| 1. |
- af Ugglas, Bjorn, et al.
(author)
-
Emergency department crowding and hospital transformation during COVID-19, a retrospective, descriptive study of a university hospital in Stockholm, Sweden
- 2020
-
In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. - : BMC. - 1757-7241. ; 28:1
-
Journal article (peer-reviewed)abstract
- Objectives COVID-19 presents challenges to the emergency care system that could lead to emergency department (ED) crowding. The Huddinge site at the Karolinska university hospital (KH) responded through a rapid transformation of inpatient care capacity together with changing working methods in the ED. The aim is to describe the KH response to the COVID-19 crisis, and how ED crowding, and important input, throughput and output factors for ED crowding developed at KH during a 30-day baseline period followed by the first 60 days of the COVID-19 outbreak in Stockholm Region. Methods Different phases in the development of the crisis were described and identified retrospectively based on major events that changed the conditions for the ED. Results were presented for each phase separately. The outcome ED length of stay (ED LOS) was calculated with mean and 95% confidence intervals. Input, throughput, output and demographic factors were described using distributions, proportions and means. Pearson correlation between ED LOS and emergency ward occupancy by phase was estimated with 95% confidence interval. Results As new working methods were introduced between phase 2 and 3, ED LOS declined from mean (95% CI) 386 (373-399) minutes to 307 (297-317). Imaging proportion was reduced from 29 to 18% and admission rate increased from 34 to 43%. Correlation (95% CI) between emergency ward occupancy and ED LOS by phase was 0.94 (0.55-0.99). Conclusions It is possible to avoid ED crowding, even during extreme and quickly changing conditions by leveraging previously known input, throughput and output factors. One key factor was the change in working methods in the ED with higher competence, less diagnostics and increased focus on rapid clinical admission decisions. Another important factor was the reduction in bed occupancy in emergency wards that enabled a timely admission to inpatient care. A key limitation was the retrospective study design.
|
|
| 2. |
|
|
| 3. |
- Ajiko, Mary Margaret, et al.
(author)
-
Prevalence of Paediatric Surgical Conditions in Eastern Uganda : A Cross-Sectional Study
- 2022
-
In: World Journal of Surgery. - New York, NY, United States : Springer Nature. - 0364-2313 .- 1432-2323. ; 46, s. 701-708
-
Journal article (peer-reviewed)abstract
- Background: The role of surgery in global health has gained greater attention in recent years. Approximately 1.8 billion children below 15 years live in low- and middle-income countries (LMIC). Many surgical conditions affect children. Therefore, paediatric surgery requires specific emphasis. Left unattended, the consequences can be dire. Despite this, there is a paucity of data regarding prevalence of surgical conditions in children in LMIC. The present objective was to investigate the prevalence of paediatric surgical conditions in children in a defined geographical area in Eastern Uganda.Method: A cross-sectional study was carried out in the Iganga-Mayuge Health and Demographic Surveillance Site located in Eastern Uganda. Through a two-stage, cluster-based sampling process, 490 households from 49 villages were randomly selected, generating a study population of 1581 children. The children’s caregivers were interviewed, and the children were physically examined by two medical doctors to identify any surgical conditions.Results: The interview was performed with 1581 children, and 1054 were physically examined. Among these, the overall prevalence of any surgical condition was 16.0 per cent (n = 169). Of these, 39 per cent had an unmet surgical need (66 of 169). This is equivalent to a 6.3 per cent prevalence of current unmet surgical need. The most common groups of surgical condition were congenital anomalies and trauma-related conditions.Conclusion: Surgical conditions in children are common in eastern Uganda. The unmet need for surgery is high. With a growing population, the need for paediatric surgical capacity will increase even further. The health care system must be reinforced to provide services for children with surgical conditions if United Nations Sustainability Development Goal 3 is to be achieved by 2030.
|
|
| 4. |
- Ajiko, Mary Margaret, et al.
(author)
-
Surgical procedures for children in the public healthcare sector: A nationwide, facility-based study in Uganda
- 2021
-
In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 11:7
-
Journal article (peer-reviewed)abstract
- Objective: This study investigated the surgical services for children at the highest levels of the public healthcare sector in Uganda. The aim was to determine volumes and types of procedure performed and the patients and the human resource involved.Design: The study was a facility-based, record review.Setting: The study was carried out at the National Referral Hospital, all 14 regional referral hospitals and 14 general hospitals in Uganda, representing the highest levels of hospital in the public healthcare sector.Participants: The subjects were children <18 years who underwent major surgery in the study hospitals during 2013 and 2014.Results: The study hospitals contribute with an average annual rate of paediatric surgery at 22.0 per 100 000 paediatric population. This is a fraction of the estimated need. Most of the procedures were performed for congenital anomalies (n=3111, 39.4%), inflammation and infection (n=2264, 28.7%) and trauma (n=1210, 15.3%). Specialist surgeons performed 60.3% (n=4758) of the procedures, and anaesthesia was administered by specialist physician anaesthetists in 11.6% (n=917) of the cases.Conclusions: A variety of paediatric surgical procedures are performed in a relatively decentralised system throughout Uganda. Task shifting and task sharing of surgery and anaesthesia are widespread: a large proportion of surgical procedures was carried out by non-specialist physicians, with anaesthesia mostly delivered by non-physician anaesthetists. Reinforcing the capacity and promoting the expansion of the health facilities studied, in particular the general hospitals and regional referral hospitals, could help reduce the immense unmet need for surgical services for children in Uganda.
|
|
| 5. |
- Ashley, Thomas, et al.
(author)
-
Outcomes After Elective Inguinal Hernia Repair Performed by Associate Clinicians vs Medical Doctors in Sierra Leone A Randomized Clinical Trial
- 2021
-
In: JAMA Network Open. - : American Medical Association. - 2574-3805. ; 4:1
-
Journal article (peer-reviewed)abstract
- IMPORTANCE Task sharing of surgical duties with medical doctors (MDs) without formal surgical training and associate clinicians (ACs; health care workers corresponding to an educational level between that of a nurse and an MD) is practiced to provide surgical services to people in low-resource settings. The safety and effectiveness of this has not been fully evaluated through a randomized clinical trial. OBJECTIVE To determine whether task sharing with MDs and ACs is safe and effective in mesh hernia repair in Sierra Leone. DESIGN, SETTING, AND PARTICIPANTS This single-blind, noninferiority randomized clinical trial included adult, healthy men with primary inguinal hernia randomized to receiving surgical treatment from an MD or an AC. In Sierra Leone, ACs practicing surgery have received 2 years of surgical training and completed a 1-year internship. The study was conducted between October 2017 and February 2019. Patients were followed up at 2 weeks and 1 year after operations. Observers were blinded to the study arm of the patients. The study was carried out in a first-level hospital in rural Sierra Leone. Data were analyzed from March to June 2019. INTERVENTIONS All patients received an open mesh inguinal hernia repair under local anesthesia. The control group underwent operations performed by MDs, and the intervention group underwent operations performed by ACs. MAIN OUTCOMES AND MEASURES The primary end point was hernia recurrence at 1 year. Outcomes were assessed by blinded observers at 2 weeks and 1 year after operations. RESULTS A total of 230 patients were recruited (mean [SD] age, 43.0 [13.5] years), and all but 1 patient underwent inguinal hernia repair between October 23, 2017, and February 2, 2018, performed by 5 MDs and 6 ACs. A total of 114 patients were operated on by MDs, and 115 patients were operated on by ACs. There were no crossovers between the study arms. The follow-up rate was 100% at 2 weeks and 94.1% at 1 year. At 1 year, hernia recurrence occurred in 7 patients (6.9%) operated on by MDs and 1 patient (0.9%) operated on by ACs (absolute difference, -6.0 [95% CI, -11.2 to 0.7] percentage points; P < .001). CONCLUSIONS AND RELEVANCE These findings demonstrate that task sharing of elective mesh inguinal hernia repair with ACs was safe and effective. The task sharing debate should progress to focus on optimizing surgical training programs for nonsurgeons and building capacity for elective surgical care in low- and middle-income countries.
|
|
| 6. |
- Ashley, Thomas, et al.
(author)
-
Standardised Competency-Based Training of Medical Doctors and Associate Clinicians in Inguinal Repair with Mesh in Sierra Leone
- 2023
-
In: World Journal of Surgery. - : SPRINGER. - 0364-2313 .- 1432-2323. ; 47:10, s. 2330-2337
-
Journal article (peer-reviewed)abstract
- IntroductionIn low-income settings, there is a high unmet need for hernia surgery, and most procedures are performed with tissue repair techniques. In preparation for a randomized clinical trial, medical doctors and associate clinicians received a short-course competency-based training on inguinal hernia repair with mesh under local anaesthesia. The aim of this study was to evaluate feasibility, safety and effectiveness of the training.MethodsAll trainees received a one-day theoretical module on mesh hernia repair under local anaesthesia followed by hands-on training. Performance was assessed using the American College of Surgeons Groin Hernia Operative Performance Rating System. Patients were followed up two weeks and one year after surgery. Outcomes of the patients operated on during the training trial were compared to the 229 trial patients operated on after the training.ResultsDuring three surgical camps, seven medical doctors and six associate clinicians were trained. In total, 129 patients were operated on as part of the training. Of the 13 trainees, 11 reached proficiency. Patients in the training group had more wound infections after two weeks (8.5% versus 3.1%; p = 0.041). There was no difference in recurrence and mortality after one year, and none of the deaths were attributed to the surgery.Discussion and conclusionMesh repair is the international standard for inguinal hernia repair worldwide. Nevertheless, this is not widely accessible in low-income settings. This study has demonstrated that short-course intensive hands-on training of MDs and ACs in mesh hernia repair is effective and safe.Trial Registration: International Clinical Trial Registry ISRCTN63478884.
|
|
| 7. |
- Backström, Fredrik, et al.
(author)
-
Surgical Needs at the End of the Battle of Mosul: Results from Mosul General Hospital
- 2020
-
In: World Journal of Surgery. - : SPRINGER. - 0364-2313 .- 1432-2323.
-
Journal article (peer-reviewed)abstract
- Purpose The aim of the study was to analyze the surgical needs of patients seeking emergency care at the Mosul General Hospital in the final phase of the battle of Mosul in northern Iraq between an international military coalition and rebel forces. During the conflict, the International Red Committee of the Red Cross (ICRC) supported the hospital with staff and resources. Ceasefire in the conflict was declared at the end of July 2017. Methods Routinely collected hospital data from the ICRC-supported Mosul General Hospital from June 6, 2017, to October 1, 2017 were collected and analyzed retrospectively. All patients with weapon-related injuries as well as all patients with other types of injuries or acute surgical illness were included. Results Some 265 patients were admitted during the study period. Non-weapon-related conditions were more common than weapon-related (55.1%). The most common non-weapon-related condition was appendicitis followed by hernia and soft tissue wounds. Blast/fragment was the most frequent weapon-related injury mechanism followed by gunshot. The most commonly injured body regions were chest and abdomen. Children accounted for 35.3% of all weapon-related injuries. Patients presented at the hospital with weapon-related injuries more than 2 months after the official declaration of ceasefire. A majority of the non-weapon-related, as well as the weapon-related conditions, needed surgery (88.1% and 87.6%, respectively). Few postoperative complications were reported. Conclusions The number of children affected by the fighting seems to be higher in this cohort compared to previous reports. Even several months after the fighting officially ceased, patients with weapon-related injuries were presenting. Everyday illnesses or non-weapon-related injuries dominated. This finding underlines the importance of providing victims of conflicts with surgery for life-threatening conditions, whether weapon related or not.
|
|
| 8. |
- Barth, Cornelia Anne, et al.
(author)
-
Retrospective observational study of characteristics of persons with amputations accessing International Committee of the Red Cross (ICRC) rehabilitation centres in five conflict and postconflict countries
- 2021
-
In: BMJ Open. - : BMJ. - 2044-6055. ; 11:12
-
Journal article (peer-reviewed)abstract
- Objectives Limb amputation incidence is particularly high in fragile contexts due to conflict, accidents and poorly managed diabetes. The study aim was to analyse (1) demographic and amputation characteristics of persons with any type of acquired amputation (PwA) and (2) time between amputation and first access to rehabilitation in five conflict and postconflict countries. Design A retrospective, observational study analysing differences in demographic and clinical factors and time to access rehabilitation between users with traumatic and non-traumatic amputations. Setting Five countries with the highest numbers of PwA in the global International Committee of the Red Cross database (Afghanistan, Cambodia, Iraq, Myanmar, Sudan). Cleaned and merged data from 2009 to 2018 were aggregated by sex; age at amputation and registration; cause, combination and anatomical level of amputation(s); living environment. Participants All PwA newly attending rehabilitation. Results Data for 28 446 individuals were included (4329 (15.2%) female). Most were traumatic amputations (73.4%, 208 90); of these, 48.6% (138 01) were conflict related. Average age at traumatic amputation for men and women was 26.9 and 24.1 years, respectively; for non-traumatic amputation it was 49.1 years and 45.9 years, respectively. Sex differences in age were statistically significant for traumatic and non-traumatic causes (p<0.001, p=0.003). Delay between amputation and rehabilitation was on average 8.2 years for those with traumatic amputation, significantly higher than an average 3 years for those with non-traumatic amputation (p<0.001). Conclusions Young age for traumatic and non-traumatic amputations indicates the devastating impact of war and fragile health systems on a society. Long delays between amputation and rehabilitation reveal the mismatch of needs and resources. For rehabilitation service providers in fragile settings, it is an enormous task to manage the diversity of PwA of various causes, age, sex and additional conditions. Improved collaboration between primary healthcare, surgical and rehabilitation services, a prioritisation of rehabilitation and increased resource provision are recommended to ensure adequate access to comprehensive rehabilitation care for PwA.
|
|
| 9. |
- Barth, Cornelia Anne, et al.
(author)
-
Ways to improve surgical outcomes in low- and middle-income countries
- 2022
-
In: Bulletin of the World Health Organization. - : WHO Press. - 0042-9686 .- 1564-0604. ; 100:11, s. 726-732
-
Journal article (peer-reviewed)abstract
- Global surgery initiatives such as the Lancet Commission on Global Surgery have highlighted the need for increased investment to enhance surgical capacity in low- and middle-income countries. A neglected issue, however, is surgery-related rehabilitation, which is known to optimize functional outcomes after surgery. Increased investment to enhance surgical capacity therefore needs to be complemented by promotion of rehabilitation interventions. We make the case for strengthening surgery-related rehabilitation in lower-resource countries, outlining the challenges but also potential solutions and policy directions. Proposed solutions include greater leadership and awareness, augmented by recent global efforts around the World Health Organization's Rehabilitation 2030 initiative, and professionalization of the rehabilitation workforce. More research on rehabilitation is needed in low- and middle-income countries, along with support for system approaches, notably on strengthening and integrating rehabilitation within the health systems. Finally, we outline a set of policy implications and recommendations, aligned to the components of the national surgical plan proposed by the Lancet Commission: infrastructure, workforce, service delivery, financing, and information management. Collaboration and sustained efforts to embed rehabilitation within national surgical plans is key to optimize health outcomes for patients with surgical conditions and ensure progress towards sustainable development goal 3: health and well-being for all.
|
|
| 10. |
- Barth, Cornelia, et al.
(author)
-
Users of rehabilitation services in 14 countries and territories affected by conflict, 1988–2018
- 2020
-
In: Bulletin of the World Health Organization. - Geneva, Switzerland : World Health Organization. - 0042-9686 .- 1564-0604. ; 98, s. 599-614
-
Journal article (peer-reviewed)abstract
- Objective To analyse the demographic and clinical characteristics of people attending physical rehabilitation centres run or supported by the International Committee of the Red Cross in countries and territories affected by conflict.Methods Of 150 such rehabilitation centres worldwide, 38 use an electronic patient management system. We invited all 38 centres to participate. We extracted de-identified data from 1988 to 2018 and categorized them by sex, age, country or territory and reason for using rehabilitation services.Findings Thirty-one of the 38 rehabilitation centres in 14 countries and territories participated. We included data for 287 274 individuals. Of people using rehabilitation services, 61.6% (176 949/287 274) were in Afghanistan, followed by 15.7% (44 959/287 274) in Cambodia. Seven places had over 9000 service users each (Afghanistan, Cambodia, Gaza Strip, Iraq, Myanmar, Somalia and Sudan). Overall, 72.6% (208 515/287 274) of service users were male. In eight countries, more than half of the users were of working age (18–59 years). Amputation was the most common reason for using rehabilitation services; 33.3% (95 574/287 274) of users were people with amputations, followed by 13.7% (39 446/287 274) with cerebral palsy. The male predominance was greater in the population aged 18–34 years (83.1%; 71 441/85 997) and in people with amputations (88.6%; 84 717/95 574) but was evident across all places, age groups and health conditions.Conclusion The considerably lower attendance of females at the rehabilitation centres highlights the need to understand the factors that affect the accessibility and acceptability of rehabilitation for women and girls in conflict settings.
|
|
