Scalability of the Basic Care Model for Very Low Birth Weight Infants and Implementation Research Considerations

Objectives: To study the scalability of the rural hospital (RH) model of basic newborn care in a general hospital (GH) by including very low birth weight (VLBW) infants, and to assess the implementation aspects. Study design: Observational Settings: RH (1988-1992) and General Hospital, (GH) (2010-2013). Subjects: VLBW infants with birth weight ranging from 1000 g to 1500 g. Interventions: (1) RH: Basic care including warmth, feeding, antibiotics, and oxygen (2) GH: Basic plus circulatory care (2010-12), and continuous positive airway pressure (CPAP) support (2013). Mechanical ventilation and surfactant therapy were not available. Main outcome measure: Mortality Results: The cumulative mortality (38.5%) with basic neonatal care in the RH model declined to 26.6% at the GH with the addition of circulatory support and a “home-made” CPAP system. Conclusions: The RH package may be scaled up by adding CPAP and circulatory support to reduce the mortality among VLBW infants. The RH model is scalable horizontally and vertically. What is already known about this subject? Implementation research constitutes a relatively new and underdeveloped field, One of the facets of health system research is the implementation research. Implementation research aims at bridging the gaps between knowledge and action. What does this study add? Tertiary care center can help in developing basic newborn care at a rural hospital. The rural hospital model can be upscaled vertically as well as horizontally. Addition of circulatory support and CPAP to basic newborn care can significantly lower neonatal mortality. How might it impact on clinical practice in the foreseeable future? The study may encourage tertiary care centers to facilitate the development of basic newborn care centers at the rural hospitals. These centers, in turn, can spread horizontally.

Impact of Enhanced Recovery Program (ERP) on Clinical Outcomes After Elective Colorectal Surgery in a Rural Hospital: A Prospective Cohort Study with Retrospective Control.

Introduction: The main purpose was to determine the impact on postoperative outcome of a standardized enhanced recovery program (ERP) for elective colorectal surgery in a rural hospital. Methods A prospective series of patients (N = 80) undergoing elective colorectal resection completing a standardized ERP protocol in 2018–2020 (ERP group) was compared to patients (N = 80) operated at the same rural hospital in 2013–2015 (pre-ERP group), before the implementation of the program. The exclusion criteria for both groups were: ASA score IV, TNM stage IV, inflammatory bowel disease, emergency surgery, and rectal cancer. The primary outcome was hospital length of stay (LoS) which was used as an estimate of functional recovery. Secondary outcomes included 30-day readmission and mortality rates as well as factors predicting both postoperative complications and prolonged hospital LoS. Results Baseline characteristics were comparable in both groups. Laparoscopic approach was performed in 95% of patients in the ERP group versus 0% in pre-ERP group. The median adherence to ERP protocol elements was 68% as opposed to 12% in the retrospective control group. The median hospital LoS in the ERP-group was significantly lower than in the pre-ERP group (5 vs. 10 days) with no increase in 30-day readmission and mortality rates. The Body Mass Index ≥ 30 and the traditional perioperative protocol were the independent predictive factors of postoperative complications, while following a traditional peri-operative protocol was the only factor predicting a prolonged hospital LoS. Conclusions Although limited hospital resources are perceived as a barrier to ERP implementation, the current experience demonstrates how adopting an ERP program in a rural area is feasible and effective, despite it requires greater effort. For patients in such areas, colorectal ERP in elective surgery may also reduce time to functional recovery, postoperative hospital LoS and complications, with no increase in mortality and 30-day re-admissions.

The Experience with a Surgical Camp in a Rural Hospital in Northern Uganda

Introduction: In Sub-Saharan Africa, surgical conditions remain neglected in its health care systems. This results in a low surgical output from district hospitals with many patients referred to Referral Hospitals in the region. Therefore surgical camps in district hospitals are often necessary where volunteer surgical teams perform a wide range of mostly elective surgical procedures. These surgical camps are pre-planned activities carried out at no cost to the patients who belong to poor and hard to reach vulnerable communities. The purpose of this surgical camp was to offer free specialised surgical service in a rural hospital and hence improve surgical access to a poor vulnerable community in Northern Uganda. Training basic surgical skills and the provision of continuous medical education to medical officers in the region was also part of the objective of this surgical camp. Methods: A descriptive study using data collected from a one week surgical camp in the year 2011 was performed at St. Joseph’s Maracha Hospital. Data from operating log forms regarding date of procedure, patient gender, clinical diagnosis, operation performed and type of anaesthesia was obtained. Data was analysed for age, sex, type and rate of surgical procedure and type of anaesthesia. The participants’ involved specialist general surgeons, medical officers, clinical officers, theatre nurses and anaesthetists. Results: In total, 105 surgical procedures were performed during the 7-day-long camp. Mean age of the patients was 39.54 years. The male: female ratio was 1:0.38. Adult inguinal herniorrhaphy formed 68.6% of all surgical procedures. Conclusions: The bulk of surgical disease encountered during the camp were inguinal hernias. Surgical camps improve access to surgical care to vulnerable hard to reach populations and should become an integral part of health service delivery in rural Africa.

Improvement in Surgical Quality Following Pancreaticoduodenectomy With Increasing Case Volume in a Rural Hospital

Background The literature is replete with studies that define the nexus of quantity and quality in complex surgical operations. These observations have heralded a call for centralization of care to high-volume centers. The purpose of this study was to chronicle improvements in quality associated with pancreaticoduodenectomy (PD) as a rural hospital matures from a low- to very high-volume center. Methods A retrospective review of a prospective pancreatic surgery database was undertaken from July 2007 to June 2020. Annual periods were characterized as low (≤12/year), high (13-29/year), and very high volume (≥30/year). Data for the following quality benchmarks were aggregated and compared: length of stay (LOS), 30-day readmissions, 30-day mortality, and 1- and 3-year survival. A subgroup analysis was undertaken in those patients undergoing PD for adenocarcinoma detailing margin status and number of lymph nodes harvested. Outcomes were compared using the Fisher’s exact and Student’s t-test. Results 375 PD were completed over the 13-year period; 62.1% were undertaken for ductal adenocarcinoma. There was a significant decrease in LOS and 30-day readmissions as the institution matured toward very high volume. There were no significant differences in 30-day mortality, 1- and 3-year survival, or margin negativity rates associated with volume. Extent of lymph node harvest significantly improved as institutional experience increased. Discussion Our pancreatic surgery program matured rapidly from low to very high volume with institutional commitment and dedicated resources. As the institution matured, operational efficiencies and surgical quality improved. Not unexpectedly, biology trumped volume as reflected in 1- and 3-year survival rates.