.

DATA EXTRACTION

Data regarding patient demographics, definitive bony/soft-tissue management, irrigation, type of antibiotics, and follow-up. Definitive intervention choices included unreamed intramedullary nailing (UN), reamed intramedullary nailing, plate fixation, multiplanar, and uniplanar external fixation (EF). The primary outcome was unplanned reoperation rate. Cochrane risk of bias tool and Grading of Recommendation Assessment, Development and Evaluation systems were used for quality analysis.

DATA SYNTHESIS

A random-effects meta-analysis of head-to-head evidence, followed by a network analysis that modeled direct and indirect data was conducted to provide precise estimates [relative risk (RR) and associated 95% confidence interval (95% CI)].

RESULTS

In open tibial shaft fractures, direct comparison UN showed a lower risk of unplanned reoperation versus EF (RR 0.67, 95% CI 0.43-1.05, P = 0.08, moderate confidence). In Gustilo type III open fractures, the risk reduction with nailing compared with EF was larger (RR 0.61, 95% CI 0.37-1.01, P = 0.05, moderate confidence). UN had a lower reoperation risk compared with reamed intramedullary nailing (RR 0.91, 95% CI 0.58-1.4, P = 0.68, low confidence); however, this was not significant and did not demonstrate a clear advantage.

CONCLUSIONS

Intramedullary nailing reduces the risk of unplanned reoperation by a third compared with EF, with a slightly larger reduction in type III open fractures. Future trials should focus on major complication rates and health-related quality of life in high-grade tibial shaft fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Assessment of surgical capacity in Chiapas, Mexico: a cross-sectional study of the public and private sector

INTRODUCTION

Surgical, anaesthesia and obstetric (SAO) care are essential, life-saving components of universal healthcare. In Chiapas, Mexico's southernmost state, the capacity of SAO care is unknown. This study aims to assess the surgical capacity in Chiapas, Mexico, as it relates to access, infrastructure, service delivery, surgical volume, quality, workforce and financial risk protection.

METHODS

A cross-sectional study of Ministry of Health public hospitals and private hospitals in Chiapas was performed. The translated Surgical Assessment Tool (SAT) was implemented in sampled hospitals. Surgical volume was collected retrospectively from hospital logbooks. Fisher's exact test and Mann-Whitney U test were used to compare public and private hospitals. Catastrophic expenditure from surgical care was calculated.

RESULTS

Data were collected from 17 public hospitals and 20 private hospitals in Chiapas. Private hospitals were smaller than public hospitals and public hospitals performed more surgeries per operating room. Not all hospitals reported consistent electricity, running water or oxygen, but private hospitals were more likely to have these basic infrastructure components compared with public hospitals (84% vs 95%; 60% vs 100%; 94.1% vs 100%, respectively). Bellwether surgical procedures performed in private hospitals cost significantly more, and posed a higher risk of catastrophic expenditure, than those performed in public hospitals.

CONCLUSION

Capacity limitations are greater in public hospitals compared with private hospitals. However, the cost of care in the private sector is significantly higher than the public sector and may result in catastrophic expenditures. Targeted interventions to improve the infrastructure, workforce availability and data collection are needed.