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Pingray V, Williams CR, Al-Beity FMA, Abalos E, Arulkumaran S, Blumenfeld A, Carvalho B, Deneux-Tharaux C, Downe S, Dumont A, Escobar MF, Evans C, Fawcus S, Galadanci HS, Hoang DTT, Hofmeyr GJ, Homer C, Lewis AG, Liabsuetrakul T, Lumbiganon P, Main EK, Maua J, Muriithi FG, Nabhan AF, Nunes I, Ortega V, Phan TNQ, Qureshi ZP, Sosa C, Varallo J, Weeks AD, Widmer M, Oladapo OT, Gallos I, Coomarasamy A, Miller S, Althabe F. Strategies for optimising early detection and obstetric first response management of postpartum haemorrhage at caesarean birth: a modified Delphi-based international expert consensus. BMJ Open 2024; 14:e079713. [PMID: 38719306 PMCID: PMC11086283 DOI: 10.1136/bmjopen-2023-079713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/19/2024] [Indexed: 05/12/2024] Open
Abstract
OBJECTIVE There are no globally agreed on strategies on early detection and first response management of postpartum haemorrhage (PPH) during and after caesarean birth. Our study aimed to develop an international expert's consensus on evidence-based approaches for early detection and obstetric first response management of PPH intraoperatively and postoperatively in caesarean birth. DESIGN Systematic review and three-stage modified Delphi expert consensus. SETTING International. POPULATION Panel of 22 global experts in PPH with diverse backgrounds, and gender, professional and geographic balance. OUTCOME MEASURES Agreement or disagreement on strategies for early detection and first response management of PPH at caesarean birth. RESULTS Experts agreed that the same PPH definition should apply to both vaginal and caesarean birth. For the intraoperative phase, the experts agreed that early detection should be accomplished via quantitative blood loss measurement, complemented by monitoring the woman's haemodynamic status; and that first response should be triggered once the woman loses at least 500 mL of blood with continued bleeding or when she exhibits clinical signs of haemodynamic instability, whichever occurs first. For the first response, experts agreed on immediate administration of uterotonics and tranexamic acid, examination to determine aetiology and rapid initiation of cause-specific responses. In the postoperative phase, the experts agreed that caesarean birth-related PPH should be detected primarily via frequently monitoring the woman's haemodynamic status and clinical signs and symptoms of internal bleeding, supplemented by cumulative blood loss assessment performed quantitatively or by visual estimation. Postoperative first response was determined to require an individualised approach. CONCLUSION These agreed on proposed approaches could help improve the detection of PPH in the intraoperative and postoperative phases of caesarean birth and the first response management of intraoperative PPH. Determining how best to implement these strategies is a critical next step.
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Affiliation(s)
- Verónica Pingray
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Caitlin R Williams
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Department of Maternal & Child Health, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Fadhlun M Alwy Al-Beity
- Department of Obstetrics & Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Edgardo Abalos
- Maternidad Martin, Secretaría de Salud Pública de la Municipalidad de Rosario, Rosario, Santa Fe, Argentina
- Centro de Estudios de Estado y Sociedad, Buenos Aires, Argentina
| | | | - Alejandro Blumenfeld
- Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
- Department of Public Health, Faculty of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Brendan Carvalho
- Stanford University School of Medicine, Stanford, California, USA
| | - Catherine Deneux-Tharaux
- Obstetrical Perinatal and Pediatric Epidemiology Research team, Centre for Research in Statistics and Epidemiology (CRESS) Université Paris Cité INSERM, Paris, France
| | - Soo Downe
- Research in Childbirth and Health, University of Central Lancashire, Preston, UK
- THRIVE Centre, School of Heath and Community Studies, University of Central Lancashire, Preston, UK
| | | | - Maria Fernanda Escobar
- Departamento de Ginecología y Obstetricia, Fundación Valle del Lili, Cali, Colombia
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
| | - Cherrie Evans
- Technical Leadership & Innovations Office, Jhpiego/USA, Baltimore, Maryland, USA
| | - Sue Fawcus
- Department of Obstetrics and Gynaecology, University of Cape Town, Rondebosch, South Africa
| | - Hadiza S Galadanci
- Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Kano, Nigeria
- Africa Center of Excellence for Population Health and Policy, Bayero University Kano, Kano, Nigeria
| | | | - G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, University of Botswana, Gaborone, Botswana
- Effective Care Research Unit, University of the Witwatersrand, Johannesburg and Walter Sisulu University, Mthatha, South Africa
| | | | | | - Tippawan Liabsuetrakul
- Department of Epidemiology, Prince of Songkla University, Hat Yai, Thailand
- Department of Obstetrics & Gynecology, Prince of Songkla University, Hat Yai, Thailand
| | - Pisake Lumbiganon
- Department of Obstetrics and Gynaecology, Khon Kaen University, Khon Kaen, Thailand
| | - Elliott K Main
- Department of Obstetrics & Gynecology-Maternal Fetal Medicine, Stanford University, Stanford, California, USA
- California Maternal Quality Care Collaborative, Standford, California, USA
| | - Judith Maua
- Liverpool School of Tropical Medicine, Nairobi, Kenya
| | - Francis G Muriithi
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
- Department of Obstetrics and Gynaecology, Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Ashraf Fawzy Nabhan
- Department of Obstetrics & Gynecology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Inês Nunes
- Department of Obstetrics and Gynaecology, Gaia/ Espinho Local Health Unit, Vila Nova de Gaia, Portugal
- RISE-HEALTH - CINTESIS-Center for Health Technology and Services Research, University of Porto, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
| | - Vanesa Ortega
- Department of Mother and Child Health Research, Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina
| | - Thuan N Q Phan
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Department of Delivery, Tu Du Hospital, Ho Chi Minh City, Viet Nam
| | - Zahida P Qureshi
- University of Nairobi Department of Obstetrics and Gynecology, Nairobi, Kenya
| | - Claudio Sosa
- Woman and Reproduction Health Unit at Maternal Health at the Latin American Center of Perinatology (CLAP/WR), Pan American Health Organization, Montevideo, District of Columbia, USA
- Department of Obstetrics and Gynecology, School of Medicine, Universidad de la República Uruguay, Montevideo, Uruguay
| | - John Varallo
- Women's Health, Global Surgery Foundation, Washington, District of Columbia, USA
| | - Andrew D Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- Liverpool Women's Hospital, Liverpool, UK
| | - Mariana Widmer
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Olufemi T Oladapo
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Ioannis Gallos
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
| | - Arri Coomarasamy
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Suellen Miller
- Bixby Center for Global reproductive Health, University of California San Francisco, San Francisco, California, USA
| | - Fernando Althabe
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Sexual and Reproductive Health and Research, WHO, Geneva, Switzerland
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Hill SK, Bempong-Ahun N, Okolo ID, Lalla AT, Worku D, Asres T, Philpotts L, Fallah PN, Varallo J, Corlew S, Kamfwa P, Parham GP, Hicks ML, Ibbotson G, Randall T. Improving access to safe, quality surgical care for gynecologic cancers through capacity-building interventions in low- and middle-income countries: A scoping review. Int J Gynaecol Obstet 2024; 165:552-561. [PMID: 37927080 DOI: 10.1002/ijgo.15156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 07/16/2023] [Accepted: 09/10/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Following the launch of the World Health Organization's Strategy to accelerate the elimination of cervical cancer, diagnosis is expected to increase, especially in low- and middle-income countries (LMICs). A well-integrated surgical system is critical to treat cervical cancer. Two major approaches have been employed to build human capacity: task-sharing and training of gynecologic oncologists (GynOncs). OBJECTIVES This review aimed to explore existing literature on capacity-building for surgical management of early-stage gynecologic cancers. SEARCH STRATEGY The search strategy was registered on Open Science Framework (doi 10.17605/OSF.IO/GTRCB) and conducted on OVID Medline, Embase, Global Index Medicus, and Web of Science. Search results were exported and screened in COVIDENCE. SELECTION CRITERIA Studies published in English, Spanish, French, and/or Portuguese conducted in LMIC settings evaluating capacity building, task-sharing, or outcomes following operation by subspecialists compared to specialists were included. DATA COLLECTION AND ANALYSIS Results were synthesized using narrative synthesis approach with emergence of key themes by frequency. MAIN RESULTS The scoping review identified 18 studies spanning our themes of interest: capacity building, subspecialized versus non-subspecialized care, and task-shifting/-sharing. CONCLUSIONS A multilayered approach is critical to achieve the WHO Strategy to Eliminate Cervical Cancer. Capacity-building and task-sharing programs demonstrate encouraging results to meet this need; nevertheless, a standardized methodology is needed to evaluate these programs, their outcomes, and cost-effectiveness.
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Affiliation(s)
- Sarah K Hill
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Isioma Dianne Okolo
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
- Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Amber Trujillo Lalla
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dawit Worku
- Department of Obstetrics and Gynecology, University Teaching Hospital of Kigali (CHUK), Kigali, Rwanda
| | - Tadios Asres
- Department of Obstetrics and Gynecology, Rwanda Military Hospital (RMH), Kigali, Rwanda
| | - Lisa Philpotts
- Treadwell Library, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Parisa N Fallah
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John Varallo
- The Global Surgery Foundation, Geneva, Switzerland
| | - Scott Corlew
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Paul Kamfwa
- Department of Gynecologic Oncology, Cancer Diseases Hospital, Lusaka, Zambia
| | - Groesbeck P Parham
- Women and Newborn Hospital-University Teaching Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Michael L Hicks
- Women and Newborn Hospital-University Teaching Hospital, Lusaka, Zambia
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Department of Gynecologic Oncology, Michigan Cancer Institute, St. Joseph Mercy Oakland, Pontiac, USA
| | - Geoffrey Ibbotson
- The Global Surgery Foundation, Geneva, Switzerland
- United Nations Institute for Training and Research, Geneva, Switzerland
| | - Thomas Randall
- The Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts, USA
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3
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Zaigham M, Varallo J, Thangaratinam S, Nicholson W, H. A. Visser G. Global disparities in caesarean section rates: Why indication-based metrics are needed. PLOS Glob Public Health 2024; 4:e0002877. [PMID: 38319901 PMCID: PMC10846695 DOI: 10.1371/journal.pgph.0002877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Mehreen Zaigham
- Obstetrics and Gynaecology, Institution of Clinical Sciences Lund, Lund University, Lund, Sweden
| | | | - Shakila Thangaratinam
- WHO Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | - Wanda Nicholson
- Department of Prevention and Community Health, George Washington Milken Institute of Public Health and the Department of Obstetrics and Gynaecology, George Washington School of Medicine, Washington, DC, United States of America
| | - Gerard H. A. Visser
- Department of Obstetrics, University Medical Center, Utrecht, The Netherlands
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4
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Betrán AP, Torloni MR, Althabe F, Altieri E, Arulkumaran S, Ashraf F, Bailey P, Bonet M, Bucagu M, Clark E, Changizi N, Churchill R, Dominico S, Downe S, Draycott T, Faye A, Feeley C, Geelhoed D, Gherissi A, Gholbzouri K, Grupta G, Hailegebriel TD, Hanson C, Hartmann K, Hassan L, Hofmeyr GJ, Jayathilaka AC, Kabore C, Kidula N, Kingdon C, Kuzmenko O, Lumbiganon P, Mola GDL, Moran A, de Muncio B, Nolens B, Opiyo N, Pattinson RC, Romero M, van Roosmalen J, Siaulys MM, Camelo JS, Smith J, Sobel HL, Sobhy S, Sosa C, Souza JP, ten Hoope-Bender P, Thangaratinam S, Varallo J, Wright A, Yates A, Oladapo OO. A research agenda to improve incidence and outcomes of assisted vaginal birth. Bull World Health Organ 2023; 101:723-729. [PMID: 37961052 PMCID: PMC10630731 DOI: 10.2471/blt.23.290140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/15/2023] [Accepted: 09/13/2023] [Indexed: 11/15/2023] Open
Abstract
Access to emergency obstetric care, including assisted vaginal birth and caesarean birth, is crucial for improving maternal and childbirth outcomes. However, although the proportion of births by caesarean section has increased during the last few decades, the use of assisted vaginal birth has declined. This is particularly the case in low- and middle-income countries, despite an assisted vaginal birth often being less risky than caesarean birth. We therefore conducted a three-step process to identify a research agenda necessary to increase the use of, or reintroduce, assisted vaginal birth: after conducting an evidence synthesis, which informed a consultation with technical experts who proposed an initial research agenda, we sought and incorporated the views of women's representatives of this agenda. This process has allowed us to identify a comprehensive research agenda, with topics categorized as: (i) the need to understand women's perceptions of assisted vaginal birth, and provide appropriate and reliable information; (ii) the importance of training health-care providers in clinical skills but also in respectful care, effective communication, shared decision-making and informed consent; and (iii) the barriers to and facilitators of implementation and sustainability. From women's feedback, we learned of the urgent need to recognize labour, childbirth and postpartum experiences as inherently physiological and dignified human processes, in which interventions should only be implemented if necessary. The promotion and/or reintroduction of assisted vaginal birth in low-resource settings requires governments, policy-makers and hospital administrators to support skilled health-care providers who can, in turn, respectfully support women in labour and childbirth.
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Affiliation(s)
- Ana Pilar Betrán
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
| | - Maria Regina Torloni
- EBH Postgraduate Programme, Department of Medicine, Sao Paulo Federal University-UNIFESP, Sao Paulo, Brazil
| | | | - Elena Altieri
- Behavioural Insights Unit, Department of Communications, World Health Organization, Geneva, Switzerland
| | - Sabaratnam Arulkumaran
- St George's University of London, London, United Kingdom of Great Britain and Northern Ireland
| | - Fatema Ashraf
- Department of Obstetrics & Gynaecology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh
| | - Patricia Bailey
- Reproductive, Maternal, Newborn and Child Health, FHI360, Durham, North Carolina, United States of America
| | - Mercedes Bonet
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
| | - Maurice Bucagu
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Emma Clark
- Maternal Child Health and Nutrition, USAID Bureau for Global Health, Arlington, United States
| | - Nasrin Changizi
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Robyn Churchill
- Maternal Child Health and Nutrition, USAID Bureau for Global Health, Arlington, United States
| | | | - Soo Downe
- Department of Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Tim Draycott
- The Chilterns, Southmead Hospital, Bristol, United Kingdom
| | - Arfang Faye
- Reproductive, Maternal, Newborn, Child and Adolescent Health Unit, Ministry of Health, Gambia
| | - Claire Feeley
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | | | - Atf Gherissi
- High School for Health Science and Techniques, University of Tunis El Manar, Tunis, Tunisia
| | | | - Gagan Grupta
- United Nations Children's Fund, New York, United States
| | | | - Claudia Hanson
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Katharina Hartmann
- Mother Hood e.V. - Federal Parents' Initiative for the Protection of Mother and Child during Pregnancy, Bonn, Germany
| | - Lubna Hassan
- Women's Health Intervention and Development Initiative, Islamabad, Pakistan
| | - George Justus Hofmeyr
- Department of Obstetrics and Gyneacology, University of Botswana, Gaborone, Botswana
| | | | - Charles Kabore
- Institut de Recherche en Sciences de la Sante, Ouagadougou, Burkina Faso
| | - Nancy Kidula
- WHO Regional Office for Africa, Brazzaville, Congo
| | - Carol Kingdon
- Research in Childbirth and Health Unit, University of Central Lancashire, Preston, United Kingdom
| | - Oleg Kuzmenko
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- EBH Postgraduate Programme, Department of Medicine, Sao Paulo Federal University-UNIFESP, Sao Paulo, Brazil
| | - Pisake Lumbiganon
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Buenos Aires, Argentina
| | - Glen DL Mola
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Behavioural Insights Unit, Department of Communications, World Health Organization, Geneva, Switzerland
| | - Allisyn Moran
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Bremen de Muncio
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- St George's University of London, London, United Kingdom of Great Britain and Northern Ireland
| | - Barbara Nolens
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Department of Obstetrics & Gynaecology, Shaheed Suhrawardy Medical College Hospital, Dhaka, Bangladesh
| | - Newton Opiyo
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
| | - Robert C Pattinson
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Reproductive, Maternal, Newborn and Child Health, FHI360, Durham, North Carolina, United States of America
| | - Mariana Romero
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Jos van Roosmalen
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Maternal Child Health and Nutrition, USAID Bureau for Global Health, Arlington, United States
| | - Monica M Siaulys
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Maternal, Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Jose Simon Camelo
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Thamini Uhai (Value Life), United Republic of Tanzania
| | - Jeffrey Smith
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Department of Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Howard L Sobel
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- The Chilterns, Southmead Hospital, Bristol, United Kingdom
| | - Soha Sobhy
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Reproductive, Maternal, Newborn, Child and Adolescent Health Unit, Ministry of Health, Gambia
| | - Claudio Sosa
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- School of Community Health and Midwifery, University of Central Lancashire, Preston, United Kingdom
| | - Joao Paulo Souza
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Tete, Mozambique
| | - Petra ten Hoope-Bender
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- High School for Health Science and Techniques, University of Tunis El Manar, Tunis, Tunisia
| | - Shakila Thangaratinam
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - John Varallo
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- United Nations Children's Fund, New York, United States
| | - Alison Wright
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Department of Global Public Health, Karolinska Institute, Stockholm, Sweden
| | - Ann Yates
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
- Mother Hood e.V. - Federal Parents' Initiative for the Protection of Mother and Child during Pregnancy, Bonn, Germany
| | - Olufemi O Oladapo
- Department of Sexual and Reproductive Health and Research, World Health Organization, Avenue Appia 20, 1202Geneva, Switzerland
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Bete DY, Sibhatu MK, Godebo MG, Abdulahi IJ, Liyew TW, Minas SM, Bryce E, Ashengo TA, Varallo J. Improving surgical safety checklist utilisation at 23 public health facilities in Ethiopia: a collaborative quality improvement project. BMJ Open Qual 2023; 12:e002406. [PMID: 37940334 PMCID: PMC10632882 DOI: 10.1136/bmjoq-2023-002406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/25/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND In 2009, the WHO introduced the surgical safety checklist (SSC) as one of the interventions for improving patient safety. The systematic use of structured checklists during surgery has been shown to reduce perioperative morbidity and mortality. However, SSC utilisation has been challenging in low-income and middle-income countries, including Ethiopia. Jhpiego Ethiopia implemented a quality improvement project (QIP) aimed to increase SSC utilisation. METHODOLOGY A model for improvement was used to design and implement a collaborative QIP to improve SSC utilisation at 23 public health facilities (13 primary health care facilities, 4 general hospitals and 6 tertiary hospitals) in Ethiopia from October 2020 to September 2021. SSC utilisation was defined as when a patient chart had SSC attached and each part of the checklist was completed. Training of surgical staff on safe surgery packages, monthly clinical mentorship and cluster-based learning platforms were implemented during the study period. We analysed bimonthly chart audit reports from each facility to assess the proportion of surgeries where the SSC was used. Shewhart charts were used to conduct a time-series analysis. Additionally, the Z-test for two sample proportions was used to determine if there is a statistically significant change from the baseline measure with a p<0.05. RESULT In the postintervention period, the overall SSC utilisation improved by 39.9 absolute percentage points to 90.3% (p<0.0001) compared with the baseline value of 50.4% early in 2020. A time-series analysis using Shewhart charts showed a shift in the mean performance and signals of special cause variation. The largest improvement was observed in primary health care facilities in which the SSC utilisation improved from 50.8% to 97.9% (p<0.0001). CONCLUSION This study demonstrates that onsite clinical capacity building, mentorship and collaborative cluster-based learning platforms can improve SSC utilisation across all levels of facilities performing surgery.
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Affiliation(s)
| | | | | | | | | | | | - Emily Bryce
- Jhpiego Corporation, Baltimore, Maryland, USA
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6
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Fitzgerald L, Tibyehabwa L, Varallo J, Ernest E, Patted A, Bertram MM, Alidina S, Mshana S, Katoto A, Simba D, Charles K, Smith V, Cainer M, Hellar A. Mentoring approaches in a safe surgery program in Tanzania: Lessons learned during COVID-19 and recommendations for the future. Surg Open Sci 2023; 14:109-113. [PMID: 37577254 PMCID: PMC10413135 DOI: 10.1016/j.sopen.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/18/2023] [Indexed: 08/15/2023] Open
Abstract
Background COVID-19 has dramatically affected the delivery of health care and technical assistance. This is true in Tanzania, where maternal mortality and surgical infection rates are significantly higher than in high-income countries. This paper describes lessons learned about the optimal application of in-person and virtual mentorship in the Safe Surgery 2020 program to improve the quality of surgical services in Tanzania before and after the COVID-19 pandemic. Methods From January 2018 through December 2020, Safe Surgery 2020 supported 40 health facilities in Tanzania's Lake Zone to improve the quality of surgical care. A blended surgical mentorship model, employing both onsite and virtual mentorship, was central to the program's capacity development approach. With COVID-19, the program pivoted to full virtual mentorship. Through continuous learning and adaptation processes, including a human-centered design workshop, surveys assessing mentors' confidence with different competencies, and focus group discussions with mentors, mentees and safe surgery program staff, the program distilled the optimal use of mentorship models. Results Developing complex surgical skills, addressing contextual considerations, problem-solving, and building trusting relationships were best suited to in-person mentorship, whereas virtual mentorship was most effective in supporting mentees' quality improvement projects, data use, case discussions, and reinforcing clinical practices. Leading successful virtual learning required enhanced facilitation skills and active engagement of health facility leadership. Conclusions In-person and virtual mentorship offer distinct benefits and complement each other when combined. Investing more in-person mentorship at the beginning of programs allows for the establishment of trust that is foundational to effective mentorship.
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Affiliation(s)
| | | | - John Varallo
- Jhpiego, 1615 Thames St, Baltimore, MD, United States
| | - Edwin Ernest
- Safe Surgery 2020 Project, Jhpiego Tanzania, Dar es Salaam, Tanzania
| | - Anmol Patted
- Jhpiego, 1615 Thames St, Baltimore, MD, United States
| | | | - Shehnaz Alidina
- Harvard T. H. Chan School of Public Health, Boston, MA, United States1
Current affiliation. - Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States2
Former affiliation.
| | - Stella Mshana
- Safe Surgery 2020 Project, Jhpiego Tanzania, Mara, Tanzania
| | - Adam Katoto
- Safe Surgery 2020 Project, Jhpiego Tanzania, Kagera, Tanzania
| | - Dorcas Simba
- Safe Surgery 2020 Project, Jhpiego Tanzania, Dar es Salaam, Tanzania
| | | | | | | | - Augustino Hellar
- Safe Surgery 2020 Project, Jhpiego Tanzania, Dar es Salaam, Tanzania
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Sibhatu MK, Taye DB, Gebreegziabher SB, Mesfin E, Bashir HM, Varallo J. Compliance with the World Health Organization's surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia. Patient Saf Surg 2022; 16:20. [PMID: 35689263 PMCID: PMC9188150 DOI: 10.1186/s13037-022-00329-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Ministry of Health (MOH) of Ethiopia adopted World Health Organization’s evidence-proven surgical safety checklist (SSC) to reduce the occurrence of surgical complications, i.e., death, disability and prolong hospitalization. MOH commissioned this evaluation to learn about SSC completeness and compliance, and its effect on magnitude of surgical complications. Methods Health institution-based cross-sectional study with retrospective surgical chart audit was used to evaluate SSC utilization in 172 public and private health facilities in Ethiopia, December 2020–May 2021. A total of 1720 major emergency and elective surgeries in 172 (140 public and 32 private) facilities were recruited for chart review by an experienced team of surgical clinicians. A pre-tested tool was used to abstract data from patient charts and national database. Analyzed descriptive, univariable and bivariable data using Stata version-15 statistical software. Results In 172 public and private health facilities across Ethiopia, 1603 of 1720 (93.2%) patient charts were audited; representations of public and private facilities were 81.4% (n = 140) and 18.6% (n = 32), respectively. Of surgeries that utilized SSC (67.6%, 1083 of 1603), the proportion of SSC that were filled completely and correctly were 60.8% (659 of 1083). Surgeries compliant to SSC guide achieved a statistically significant reduction in perioperative mortality (P = 0.002) and anesthesia adverse events (P = 0.005), but not in Surgical Site Infection (P = 0.086). Non-compliant surgeries neither utilized SSC nor completed the SSC correctly, 58.9% (944 of 1603). Conclusions Surgeries that adhered to the SSC achieved a statistically significant reduction in perioperative complications, including mortality. Disappointingly, a significant number of surgeries (58.9%) failed to adhere to SSC, a missed opportunity for reducing complications. Supplementary Information The online version contains supplementary material available at 10.1186/s13037-022-00329-6.
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Affiliation(s)
- Manuel Kassaye Sibhatu
- Jhpiego Ethiopia, Johns Hopkins University Affiliate, Mailbox 607. Bole subcity, Woreda 13, House No. B17/3, Addis Ababa, Ethiopia.
| | | | | | - Edlawit Mesfin
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | - John Varallo
- Jhpiego Corporation, Johns Hopkins University Affiliate, Baltimore, USA
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Ernest EC, Hellar A, Varallo J, Tibyehabwa L, Bertram MM, Fitzgerald L, Katoto A, Mshana S, Simba D, Gwitaba K, Boddu R, Alidina S, Giiti G, Kihunrwa A, Balandya B, Urassa D, Hussein Y, Damien C, Wackenreuter B, Barash D, Morrison M, Reynolds C, Christensen A, Makuwani A. Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention. BMJ Glob Health 2021; 6:e006788. [PMID: 34876458 PMCID: PMC8655579 DOI: 10.1136/bmjgh-2021-006788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 11/01/2021] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Despite ongoing maternal health interventions, maternal deaths in Tanzania remain high. One of the main causes of maternal mortality includes postoperative infections. Surgical site infection (SSI) rates are higher in low/middle-income countries (LMICs), such as Tanzania, compared with high-income countries. We evaluated the impact of a multicomponent safe surgery intervention in Tanzania, hypothesising it would (1) increase adherence to safety practices, such as the WHO Surgical Safety Checklist (SSC), (2) reduce SSI rates following caesarean section (CS) and (3) reduce CS-related perioperative mortality rates (POMRs). METHODS We conducted a pre-cross-sectional/post-cross-sectional study design to evaluate WHO SSC utilisation, SSI rates and CS-related POMR before and 18 months after implementation. Our interventions included training of inter-professional surgical teams, promoting use of the WHO SSC and introducing an infection prevention (IP) bundle for all CS patients. We assessed use of WHO SSC and SSI rates through random sampling of 279 individual CS patient files. We reviewed registers and ward round reports to obtain the number of CS performed and CS-related deaths. We compared proportions of individuals with a characteristic of interest during pre-implementation and post implementation using the two-proportion z-test at p≤0.05 using STATA V.15. RESULTS The SSC utilisation rate for CS increased from 3.7% (5 out of 136) to 95.1% (136 out of 143) with p<0.001. Likewise, the proportion of women with SSI after CS reduced from 14% during baseline to 1% (p=0.002). The change in SSI rate after the implementation of the safe surgery interventions is statistically significant (p<0.001). The CS-related POMR decreased by 38.5% (p=0.6) after the implementation of safe surgery interventions. CONCLUSION Our findings show that our intervention led to improved utilisation of the WHO SSC, reduced SSIs and a drop in CS-related POMR. We recommend replication of the interventions in other LMICs.
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Affiliation(s)
| | | | | | | | | | | | - Adam Katoto
- JHPIEGO, Dar es Salaam, Tanzania, United Republic of
| | - Stella Mshana
- JHPIEGO, Dar es Salaam, Tanzania, United Republic of
| | - Dorcas Simba
- JHPIEGO, Dar es Salaam, Tanzania, United Republic of
| | | | - Rohini Boddu
- Johns Hopkins University, Baltimore, Maryland, USA
| | - Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
| | - Geofrey Giiti
- Department of Surgery, Catholic University of Health and Allied Sciences Bugando, Mwanza, Tanzania, United Republic of
| | - Albert Kihunrwa
- Department of Obstetrics and Gynaecology, Bugando Medical Centre, Mwanza, Tanzania, United Republic of
| | - Belinda Balandya
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - David Urassa
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania, United Republic of
| | - Yahya Hussein
- President Office Regional Authority and Local Government, Dar es Salaam, Tanzania, United Republic of
| | - Caroline Damien
- Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania, United Republic of
| | | | - David Barash
- Developing Health Globally, GE Foundation, Fairfield, Connecticut, USA
| | - Melissa Morrison
- The ELMA Philanthropies Services (U.S.), New York, New York, USA
| | | | | | - Ahmed Makuwani
- Ministry of Health Community Development Gender Elderly and Children, Dar es Salaam, Tanzania, United Republic of
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Alidina S, Tibyehabwa L, Alreja SS, Barash D, Bien-Aime D, Cainer M, Charles K, Ernest E, Eyembe J, Fitzgerald L, Giiti GC, Hellar A, Hussein Y, Kahindo F, Kenemo B, Kihunrwa A, Kisakye S, Kissima I, Meara JG, Reynolds C, Staffa SJ, Sydlowski M, Varallo J, Zanial N, Kapologwe NA, Mayengo CD. A multimodal mentorship intervention to improve surgical quality in Tanzania's Lake Zone: a convergent, mixed methods assessment. Hum Resour Health 2021; 19:115. [PMID: 34551758 PMCID: PMC8458007 DOI: 10.1186/s12960-021-00652-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/01/2021] [Indexed: 05/11/2023]
Abstract
BACKGROUND Safe, high-quality surgical care in many African countries is a critical need. Challenges include availability of surgical providers, improving quality of care, and building workforce capacity. Despite growing evidence that mentoring is effective in African healthcare settings, less is known about its role in surgery. We examined a multimodal approach to mentorship as part of a safe surgery intervention (Safe Surgery 2020) to improve surgical quality. Our goal was to distill lessons for policy makers, intervention designers, and practitioners on key elements of a successful surgical mentorship program. METHODS We used a convergent, mixed-methods design to examine the experiences of mentees, mentors, and facility leaders with mentorship at 10 health facilities in Tanzania's Lake Zone. A multidisciplinary team of mentors worked with surgical providers over 17 months using in-person mentorship, telementoring, and WhatsApp. We conducted surveys, in-depth interviews, and focus groups to capture data in four categories: (1) satisfaction with mentorship; (2) perceived impact; (3) elements of a successful mentoring program; and (4) challenges to implementing mentorship. We analyzed quantitative data using frequency analysis and qualitative data using the constant comparison method. Recurrent and unifying concepts were identified through merging the qualitative and quantitative data. RESULTS Overall, 96% of mentees experienced the intervention as positive, 88% were satisfied, and 100% supported continuing the intervention in the future. Mentees, mentors, and facility leaders perceived improvements in surgical practice, the surgical ecosystem, and in reducing postsurgical infections. Several themes related to the intervention's success emerged: (1) the intervention's design, including its multimodality, side-by-side mentorship, and standardization of practices; (2) the mentee-mentor relationship, including a friendly, safe, non-hierarchical, team relationship, as well as mentors' understanding of the local context; and (3) mentorship characteristics, including non-judgmental feedback, experience, and accessibility. Challenges included resistance to change, shortage of providers, mentorship dose, and logistics. CONCLUSIONS Our study suggests a multimodal mentorship approach is promising in building the capacity of surgical providers. By distilling the experiences of the mentees, mentors, and facility leaders, our lessons provide a foundation for future efforts to establish effective surgical mentorship programs that build provider capacity and ultimately improve surgical quality.
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Affiliation(s)
- Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - Leopold Tibyehabwa
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania and Baltimore, MD USA
| | - Sakshie Sanjay Alreja
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | | | - Danta Bien-Aime
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - Monica Cainer
- Assist International, Dar es Salaam, Tanzania and Ripon, CA USA
| | - Kevin Charles
- Assist International, Dar es Salaam, Tanzania and Ripon, CA USA
| | - Edwin Ernest
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania and Baltimore, MD USA
| | | | - Laura Fitzgerald
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania and Baltimore, MD USA
| | - Geofrey C. Giiti
- Department of Surgery and Department of Obstetrics and Gynaecology, Bugando Medical Center, Mwanza, Tanzania
| | - Augustino Hellar
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania and Baltimore, MD USA
| | - Yahaya Hussein
- Department of Health, Social Welfare, and Nutrition Service, President’s Office – Regional Administration and Local Government, Dodoma, Tanzania
| | | | - Benard Kenemo
- Department of Surgery and Department of Obstetrics and Gynaecology, Bugando Medical Center, Mwanza, Tanzania
| | - Albert Kihunrwa
- Department of Surgery and Department of Obstetrics and Gynaecology, Bugando Medical Center, Mwanza, Tanzania
| | - Steve Kisakye
- D-Implement, Dalberg Advisors, Dar es Salaam, Tanzania
| | | | - John G. Meara
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Cheri Reynolds
- Assist International, Dar es Salaam, Tanzania and Ripon, CA USA
| | - Steven J. Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Meaghan Sydlowski
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - John Varallo
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania and Baltimore, MD USA
| | - Noor Zanial
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115 USA
| | - Ntuli A. Kapologwe
- Department of Health, Social Welfare, and Nutrition Service, President’s Office – Regional Administration and Local Government, Dodoma, Tanzania
| | - Caroline Damian Mayengo
- Department of Curative Services, Ministry of Health, Community Development, Gender, Elderly, and Children, Dodoma, Tanzania
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Alidina S, Menon G, Staffa SJ, Alreja S, Barash D, Barringer E, Cainer M, Citron I, DiMeo A, Ernest E, Fitzgerald L, Ghandour H, Gruendl M, Hellar A, Jumbam DT, Katoto A, Kelly L, Kisakye S, Kuchukhidze S, Lama T, Lodge Ii W, Maina E, Massaga F, Mazhiqi A, Meara JG, Mshana S, Nason I, Reynolds C, Reynolds C, Segirinya H, Simba D, Smith V, Strader C, Sydlowski M, Tibyehabwa L, Tinuga F, Troxel A, Ulisubisya M, Varallo J, Wurdeman T, Zanial N, Zurakowski D, Kapologwe N, Maongezi S. Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study. Int J Qual Health Care 2021; 33:6289905. [PMID: 34057187 PMCID: PMC8240014 DOI: 10.1093/intqhc/mzab087] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/12/2021] [Accepted: 05/30/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Evidence-based strategies for improving surgical quality and patient outcomes in low-resource settings are a priority. OBJECTIVE To evaluate the impact of a multicomponent safe surgery intervention (Safe Surgery 2020) on (1) adherence to safety practices, teamwork and communication, and documentation in patient files, and (2) incidence of maternal sepsis, postoperative sepsis, and surgical site infection. METHODS We conducted a prospective, longitudinal study in 10 intervention and 10 control facilities in Tanzania's Lake Zone, across a 3-month pre-intervention period in 2018 and 3-month post-intervention period in 2019. SS2020 is a multicomponent intervention to support four surgical quality areas: (i) leadership and teamwork, (ii) evidence-based surgery, anesthesia and equipment sterilization practices, (iii) data completeness and (iv) infrastructure. Surgical team members received training and mentorship, and each facility received up to a $10 000 infrastructure grant. Inpatients undergoing major surgery and postpartum women were followed during their stay up to 30 days. We assessed adherence to 14 safety and teamwork and communication measures through direct observation in the operating room. We identified maternal sepsis (vaginal or cesarean delivery), postoperative sepsis and SSIs prospectively through daily surveillance and assessed medical record completeness retrospectively through chart review. We compared changes in surgical quality outcomes between intervention and control facilities using difference-in-differences analyses to determine areas of impact. RESULTS Safety practices improved significantly by an additional 20.5% (95% confidence interval (CI), 7.2-33.7%; P = 0.003) and teamwork and communication conversations by 33.3% (95% CI, 5.7-60.8%; P = 0.02) in intervention facilities compared to control facilities. Maternal sepsis rates reduced significantly by 1% (95% CI, 0.1-1.9%; P = 0.02). Documentation completeness improved by 41.8% (95% CI, 27.4-56.1%; P < 0.001) for sepsis and 22.3% (95% CI, 4.7-39.8%; P = 0.01) for SSIs. CONCLUSION Our findings demonstrate the benefit of the SS2020 approach. Improvement was observed in adherence to safety practices, teamwork and communication, and data quality, and there was a reduction in maternal sepsis rates. Our results support the emerging evidence that improving surgical quality in a low-resource setting requires a focus on the surgical system and culture. Investigation in diverse contexts is necessary to confirm and generalize our results and to understand how to adapt the intervention for different settings. Further work is also necessary to assess the long-term effect and sustainability of such interventions.
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Affiliation(s)
- Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Gopal Menon
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02215, USA
| | - Sakshie Alreja
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - David Barash
- GE Foundation, 5 Necco Street, Boston, MA 02210, USA
| | - Erin Barringer
- Dalberg Implement-Dalberg, Indian Ocean Building, Block C, 4th Floor, 383 Toure Drive, Dar es Salaam, Tanzania
| | - Monica Cainer
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Amanda DiMeo
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Edwin Ernest
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Laura Fitzgerald
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Hiba Ghandour
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Magdalena Gruendl
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Audustino Hellar
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Desmond T Jumbam
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Adam Katoto
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Lauren Kelly
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Steve Kisakye
- Dalberg Implement-Dalberg, Indian Ocean Building, Block C, 4th Floor, 383 Toure Drive, Dar es Salaam, Tanzania
| | - Salome Kuchukhidze
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Tenzing Lama
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - William Lodge Ii
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Erastus Maina
- Dalberg Implement-Dalberg, Indian Ocean Building, Block C, 4th Floor, 383 Toure Drive, Dar es Salaam, Tanzania
| | - Fabian Massaga
- Department of Surgery, Bugando Medical Center, Block Z, Plot 229 Wurzbarg Road, Mwanza, Tanzania
| | - Adelina Mazhiqi
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02215, USA
| | - Stella Mshana
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Ian Nason
- Department of Health Policy and Management, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, USA
| | - Chase Reynolds
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | - Cheri Reynolds
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | | | - Dorcas Simba
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Victoria Smith
- Assist International, 800 South Stockton Avenue, Ripon, CA 95366, USA
| | - Christopher Strader
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Meaghan Sydlowski
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Leopold Tibyehabwa
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Florian Tinuga
- Department of Health, Social Welfare and Nutrition Service, President's Office-Regional Administration and Local Government, Tamisemi Street, Government City-Mtumba, Dodoma, Tanzania
| | - Alena Troxel
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Mpoki Ulisubisya
- Department of Curative Services, Ministry of Health, Community Development, Gender, Elderly and Children, Government City-Mtumba, Dodoma, Tanzania
| | - John Varallo
- Safe Surgery 2020 Project, Plot No. 72, Block 45 B Victoria Area, New Bagamoyo Road, Jhpiego, Dar es Salaam, Tanzania
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - Noor Zanial
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02215, USA
| | - Ntuli Kapologwe
- Department of Health, Social Welfare and Nutrition Service, President's Office-Regional Administration and Local Government, Tamisemi Street, Government City-Mtumba, Dodoma, Tanzania
| | - Sarah Maongezi
- Department of Curative Services, Ministry of Health, Community Development, Gender, Elderly and Children, Government City-Mtumba, Dodoma, Tanzania
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Lodge W, Menon G, Kuchukhidze S, Jumbam DT, Maongezi S, Alidina S, Nguhuni B, Kapologwe NA, Varallo J. Assessing completeness of patient medical records of surgical and obstetric patients in Northern Tanzania. Glob Health Action 2021; 13:1765526. [PMID: 32476620 PMCID: PMC7782986 DOI: 10.1080/16549716.2020.1765526] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Background Strengthening surgical services in resource-constrained settings is contingent on using high-quality data to inform decision making at clinical, facility, and policy levels. However, the evidence is sparse on gaps in paper-based medical record quality for surgical and obstetric patients in low-resource settings. Objective We aim to examine surgical and obstetric patient medical record data quality in health facilities as part of a surgical system strengthening initiative in northern Tanzania. Methods To measure the incidence of Surgical Site Infections (SSIs), sepsis and maternal sepsis surgical and obstetric inpatients were followed prospectively, over three months in ten primary, district, and regional health facilities in northern Tanzania. Between April 22nd to May 1st, 2018, we retrospectively reviewed paper-based medical records of surgical and obstetric patients diagnosed with SSIs, post-operative sepsis, and maternal sepsis in the three-month follow-up period. A data quality assessment tool with18 data elements related to documentation of SSIs and sepsis diagnosis, their respective symptoms and vital signs, inpatient daily monitoring indicators, and demographic information was developed and used to assess the completeness of patient medical records. Results Among the 157 patients diagnosed with SSI and sepsis, we found and reviewed 68% of all medical records. Among records reviewed, approximately one third (34%) and one quarter (23%) included documentation of SSI and sepsis diagnoses, respectively. 6% of reviewed records included documentation of all SSI and sepsis diagnoses, symptoms and vital signs, inpatient daily monitoring indicators, and demographic data. Conclusions Strengthening data quality and record-keeping is essential for surgical team communication, continuity of care, and patient safety, especially in low resource settings where paper-based records are the primary means of data collection. High-quality primary health information provides facilities with actionable data for improving surgical and obstetric care quality at the facility level.
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Affiliation(s)
- William Lodge
- Department of Global Health and Social Medicine, Harvard Medical School , Boston, MA, USA
| | - Gopal Menon
- Department of Global Health and Social Medicine, Harvard Medical School , Boston, MA, USA
| | - Salome Kuchukhidze
- Department of Global Health and Social Medicine, Harvard Medical School , Boston, MA, USA
| | - Desmond T Jumbam
- Department of Global Health and Social Medicine, Harvard Medical School , Boston, MA, USA
| | - Sarah Maongezi
- Department of Adult Non-communicable Diseases, Ministry of Health, Community Development, Gender, Elderly, and Children (Mohcdgec) , Tanzania, Dodoma
| | - Shehnaz Alidina
- Department of Global Health and Social Medicine, Harvard Medical School , Boston, MA, USA
| | - Boniface Nguhuni
- Department of Health, Social Welfare and Nutritional Service, President's Office - Regional Administration and Local Government , Dodoma, Tanzania
| | - Ntuli A Kapologwe
- Department of Health, Social Welfare and Nutritional Service, President's Office - Regional Administration and Local Government , Dodoma, Tanzania
| | - John Varallo
- Safe Surgery 2020 Project, Jhpiego , Baltimore, MD, USA
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Alidina S, Chatterjee P, Zanial N, Alreja SS, Balira R, Barash D, Ernest E, Giiti GC, Maina E, Mazhiqi A, Mushi R, Reynolds C, Sydlowski M, Tinuga F, Maongezi S, Meara JG, Kapologwe NA, Barringer E, Cainer M, Citron I, DiMeo A, Fitzgerald L, Ghandour H, Gruendl M, Hellar A, Jumbam DT, Katoto A, Kelly L, Kisakye S, Kuchukhidze S, Lama TN, Menon G, Mshana S, Reynolds C, Segirinya H, Simba D, Smith V, Staffa SJ, Strader C, Tibyehabwa L, Troxel A, Varallo J, Wurdeman T, Zurakowski D. Improving surgical quality in low-income and middle-income countries: why do some health facilities perform better than others? BMJ Qual Saf 2021; 30:937-949. [PMID: 33547219 PMCID: PMC8606467 DOI: 10.1136/bmjqs-2020-011795] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 12/15/2020] [Accepted: 01/18/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Evidence on heterogeneity in outcomes of surgical quality interventions in low-income and middle-income countries is limited. We explored factors driving performance in the Safe Surgery 2020 intervention in Tanzania's Lake Zone to distil implementation lessons for low-resource settings. METHODS We identified higher (n=3) and lower (n=3) performers from quantitative data on improvement from 14 safety and teamwork and communication indicators at 0 and 12 months from 10 intervention facilities, using a positive deviance framework. From 72 key informant interviews with surgical providers across facilities at 1, 6 and 12 months, we used a grounded theory approach to identify practices of higher and lower performers. RESULTS Performance experiences of higher and lower performers differed on the following themes: (1) preintervention context, (2) engagement with Safe Surgery 2020 interventions, (3) teamwork and communication orientation, (4) collective learning orientation, (5) role of leadership, and (6) perceived impact of Safe Surgery 2020 and beyond. Higher performers had a culture of teamwork which helped them capitalise on Safe Surgery 2020 to improve surgical ecosystems holistically on safety practices, teamwork and communication. Lower performers prioritised overhauling safety practices and began considering organisational cultural changes much later. Thus, while also improving, lower performers prioritised different goals and trailed higher performers on the change continuum. CONCLUSION Future interventions should be tailored to facility context and invest in strengthening teamwork, communication and collective learning and facilitate leadership engagement to build a receptive climate for successful implementation of safe surgery interventions.
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Affiliation(s)
- Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Pritha Chatterjee
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Department of Social and Behavioral Sciences, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Noor Zanial
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Sakshie Sanjay Alreja
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Rebecca Balira
- Department of Epidemiology, National Institute for Medical Research Mwanza Research Centre, Mwanza, Tanzania
| | | | - Edwin Ernest
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
| | | | | | - Adelina Mazhiqi
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Rahma Mushi
- Department of Obstetrics and Gynecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Cheri Reynolds
- Department of Global Health, Assist International, Ripon, California, USA
| | - Meaghan Sydlowski
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Florian Tinuga
- Department of Health, Social Welfare and Nutrition Service, President's Office - Regional Administration and Local Government, Dodoma, Tanzania
| | - Sarah Maongezi
- Department of Adult Non-Communicable Diseases, Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ntuli A Kapologwe
- Department of Health, Social Welfare and Nutrition Service, President's Office - Regional Administration and Local Government, Dodoma, Tanzania
| | - Erin Barringer
- Dalberg Advisors, Dalberg Group, New York, New York, USA
| | - Monica Cainer
- Department of Global Health, Assist International, Ripon, California, USA
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Amanda DiMeo
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | | | - Hiba Ghandour
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Magdalena Gruendl
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | | | - Desmond T Jumbam
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Adam Katoto
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
| | - Lauren Kelly
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Steve Kisakye
- Dalberg Implement, Dalberg Group, Dar es Salaam, Tanzania
| | - Salome Kuchukhidze
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Tenzing N Lama
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Gopal Menon
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - Stella Mshana
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
| | - Chase Reynolds
- Department of Global Health, Assist International, Ripon, California, USA
| | | | - Dorcas Simba
- Safe Surgery 2020 Project, Jhpiego, Dar es Salaam, Tanzania
| | - Victoria Smith
- Department of Global Health, Assist International, Ripon, California, USA
| | - Steven J Staffa
- Departments of Anesthesiology and Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Christopher Strader
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | | | - Alena Troxel
- Safe Surgery 2020 Project, Jhpiego, Baltimore, Maryland, USA
| | - John Varallo
- Safe Surgery 2020 Project, Jhpiego, Baltimore, Maryland, USA
| | - Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School Department of Global Health and Social Medicine, Boston, Massachusetts, USA
| | - David Zurakowski
- Departments of Anesthesiology and Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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Bari S, Incorvia J, Ahearn O, Dara L, Sharma S, Varallo J, Smith V, Cainer M, Samphy C, Rathamony K, Kanora N, Dara V, Meara JG, Koy V, Alidina S. Building safe surgery knowledge and capacity in Cambodia: a mixed-methods evaluation of an innovative training and mentorship intervention. Glob Health Action 2021; 14:1998996. [PMID: 34927579 PMCID: PMC8725702 DOI: 10.1080/16549716.2021.1998996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Working in partnership with the Cambodian Ministry of Health, the Safe Surgery 2020 initiative (SS2020) supports the prioritization of surgery and mobilization of resources to target limited workforce capacity. An evaluation study was conducted to assess the impact of SS2020 on intervention hospitals in Cambodia. OBJECTIVE To understand the impact of the SS2020 program on intervention hospitals in Cambodia by assessing the changes in key surgical performance indicators before and after the intervention, identifying key barriers and facilitators to adoption of learnings, and discovering lessons on the uptake and diffusion of this initiative in Cambodia and other similar contexts. METHODS This study is a convergent mixed-methods evaluation of a one-year multicomponent SS2020 intervention. Surgical observations were conducted in 8 intervention hospitals at baseline and endline to evaluate pre and post adherence to 20 safety, teamwork, and communication items. Fifteen focus groups were conducted in all intervention sites at endline to assess key facilitators and barriers to positive impact. RESULTS There was significant improvement in 19 of 20 indicators assessed during surgical observations. Among the highest performing indicators were safety items; among the lowest were communication items. Participants self-reported improved knowledge and positive behavior change after the intervention. Institutional change and direct patient impact were not widely reported. Most participants had favorable views of the mentorship model and were eager for the program to continue implementation. CONCLUSIONS The results provide evidence that change in surgical ecosystems can be achieved on a short timeline with limited resources. The hub-and-spoke mentorship model can be successful in improving knowledge and changing behavior in surgical safety. Workforce development is important to improving surgical systems, but greater financial and human resources are needed. Ministry support in adopting, leading, and scaling is crucial to the continued success of safe surgery interventions in Cambodia.
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Affiliation(s)
- Sehrish Bari
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Joseph Incorvia
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Olivia Ahearn
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
| | - Lem Dara
- Calmette Hospital, Phnom Penh, Cambodia
| | | | | | | | | | | | | | | | | | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Virya Koy
- Department of Hospital Services, Ministry of Health, Phnom Penh, Cambodia
| | - Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
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14
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Wurdeman T, Strader C, Alidina S, Barash D, Citron I, Kapologwe N, Maina E, Massaga F, Mazhiqi A, Meara JG, Menon G, Reynolds C, Sydlowski M, Varallo J, Maongezi S, Ulisubisya M. In-Hospital Postoperative Mortality Rates for Selected Procedures in Tanzania's Lake Zone. World J Surg 2020; 45:41-49. [PMID: 32995932 PMCID: PMC7752880 DOI: 10.1007/s00268-020-05802-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2020] [Indexed: 01/22/2023]
Abstract
Background Postoperative mortality rate is one of six surgical indicators identified by the Lancet Commission on Global Surgery for monitoring access to high-quality surgical care. The primary aim of this study was to measure the postoperative mortality rate in Tanzania’s Lake Zone to provide a baseline for surgical strengthening efforts. The secondary aim was to measure the effect of Safe Surgery 2020, a multi-component intervention to improve surgical quality, on postoperative mortality after 10 months. Methods We prospectively collected data on postoperative mortality from 20 health centers, district hospitals, and regional hospitals in Tanzania’s Lake Zone over two time periods: pre-intervention (February to April 2018) and post-intervention (March to May 2019). We analyzed postoperative mortality rates by procedure type. We used logistic regression to determine the impact of Safe Surgery 2020 on postoperative mortality. Results The overall average in-hospital non-obstetric postoperative mortality rate for all surgery procedures was 2.62%. The postoperative mortality rates for laparotomy were 3.92% and for cesarean delivery was 0.24%. Logistic regression demonstrated no difference in the postoperative mortality rate after the Safe Surgery 2020 intervention. Conclusions Our results inform national surgical planning in Tanzania by providing a sub-national baseline estimate of postoperative mortality rates for multiple surgical procedures and serve as a basis from which to measure the impact of future surgical quality interventions. Our study showed no improvement in postoperative mortality after implementation of Safe Surgery 2020, possibly due to low power to detect change. Electronic supplementary material The online version of this article (10.1007/s00268-020-05802-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Taylor Wurdeman
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA. .,University of Miami Miller School of Medicine, Miami, FL, USA.
| | - Christopher Strader
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.,Department of Surgery, University of Massachusetts, Worcester, MA, USA
| | - Shehnaz Alidina
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
| | | | - Isabelle Citron
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
| | - Ntuli Kapologwe
- Department of Health, Social Welfare and Nutrition Service, President's Office - Regional Administration and Local Government, Dodoma, Tanzania
| | | | - Fabian Massaga
- Bugando Medical Centre, Consultant and Teaching University Hospital, Mwanza, Tanzania
| | - Adelina Mazhiqi
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.,Department of Internal Medicine, Ängelholm Hospital, Ängelholm, Sweden
| | - John G Meara
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA.,Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Gopal Menon
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
| | | | - Meaghan Sydlowski
- Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Avenue, Boston, MA, 02115, USA
| | | | - Sarah Maongezi
- Ministry of Health, Community Development, Gender, Elderly & Children, Dodoma, Tanzania
| | - Mpoki Ulisubisya
- Ministry of Health, Community Development, Gender, Elderly & Children, Dodoma, Tanzania
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15
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Jumbam DT, Menon G, Lama TN, Lodge II W, Maongezi S, Kapologwe NA, Citron I, Barash D, Varallo J, Barringer E, Cainer M, Ulisubisya M, Alidina S, Nguhuni B. Surgical referrals in Northern Tanzania: a prospective assessment of rates, preventability, reasons and patterns. BMC Health Serv Res 2020; 20:725. [PMID: 32771008 PMCID: PMC7414731 DOI: 10.1186/s12913-020-05559-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 07/20/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND An effective referral system is essential for a high-quality health system that provides safe surgical care while optimizing patient outcomes and ensuring efficiency. The role of referral systems in countries with under-resourced health systems is poorly understood. The aim of this study was to examine the rates, preventability, reasons and patterns of outward referrals of surgical patients across three levels of the healthcare system in Northern Tanzania. METHODS Referrals from surgical and obstetric wards were assessed at 20 health facilities in five rural regions prospectively over 3 months. Trained physician data collectors used data collection forms to capture referral details daily from hospital referral letters and through discussions with clinicians and nurses. Referrals were deemed preventable if the presenting condition was one that should be managed at the referring facility level per the national surgical, obstetric and anaesthesia plan but was referred. RESULTS Seven hundred forty-three total outward referrals were recorded during the study period. The referral rate was highest at regional hospitals (2.9%), followed by district hospitals (1.9%) and health centers (1.5%). About 35% of all referrals were preventable, with the highest rate from regional hospitals (70%). The most common reasons for referrals were staff-related (76%), followed by equipment (55%) and drugs or supplies (21%). Patient preference accounted for 1% of referrals. Three quarters of referrals (77%) were to the zonal hospital, followed by the regional hospitals (17%) and district hospitals (12%). The most common reason for referral to zonal (84%) and regional level (66%) hospitals was need for specialist care while the most common reason for referral to district level hospitals was non-functional imaging diagnostic equipment (28%). CONCLUSIONS Improving the referral system in Tanzania, in order to improve quality and efficiency of patient care, will require significant investments in human resources and equipment to meet the recommended standards at each level of care. Specifically, improving access to specialists at regional referral and district hospitals is likely to reduce the number of preventable referrals to higher level hospitals, thereby reducing overcrowding at higher-level hospitals and improving the efficiency of the health system.
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Affiliation(s)
- Desmond T. Jumbam
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Gopal Menon
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Tenzing N. Lama
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
| | - William Lodge II
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Department of Plastic and Oral Surgery, Boston Children’s Hospital, Boston, MA USA
| | - Sarah Maongezi
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Ntuli A. Kapologwe
- President’s Office, Regional Administration and Local Government, Dodoma, Tanzania
| | - Isabelle Citron
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | | | | | | | | | - Mpoki Ulisubisya
- Ministry of Health, Community Development, Gender, Elderly and Children, Dodoma, Tanzania
| | - Shehnaz Alidina
- Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - Boniface Nguhuni
- President’s Office, Regional Administration and Local Government, Dodoma, Tanzania
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16
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Hellar A, Tibyehabwa L, Ernest E, Varallo J, Betram MM, Fitzgerald L, Giiti G, Kihundrwa A, Kapologwe N, Drake M, Zoungrana J, Troxel A, Lemwayi R, Alidina S, Maongezi S, Makuwani A, Varallo J. A Team-Based Approach to Introduce and Sustain the Use of the WHO Surgical Safety Checklist in Tanzania. World J Surg 2019; 44:689-695. [DOI: 10.1007/s00268-019-05292-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Anderson J, Wysong M, Estep D, Besana G, Kibwana S, Varallo J, Sun K, Lu E. Evaluation of Cervical Cancer Screening Programs in Côte d'Ivoire, Guyana, and Tanzania: Effect of HIV Status. PLoS One 2015; 10:e0139242. [PMID: 26405784 PMCID: PMC4583505 DOI: 10.1371/journal.pone.0139242] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 09/09/2015] [Indexed: 11/18/2022] Open
Abstract
Background HIV infection increases a woman’s risk for cervical cancer, and cervical cancer incidence and mortality rates are higher in countries with high HIV prevalence and limited resources for screening. Visual inspection with acetic acid (VIA) allows screening and treatment of cervical lesions in a single-visit approach (SVA), but data on its performance in HIV-infected women are limited. This study’s objective was to examine cervical cancer screening using VIA/SVA in programs serving HIV-infected women. Methods A VIA/SVA program with cryotherapy for VIA-positive lesions was implemented in Côte d’Ivoire, Guyana, and Tanzania from 2009 to 2012. The effect of HIV status on VIA positivity and on presence of cryotherapy-eligible lesions was examined using a cross-sectional study design, with Chi-square tests for comparisons and constructed multivariate logistic regression models. A P-value of < 0.05 was significant. Findings VIA was performed on 34,921 women, 10% (3,580) were VIA positive; 2,508 (85%) eligible women received cryotherapy during the same visit; only 234 (52%) of those who postponed returned for treatment; 622 (17%) VIA-positive women had lesions too large to be treated with cryotherapy and were referred for excisional treatment. In multivariate analysis—controlling for HIV status, location of the screening clinic, facility location, facility type, and country—compared to HIV-uninfected/unknown women, HIV-infected women had higher odds of being VIA positive (OR 1.95, 95% CI 1.76, 2.16, P<0.0001) and of having large lesions requiring referral (OR 1.93, 95% CI 1.49, 2.51, P< 0.0001). Minor treatment complications occurred in 19 of 3,032 (0.63%) women; none required further intervention. Conclusions This study found that compared to HIV-uninfected/unknown women, HIV-infected women had nearly twice the odds of being VIA-positive and to require referral for large lesions. SVA was safe and resulted in significant reductions in loss to follow-up. There is increased need for excisional treatment in countries with high HIV prevalence.
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Affiliation(s)
- Jean Anderson
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America
- * E-mail:
| | - Megan Wysong
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Deb Estep
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Giulia Besana
- Jhpiego/Tanzania, an affiliate of Johns Hopkins University, Dar es Salaam, Tanzania
| | - Sharon Kibwana
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - John Varallo
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Kai Sun
- Johns Hopkins Medical Institutions, Baltimore, Maryland, United States of America
| | - Enriquito Lu
- Jhpiego, an affiliate of Johns Hopkins University, Baltimore, Maryland, United States of America
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18
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Martin CE, Tergas AI, Wysong M, Reinsel M, Estep D, Varallo J. Evaluation of a single-visit approach to cervical cancer screening and treatment in Guyana: feasibility, effectiveness and lessons learned. J Obstet Gynaecol Res 2015; 40:1707-16. [PMID: 24888938 DOI: 10.1111/jog.12366] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 12/02/2013] [Indexed: 11/29/2022]
Abstract
AIM To evaluate a cervical cancer prevention project in Guyana utilizing visual inspection with acetic acid (VIA) and immediate cryotherapy in a single-visit approach; and to identify lessons learned to inform the improvement of cervical cancer prevention programs in Guyana and other low-resource settings. METHODS Service records from January 2009 to June 2012 were analyzed for 18 cervical cancer prevention sites across Guyana. Records included women's HIV status, data on visual inspection with acetic acid screening and treatment status for women's initial and 1-year follow-up screenings, provider training and retention. A process evaluation was conducted in 2011 to identify programmatic strengths and interventions for integration, scale-up and sustainability. RESULTS During the 42-month interval, 21,597 new screenings were performed, reaching 95% of HIV(+) women enrolled in care and 17% of women aged 25-49 years in Guyana. The VIA(+) rate was 13% (n = 2806); 85% of women eligible for cryotherapy received immediate treatment. Half of VIA(+) women treated with cryotherapy or loop electrosurgical excision procedure returned for a 1-year follow-up screening (n = 1027); 95% were VIA(-) at the second screening. Non-physician providers were more likely to continue offering services than physicians. Most programmatic challenges were related to systemic rather than technical/clinical issues. CONCLUSION The single-visit approach-based program is feasible, effective, and when scaled up, likely to have an impact on overall incidence of cervical cancer. Services can be shifted to non-physicians for scale-up of high-quality cervical cancer prevention services nationally. To ensure sustainability and expansion, support structures should be prioritized.
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Affiliation(s)
- Caitlin E Martin
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
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19
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Ricca J, Dwivedi V, Varallo J, Singh G, Pallipamula SP, Amade N, de Luz Vaz M, Bishanga D, Plotkin M, Al-Makaleh B, Suhowatsky S, Smith JM. Uterotonic use immediately following birth: using a novel methodology to estimate population coverage in four countries. BMC Health Serv Res 2015; 15:9. [PMID: 25609355 PMCID: PMC4307135 DOI: 10.1186/s12913-014-0667-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 12/16/2014] [Indexed: 12/05/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) is the leading cause of maternal mortality in developing countries. While incidence of PPH can be dramatically reduced by uterotonic use immediately following birth (UUIFB) in both community and facility settings, national coverage estimates are rare. Most national health systems have no indicator to track this, and community-based measurements are even more scarce. To fill this information gap, a methodology for estimating national coverage for UUIFB was developed and piloted in four settings. Methods The rapid estimation methodology consisted of convening a group of national technical experts and using the Delphi method to come to consensus on key data elements that were applied to a simple algorithm, generating a non-precise national estimate of coverage of UUIFB. Data elements needed for the calculation were the distribution of births by location and estimates of UUIFB in each of those settings, adjusted to take account of stockout rates and potency of uterotonics. This exercise was conducted in 2013 in Mozambique, Tanzania, the state of Jharkhand in India, and Yemen. Results Available data showed that deliveries in public health facilities account for approximately half of births in Mozambique and Tanzania, 16% in Jharkhand and 24% of births in Yemen. Significant proportions of births occur in private facilities in Jharkhand and faith-based facilities in Tanzania. Estimated uterotonic use for facility births ranged from 70 to 100%. Uterotonics are not used routinely for PPH prevention at home births in any of the settings. National UUIFB coverage estimates of all births were 43% in Mozambique, 40% in Tanzania, 44% in Jharkhand, and 14% in Yemen. Conclusion This methodology for estimating coverage of UUIFB was found to be feasible and acceptable. While the exercise produces imprecise estimates whose validity cannot be assessed objectively in the absence of a gold standard estimate, stakeholders felt they were accurate enough to be actionable. The exercise highlighted information and practice gaps and promoted discussion on ways to improve UUIFB measurement and coverage, particularly of home births. Further follow up is needed to verify actions taken. The methodology produces useful data to help accelerate efforts to reduce maternal mortality.
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Affiliation(s)
- Jim Ricca
- Maternal and Child Survival Program, Jhpiego, 1776 Massachusetts Ave., NW #300, Washington, DC, 20036, USA.
| | - Vikas Dwivedi
- Maternal and Child Survival Program, JSI Research & Training Institute, Inc, 1776 Massachusetts Ave., NW #300, Washington, DC, 20036, USA.
| | - John Varallo
- Maternal and Child Survival Program, Jhpiego, 1776 Massachusetts Ave., NW #300, Washington, DC, 20036, USA.
| | - Gajendra Singh
- Jhpiego, 221, Okhla Phase III, New Delhi, 110 020, India.
| | - Suranjeen Prasad Pallipamula
- Maternal Child Integrated Program (MCHIP), Jhpiego, Government Vaccine Institute Campus, Namkum, Ranchi, Jharkhand, 834010, India.
| | - Nazir Amade
- Director of Maternal and Child Health, Ministry of Health, Maputo, Mozambique.
| | | | | | - Marya Plotkin
- Jhpiego Tanzania, PO Box 9170, Dar es Salaam, Tanzania.
| | | | - Stephanie Suhowatsky
- Maternal and Child Survival Program, Jhpiego, 1776 Massachusetts Ave., NW #300, Washington, DC, 20036, USA.
| | - Jeffrey Michael Smith
- Maternal and Child Survival Program, Jhpiego, 1776 Massachusetts Ave., NW #300, Washington, DC, 20036, USA.
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