Access delays to essential surgical care using the Three Delays Framework and Bellwether procedures at Timor Leste’s national referral hospital

ObjectivesOur objectives were to characterise the nature and extent of delay times to essential surgical care in a developing nation by measuring the actual stages of delay for patients receiving Bellwether procedures.SettingThe study was conducted at Timor Leste’s national referral hospital in Dili, the country’s capital.ParticipantsAll patients requiring a Bellwether procedure over a 2-month period were included in the study. Participants whose procedure was undertaken more than 24 hours from initial hospital presentation were excluded.Primary and secondary outcome measuresData pertaining to the patient journey from onset of symptoms to emergency procedure was collected by interview of patients, their treating surgeons or anaesthetists and the medical records. Timelines were then calculated against the Three Delays Framework.ResultsFifty-six patients were entered into the study. Their mean delay from symptom onset to entering the anaesthesia bay for a procedure was 32.3 hours (+/-11.6). The second delay (4.1+/-2.5 hours) was significantly less than the first (20.9+/-11.5 hours; p<0.005) and third delays (7.2+/-1.2 hours; p<0.05). Additionally, patients with acute abdominal pain (of which 18/20 ultimately had open appendicectomy and two emergency laparotomies) had a delay time of 53.3 hours (+/-21.3), significantly more than that for emergency caesarean (22.9+/-18.6 hours; p<0.05) or management of an open long-bone fracture (15.5+/-5.56 hours; p<0.05).ConclusionsSubstantial delays were observed for all three stages and each Bellwether procedure. This study methodology could be used to measure access and the three delays to emergency surgical care in low/middle-income countries, although the actual reasons for delay may vary between regions and countries and would require a qualitative study.

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Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments

BMJ Global Health ◽

10.1136/bmjgh-2020-004324 ◽

2021 ◽

Vol 6 (5) ◽

pp. e004324

Author(s):

John Whitaker ◽

Nollaig O'Donohoe ◽

Max Denning ◽

Dan Poenaru ◽

Elena Guadagno ◽

...

Keyword(s):

Systematic Review ◽

Health System ◽

Evidence Synthesis ◽

Rapid Assessment ◽

Sub Saharan Africa ◽

Trauma Systems ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries ◽

Three Delays

BackgroundThe large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles.MethodsWe conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment.ResultsOf 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment.ConclusionsWhole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

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15th Bethune Round Table Conference on International SurgeryCaustic soda for the manufacture of a local variety of soap — the cause of untold suffering in the lives of children in a developing countryBarriers to care and patterns of congenital malformations in Eastern Democratic Republic of CongoAnesthesia capacity in rural hospitals in Enugu, NigeriaPostcrash management of road traffic injury victims in TanzaniaA framework for the monitoring and evaluation of international surgical initiatives in low- and middle-income countriesMaternal near miss and mortality in a tertiary care hospital in RwandaThe socioeconomic impact of lower extremity fractures in Uganda: 1-year results of a prospective case seriesPost–cesarean section pain control at Mbarara Regional Referral Hospital: a comparison of intrathecal morphine and transversus abdominis plane blockPediatric plastic surgery in global health: a scoping reviewUsing local theatre to reduce the surgical burden of childhood burns in East AfricaMeeting local needs in neonatal anesthesia to improve outcome in surgeryContext-specific challenges faced by Rwandan surgeons: development of an evidence-based resident curriculum in nontechnical skills to overcome resource variabilityUsing data to drive prehospital quality improvement in trauma: a mixed-methods analysis of the Rwandan experienceSurgical follow-up rates at HEAL Africa Hospital in Eastern Democratic Republic of CongoProof of concept methodology: feasibility of postoperative follow-up using cellular phones at HEAL Africa Hospital in the Eastern Democratic Republic of CongoDeveloping a critical care (CC) curriculum fit for purpose for the College of Surgeons of East, Central and Southern Africa (COSECSA)WHO Surgical Safety Checklist to reduce cost in a rural communityFacilitation of surgical skills acquisition by interns through simulation at UITH, NigeriaInnovations in minimally invasive surgeries for rural areasThe low-cost topical vacuum therapy unit: salvaging diabetic footEngaging communities in influencing quality of health care servicesSafety and efficacy of oral ketamine for premedication in children undergoing day surgerySurgical device innovation for low-resource settings: an alternative for bone drillingDeveloping an effective surgical skills simulation program for surgical residents in a resource-constrained settingBridging the communication gap between communities and health facilities using modern accessible technology with information power for improved care of vulnerable mothers and newborns: a case of 4 rural hospitals in UgandaFrom community laywomen to breast health workers: a successful training model for implementing a clinical breast exam screening program in MalawiImproving intra- and interhospital communication using caller user groups (CUG) for health service providers for material newborn healthAssessing access to surgical care in Nepal via a countrywide surveyManagement of bladder exstrophy using the mainz II procedure in a resource-limited setting: a multisite studyAddressing the value equation in global surgery: Connecticut’s experience with surgical care in low- and middle-income countriesInguinal hernia repair in Rwanda: a survey of the surgical residentsCompleteness and utility of surgical data capture at a rural Ugandan regional referral hospital: a foundation for quality improvement initiativesBuilding perioperative nursing capacity in Ethiopia through educationDevelopment of a combined surgery/oncology breast clinic in RwandaSurgical education partnerships: a socially responsible approach to augment surgical capacityCommunity needs assessment for prehospital trauma care in Northwestern CambodiaShumba Medical Society: practising pro-African medicine

Canadian Journal of Surgery ◽

10.1503/cjs.008715 ◽

2015 ◽

Vol 58 (4 Suppl 1) ◽

pp. S157-S168

Author(s):

Mohammed Bukari ◽

Luc Kalisya Malemo ◽

Obinna Ajuzieogu ◽

Respicious Boniface ◽

George Ibrahim ◽

...

Keyword(s):

Quality Improvement ◽

Democratic Republic ◽

Surgical Care ◽

Rural Hospitals ◽

Surgical Skills ◽

Referral Hospital ◽

Middle Income ◽

Regional Referral Hospital ◽

Low And Middle Income

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Barriers to Essential Surgical Care in Low- and Middle-Income Countries: A Pilot Study of a Comprehensive Assessment Tool in Ghana

World Journal of Surgery ◽

10.1007/s00268-015-3168-4 ◽

2015 ◽

Vol 39 (11) ◽

pp. 2613-2621 ◽

Cited By ~ 14

Author(s):

Barclay T. Stewart ◽

Adam Gyedu ◽

Francis Abantanga ◽

Abdul Rashid Abdulai ◽

Godfred Boakye ◽

...

Keyword(s):

Pilot Study ◽

Assessment Tool ◽

Surgical Care ◽

Comprehensive Assessment ◽

Middle Income ◽

Middle Income Countries ◽

Essential Surgical Care ◽

Low And Middle Income

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Theatres without borders: a systematic review of the use of intraoperative telemedicine in low- and middle-income countries (LMICs)

BMJ Innovations ◽

10.1136/bmjinnov-2021-000837 ◽

2021 ◽

pp. bmjinnov-2021-000837

Author(s):

Hariharan Subbiah Ponniah ◽

Viraj Shah ◽

Arian Arjomandi Rad ◽

Robert Vardanyan ◽

George Miller ◽

...

Keyword(s):

Systematic Review ◽

Low Income ◽

Case Reports ◽

Surgical Care ◽

Cochrane Collaboration ◽

Optimal Care ◽

Eligibility Criteria ◽

Middle Income ◽

Middle Income Countries ◽

Low Middle Income Countries

ObjectiveThis systematic review aims to provide a summary of the use of real-time telementoring, telesurgical consultation and telesurgery in surgical procedures in patients in low/middle-income countries (LMICs).DesignA systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Collaboration published guidelines.Data sourcesEMBASE, MEDLINE, Cochrane, PubMed and Google Scholar were searched for original articles and case reports that discussed telementoring, telesurgery or telesurgical consultation in countries defined as low-income or middle-income (as per the World Banks’s 2021–2022 classifications) from inception to August 2021.Eligibility criteria for selecting studiesAll original articles and case reports were included if they reported the use of telemedicine, telesurgery or telesurgical consultation in procedures conducted on patients in LMICs.ResultsThere were 12 studies which discussed the use of telementoring in 55 patients in LMICs and included a variety of surgical specialities. There was one study that discussed the use of telesurgical consultation in 15 patients in LMICs and one study that discussed the use of telesurgery in one patient.ConclusionThe presence of intraoperative telemedicine in LMICs represents a principal move towards improving access to specialist surgical care for patients in resource-poor settings. Not only do several studies demonstrate that it facilitates training and educational opportunities, but it remains a relatively frugal and efficient method of doing so, through empowering local surgeons in LMICs towards offering optimal care while remaining in their respective communities.

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Access to burn care in low-and middle-income countries: An assessment of timeliness, surgical capacity, and affordability in a regional referral hospital in Tanzania

Journal of Burn Care & Research ◽

10.1093/jbcr/irab191 ◽

2021 ◽

Author(s):

Matthijs Botman ◽

Thom C C Hendriks ◽

Louise de Haas ◽

Grayson Mtui ◽

Joost Binnerts ◽

...

Keyword(s):

Burn Injury ◽

Surgical Care ◽

Referral Hospital ◽

Surgical Capacity ◽

Burn Wound ◽

Middle Income ◽

Regional Referral Hospital ◽

Burn Victims ◽

Burn Care ◽

Low And Middle Income

Abstract This study investigates patients’ access to surgical care for burns in a low-and-middle-income setting by studying timeliness, surgical capacity, and affordability. A survey was conducted in a regional referral hospital in Manyara, Tanzania. In total, 67 patients were included. To obtain information on burn victims in need of surgical care, irrespective of time lapsed from the burn injury, both patients with burn wounds and patients with contractures were included. Information provided by patients and/or caregivers was supplemented with data from patient files and interviews with hospital administration and physicians. In the burn wound group, 50 percent reached a facility within 24 hours after the injury. Referrals from other health facilities to the regional referral hospital were made within three weeks for 74 percent in this group. Of contracture patients, seventy four percent, had sought healthcare after the acute burn injury. Of the same group, only 4 percent had been treated with skin grafts beforehand, and 70 percent never received surgical care or a referral. Combined, both groups indicated that lack of trust, surgical capacity, and referral timeliness were important factors negatively impacting patient access to surgical care. Accounting for hospital fees indicated patients routinely exceeded the catastrophic expenditure threshold. It was determined that healthcare for burn victims is without financial risk protection. We recommend strengthening burn care and reconstructive surgical programs in similar settings, using a more comprehensive health systems approach to identify and address both medical and socio-economic factors that determine patient mortality and disability.

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Pediatric Perioperative Mortality in Kenya

Anesthesiology ◽

10.1097/aln.0000000000003070 ◽

2020 ◽

Vol 132 (3) ◽

pp. 452-460 ◽

Cited By ~ 3

Author(s):

Mark W. Newton ◽

Savannah E. Hurt ◽

Matthew D. McEvoy ◽

Yaping Shi ◽

Matthew S. Shotwell ◽

...

Keyword(s):

Mortality Rate ◽

Pediatric Surgery ◽

Surgical Care ◽

Perioperative Mortality ◽

Middle Income ◽

Factors Associated ◽

Safe Surgery ◽

Low Middle Income Countries ◽

Care Systems ◽

Data Elements

Abstract Background The global surgery access imbalance will have a dramatic impact on the growing population of the world’s children. In regions of the world with pediatric surgery and anesthesia manpower deficits and pediatric surgery–specific infrastructure and supply chain gaps, this expanding population will present new challenges. Perioperative mortality rate is an established indicator of the quality and safety of surgical care. To establish a baseline pediatric perioperative mortality rate and factors associated with mortality in Kenya, the authors designed a prospective cohort study and measured 24-h, 48-h, and 7-day perioperative mortality. Methods The authors trained anesthesia providers to electronically collect 132 data elements for pediatric surgical cases in 24 government and nongovernment facilities at primary, secondary, and tertiary hospitals from January 2014 to December 2016. Data assistants tracked all patients to 7 days postoperative, even if they had been discharged. Adjusted analyses were performed to compare mortality among different hospital levels after adjusting for prespecified risk factors. Results Of 6,005 cases analyzed, there were 46 (0.8%) 24-h, 62 (1.1%) 48-h, and 77 (1.7%) 7-day cumulative mortalities reported. In the adjusted analysis, factors associated with a statistically significant increase in 7-day mortality were American Society of Anesthesiologists Physical Status of III or more, night or weekend surgery, and not having the Safe Surgery Checklist performed. The 7-day perioperative mortality rate is less in the secondary (1.4%) and tertiary (2.4%) hospitals when compared with the primary (3.7%) hospitals. Conclusions The authors have established a baseline pediatric perioperative mortality rate that is greater than 100 times higher than in high-income countries. The authors have identified factors associated with an increased mortality, such as not using the Safe Surgery Checklist. This analysis may be helpful in establishing pediatric surgical care systems in low–middle income countries and develop research pathways addressing interventions that will assist in decreasing mortality rate. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Strengthening Surgical Services at the Soum (First-referral) Hospital: The WHO Emergency and Essential Surgical Care (EESC) Program in Mongolia

World Journal of Surgery ◽

10.1007/s00268-012-1668-z ◽

2012 ◽

Vol 36 (10) ◽

pp. 2359-2370 ◽

Cited By ~ 21

Author(s):

Jaymie A. Henry ◽

Sergelen Orgoi ◽

Salik Govind ◽

Raymond R. Price ◽

Ganbold Lundeg ◽

...

Keyword(s):

Surgical Care ◽

Referral Hospital ◽

Surgical Services ◽

Essential Surgical Care

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Quality of essential surgical care in low- and middle-income countries: a systematic review of the literature

International Journal for Quality in Health Care ◽

10.1093/intqhc/mzy141 ◽

2018 ◽

Vol 31 (3) ◽

pp. 166-172 ◽

Cited By ~ 4

Author(s):

Saurabh Saluja ◽

Swagoto Mukhopadhyay ◽

Julia R Amundson ◽

Allison Silverstein ◽

Jessica Gelman ◽

...

Keyword(s):

Systematic Review ◽

Surgical Care ◽

Review Of The Literature ◽

Middle Income ◽

Middle Income Countries ◽

Essential Surgical Care ◽

Low And Middle Income

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Influenza preparedness in low-resource settings: a look at oxygen delivery in 12 African countries

The Journal of Infection in Developing Countries ◽

10.3855/jidc.859 ◽

2010 ◽

Vol 4 (07) ◽

pp. 419-424 ◽

Cited By ~ 49

Author(s):

Janeil M Belle ◽

Hillary J Cohen ◽

Nahoko Shindo ◽

Matthew L Lim ◽

Adriana Velazquez-Berumen ◽

...

Keyword(s):

Oxygen Delivery ◽

Access To Health Care ◽

Surgical Care ◽

Health Facilities ◽

World Health ◽

Situational Analysis ◽

African Countries ◽

Middle Income ◽

First Line Therapy ◽

Essential Surgical Care

Background: Pandemic influenza poses a serious threat to populations in low and lower-middle income countries that face delays in access to health care and inadequately equipped facilities. Oxygen is first-line therapy for influenza-related hypoxia and a standard component of emergency respiratory resuscitation, yet remains a scarce resource in many countries. Methodology: A snapshot survey of oxygen supply and associated infrastructure was performed at 231 health centres and hospitals in twelve African countries using the World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care. WHO Global Initiative for Emergency and Essential Surgical Care, WHO regional and country offices, and local Ministries of Health facilitated data collection from facilities surveyed. Data was stored in the WHO DataCol SQL database and computerized spreadsheet tools were used to generate descriptive statistics. Results: Ninety-nine (43.8%) of facilities surveyed reported uninterrupted access to an oxygen source and 55 (24.6%) possessed a fully functioning oxygen concentrator. Electricity was fully available at only 81 (35.1%) health facilities. Conclusions: In addition to efforts to secure vaccines and antivirals, future global influenza preparedness efforts should include investments in oxygen and associated equipment and infrastructure at first referral health facilities, to minimize morbidity and mortality from influenza in regions with limited medical resources. Increasing oxygen delivery capacity in these areas may also provide long-term, post-pandemic benefits in the management of other medical conditions of significance, including trauma, neonatal pulmonary hypofunction, and HIV-related and childhood pneumonia.

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