Surgical System Efficiency and Operative Productivity in Public and Private Health Facilities in Ethiopia: A Cross-Sectional Evaluation.

BACKGROUND: Global and local health organizations track surgical system efficiency to improve surgical system performance using various efficiency metrics, such as operating room (OR) output, surgical incision start time (SIST), turnover time (TOT), cancellation rate among elective surgeries, and in-hospital surgery wait time. We evaluated the surgical system efficiency and factors affecting the efficiency in health facilities across Ethiopia. METHODS: A cross-sectional study design with retrospective record review was used to evaluate the surgical system efficiency in 163 public and private health facilities in Ethiopia from December 2020 to June 2021. Experienced, trained surgical clinicians abstracted efficiency data from service registers and patient charts using a pretested tool. A bivariable and multivariable regression analysis was conducted. RESULTS: In the study facilities, 84.11% of the operating tables were functional, and 68,596 major surgeries were performed. The aggregate OR output in both public and private health facilities was 2 surgeries per day per OR table. Operating productivity was shown to be affected by first-case SIST (P=.004). However, of the total 881 surgery incision times audited, 19.86% of the first-of-the-day elective surgeries started after 10:01 am. The SIST was strongly associated with an in-hospital wait time for surgery (P=.016). The elective surgery cancellation rate was 5.2%, and aggregate mean TOT was 50.25 minutes. The mean in-hospital surgery wait time was 45.40 hours, longer than the national cutoff for wait time. In a bivariable analysis, the independent variables that demonstrated association operating room productivity were then inputted into a multivariable regression analysis model. However, none of the predictor/independent variables showed significance in the multivariable regression analysis model. CONCLUSION: The volume of surgery and overall OR productivity in Ethiopia is low. This calls for concerted action to optimize OR efficiency and improve access to timely and safe surgical care in Ethiopia and other LMICs.

Improving surgical safety checklist utilisation at 23 public health facilities in Ethiopia: a collaborative quality improvement project.

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.

Access to surgical care in Ethiopia: a cross-sectional retrospective data review.

BACKGROUND: Access to emergency and essential surgical care is still unmet and accessibility is disproportionately inequitable in Ethiopia and other low-and middle-income countries. The aim of this study was to assess surgical care access in terms of capability, capacity, and timeliness of care in different levels of health care in Ethiopia. METHODS: A cross-sectional study with retrospective data review was conducted in 172 health facilities from December 30, 2020 to June 10, 2021. Descriptive statistics such as median with interquartile range and proportion were computed using STATA Version 15 statistical software. RESULTS: Within a 90-day interval of the study period, 69,717 major and minor surgeries, and 33,052 bellwether procedures were performed, and major surgeries accounted for 58% of the surgeries. About 1.6%, 23.56%, 25.34%, and 32.2% of both major and minor, and 3.1%, 12.8%, 27.6%, and 45.3% of bellwether procedures were performed in health center OR blocks, primary, general, and specialized hospitals, respectively. Private hospitals performed 17.33% of major and minor and 11.2% of bellwether procedures for the period. The average pre-admission waiting time for surgical patients in primary, general, and specialized hospitals was 9.68, 37.6, and 35.9 days, respectively, whereas, in private hospitals, the average pre-admission waiting time was 1.42 days. On average, surgical patients traveled 5 Hrs, 11 Hrs, 28.4 Hrs, and 21.3 Hrs to access surgical services in primary, general, specialized, and private hospitals, respectively. The surgical workforce to the population served ratio was 7.5, 1.15, and 1.31/100.000 population in primary, specialized and general hospitals, respectively. CONCLUSION: Most surgical procedures were performed in specialized hospitals, indicating that there is a burden in these health facilities. The pre-admission waiting time for surgical patients was long in higher-level public hospitals. Surgical patients traveled a long distance to access surgical service in higher level hospitals. The ratio of surgical workforce per 100,000 population served was low in all levels of public health facilities in general, and in higher level hospitals in particular. Efforts should therefore be made to strengthen all levels of the health system and improve surgical care access in terms of capacity, capability, and timeliness in the country.

Compliance with the World Health Organization's surgical safety checklist and related postoperative outcomes: a nationwide survey among 172 health facilities in Ethiopia.

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.

Adverse events of Oxford/AstraZeneca's COVID-19 vaccine among health care workers of Ayder Comprehensive Specialized Hospital, Tigray, Ethiopia.

Background: : The safety of COVID vaccines should be continuously followed. This study reports adverse events of the Oxford/AstraZeneca COVID-19 vaccine. Methods: : A prospective single-cohort study design was conducted to assess adverse events following immunization and associated factors of the first dose of Oxford/AstraZeneca's COVID-19 vaccine in Ayder Comprehensive specialized hospital. A structured questionnaire was administered consecutively to 423 participants. Follow-up data were collected 72 hours after vaccination via phone. Bivariate and multivariate logistic regression models were used to find associations between adverse events and independent variables. Statistical significance was declared at P<0.05. Results: : Out of 423 health care workers approached, 395 responded. At least one adverse event (95% CI: 63.58, 72.77) was reported by 270 participants. Local and systemic symptoms occurred in 46.8% (95% CI: 41.94, 51.79) and 58.48% (95% CI: 53.53, 63.26)], respectively. Muscle ache, fatigue, headache and fever were the most common local symptoms. No reports of hospitalization, disability or death. Age (adjusted odds ratio [AOR]=0.97, P=0.048), female sex (AOR=1.84, P=0.028), and comorbidity (AOR=2.28, P=0.040) were independent predictors of adverse events. Conclusion and recommendation: : Adverse events following immunization are commonly reported after the first dose of the Oxford/AstraZeneca COVID-19 vaccine; age, female sex and comorbidity are independent predictors.