Addressing knowledge gaps in Surgical Safety Checklist use: statistical process control analysis of a surgical quality improvement programme in Ethiopia.

BACKGROUND: The WHO Surgical Safety Checklist reduces morbidity and mortality after surgery, but uptake remains challenging. In particular, low-income countries have been found to have lower rates of checklist use compared with high-income countries. The aim of this study was to determine the impact of educational workshops on Surgical Safety Checklist use implemented as part of a quality improvement initiative in five hospitals in Ethiopia that had variable experience with the Surgical Safety Checklist. METHODS: From April 2019 to September 2020, each hospital implemented a 6-month surgical quality improvement programme, which included a Surgical Safety Checklist workshop. Statistical process control methodology was used to understand the variation in Surgical Safety Checklist compliance before and after workshops and a time-series analysis was performed using population-averaged generalized estimating equation Poisson regression. Checklist compliance was defined as correctly completing a sign in, timeout, and sign out. Incidence rate ratios of correct checklist use pre- and post-intervention were calculated and the change in mean weekly compliance was predicted. RESULTS: Checklist compliance data were obtained from 2767 operations (1940 (70 per cent) pre-intervention and 827 (30 per cent) post-intervention). Mean weekly checklist compliance improved from 27.3 to 41.2 per cent (mean difference 13.9 per cent, P = 0.001; incidence rate ratio 1.51, P = 0.001). Hospitals with higher checklist compliance at baseline had the greatest overall improvements in compliance, more than 50 per cent over pre-intervention, while low-performing hospitals showed no improvement. CONCLUSION: Surgical Safety Checklist workshops improved checklist compliance in hospitals with some experience with its use. Workshops had little effect in hospitals unfamiliar with the Surgical Safety Checklist, emphasizing the importance of multifactorial interventions and culture-change approaches. In receptive facilities, short workshops can accelerate behaviour change.

Mapping population access to essential surgical care in Liberia using equipment, personnel, and bellwether capability standards.

BACKGROUND: Accurate surveillance of population access to essential surgery is key for strategic healthcare planning. This study aimed to estimate population access to surgical facilities meeting standards for safe surgery equipment, specialized surgical personnel, and bellwether capability, cesarean delivery, emergency laparotomy, and long-bone fracture fixation and to evaluate the validity of using these standards to describe the full breadth of essential surgical care needs in Liberia. METHOD: An observational study of surgical facilities was conducted in Liberia between 20 September and 8 November 2018. Facility data were combined with geospatial data and analysed in an online visualization platform. RESULTS: Data were collected from 51 of 52 surgical facilities. Nationally, 52.9 per cent of the population (2 392 000 of 4 525 000 people) had 2-h access to their closest surgical facility, whereas 41.1 per cent (1 858 000 people) and 48.6 per cent (2 199 000 people) had 2-h access to a facility meeting the personnel and equipment standards respectively. Six facilities performed all bellwether procedures; 38.7 per cent of the population (1 751 000 people) had 2-h access to one of these facilities. Bellwether-capable facilities were more likely to perform other essential surgical procedures (OR 3.13, 95 per cent c.i. 1.28 to 7.65; P = 0.012). These facilities delivered a median of 13.0 (i.q.r. 11.3-16.5) additional essential procedures. CONCLUSION: Population access to essential surgery is limited in Liberia; strategies to reduce travel times ought to be part of healthcare policy. Policymakers should also be aware that bellwether capability might not be a valid proxy for the full breadth of essential surgical care in low-income settings.

Exploring the Use of a Fit-for-Purpose Surgical Headlight in Sub-Saharan Africa: Mixed Methods Study.

BACKGROUND: High-quality surgical lighting is often lacking in low-resource settings. Commercial surgical headlights are unavailable due to high cost and supply and maintenance challenges. We aimed to understand user needs of a surgical headlight for low-resource settings by evaluating a preselected robust but relatively inexpensive headlight and lighting conditions. METHODS: We observed headlight use by ten surgeons in Ethiopia and six in Liberia. All surgeons completed surveys about their lighting environment and experience using headlight, and were subsequently interviewed. Twelve surgeons completed logbooks on headlight use. We distributed headlights to 48 additional surgeons, and all surgeons were surveyed for feedback. RESULTS: In Ethiopia, five surgeons ranked operating room light quality as poor or very poor; seven delayed or cancelled operations within the last year and five described intraoperative complications due to poor lighting. In Liberia, lighting was rated as "good", however fieldnotes, and interviews noted generator fuel-rationing, and poor lighting conditions. In both countries, the headlight was considered extremely useful. Surgeons recommended nine improvements, including comfort, durability, affordability and availability of multiple rechargeable batteries. Thematic analysis identified factors influencing headlight use, specifications and feedback, and infrastructure challenges. CONCLUSION: Lighting in surveyed operating rooms was poor. Although conditions and need for the headlights differed between Ethiopia and Liberia, headlights were considered highly useful. However, discomfort was a major limiting factor for ongoing use, and the hardest to objectively characterise for specification and engineering purposes. Specific needs for surgical headlights include comfort and durability. Refinement of a fit-for-purpose surgical headlight is ongoing.

Pulse oximeter provision and training of non-physician anesthetists in Zambia: a qualitative study exploring perioperative care after training.

BACKGROUND: Pulse oximetry monitoring is included in the WHO Safe Surgery Checklist and recognized as an essential perioperative safety monitoring device. However, many low resource countries do not have adequate numbers of pulse oximeters available or healthcare workers trained in their use. Lifebox, a nonprofit organization focused on improving anesthetic and surgical safety, has procured and distributed pulse oximeters and relevant educational training in over 100 countries. We aimed to understand qualitatively how pulse oximetry provision and training affected a group of Zambian non-physician anesthetists' perioperative care and what, if any, capacity gaps remain. METHODS: We identified and approached non-physician anesthetists (NPAPs) in Zambia who attended a 2019 Lifebox pulse oximetry training course to participate in a semi-structured interview. Interviews were audio recorded and transcribed. Codes were iteratively derived; the codebook was tested for inter-rater reliability (pooled kappa > 0.70). Team-based thematic analysis identified emergent themes on pulse oximetry training and perioperative patient care. RESULTS: Ten of the 35 attendees were interviewed. Two themes emerged concerning pulse oximetry provision and training in discussion with non-physician anesthetists about their experience after training: (1) Impact on Non-Physician Anesthetists and the Healthcare Team and (2) Impact on Perioperative Patient Monitoring. These broad themes were further explored through subthemes. Increased knowledge brought confidence in monitoring and facilitated quick interventions. NPAPs reported improved preoperative assessments and reaffirmed the necessity of having pulse oximetry intraoperatively. However, lack of device availability led to case delays or cancellations. A portable device travelling with the patient to the recovery ward was noted as a major improvement in postoperative care. Pulse oximeters also improved communication between nurses and NPAPs, giving NPAPs confidence in the recovery process. However, this was not always possible, as lack of pulse oximeters and ward staff unfamiliarity with oximetry was commonly reported. NPAPs expressed that wider pulse oximetry availability and training would be beneficial. CONCLUSION: Among a cohort of non-physician anesthetists in Zambia, the provision of pulse oximeters and training was perceived to improve patient care throughout the perioperative timeline. However, capacity and resource gaps remain in their practice settings, especially during transfers of care. NPAPs identified a number of areas where patient care and safety could be improved, including expanding access to pulse oximetry training and provision to ward and nursing staff to ensure the entire healthcare team is aware of the benefits and importance of its use.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report.

BACKGROUND: Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally. METHODS AND FINDINGS: The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees. CONCLUSIONS: To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

Impact of the Affordable Care Act Insurance Marketplaces on Out-of-Pocket Spending Among Surgical Patients.

OBJECTIVE: To evaluate the association between the introduction of the Affordable Care Act (ACA) Health Insurance Marketplaces ("Marketplaces") and financial protection for patients undergoing surgery. BACKGROUND: The ACA established Marketplaces through which individuals could purchase subsidized insurance coverage. However, the effect of these Marketplaces on surgical patients' healthcare spending remains largely unknown. METHODS: We analyzed a nationally representative sample of adults aged 19-64 who underwent surgery in 2010-2017, using the Medical Expenditure Panel Survey. Low-income patients eligible for cost-sharing and premium subsidies in the Marketplaces [income 139%-250% federal poverty level (FPL)] and middle-income patients eligible only for premium subsidies (251%-400% FPL) were compared to high-income controls ineligible for subsidies (>400% FPL) using a quasi-experimental difference-in-differences approach. We evaluated 3 main outcomes: (1) out-of-pocket spending, (2) premium contributions, and (3) likelihood of experiencing catastrophic expenditures, defined as out-of-pocket plus premium spending exceeding 19.5% of family income. RESULTS: Our sample included 5450 patients undergoing surgery, representing approximately 69 million US adults. Among low-income patients, Marketplace implementation was associated with $601 lower [95% confidence interval (CI): -$1169 to -$33; P = 0.04) out-of-pocket spending; $968 lower (95% CI: -$1652 to -$285; P = 0.006) premium spending; and 34.6% lower probability (absolute change: -8.3 percentage points; 95% CI: -14.9 to -1.7; P = 0.01) of catastrophic expenditures. We found no evidence that health expenditures changed for middle-income surgical patients. CONCLUSIONS: The ACA's insurance Marketplaces were associated with improved financial protection among low-income surgical patients eligible for both cost-sharing and premium subsidies, but not in middle-income patients eligible for only premium subsidies.

Identifying a Basket of Surgical Procedures to Standardize Global Surgical Metrics: An International Delphi Study.

OBJECTIVE: We aimed to define a globally applicable list of surgical procedures, or "basket," which could represent a health system's capacity to provide surgical care and standardize global surgical measurement. SUMMARY OF BACKGROUND DATA: Six indicators have been proposed to assess access to safe, affordable, timely surgical and anesthesia care, with a focus on laparotomy, cesarean section, and treatment of open fracture. However, comparability, particularly for these procedures, has been limited by a lack of definitional clarity and their overly broad scope. METHODS: We conducted a 3 round international expert Delphi exercise between April and June 2019 using REDCap to identify a set of procedures representative of surgical capacity. To be included, procedures had to be important for treating common conditions, well-defined, and impactful (ie, well-recognized clinical or functional benefit). Procedures were eliminated or prioritized in each round, and those noted as "extremely" or "very important" by ≥50% of respondents in round 3 were included in the final "basket." RESULTS: Altogether 331 respondents from 78 countries participated in the Delphi process. A final basket of 32 procedures representing disease categories in trauma, cancer, congenital anomalies, maternal/reproductive health, aging, and infection were identified for inclusion to assess surgical capacity. CONCLUSIONS: This surgical basket facilitates a more standardized assessment of a country's surgical system. Further testing and refinement will likely be needed, but this basket can be used immediately to guide ongoing monitoring and evaluation of global surgery capacities to improve and strengthen surgery and anesthesia care.

We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations.

BACKGROUND: As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic. METHODS: 18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus. RESULTS: From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation. CONCLUSIONS: This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

Correction to: Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers.

In the original version of the article, Dominique Vervoort's last name was misspelled. It is correct as reflected here. The original article has been updated.

Global Survey of Perceptions of the Surgical Safety Checklist Among Medical Students, Trainees, and Early Career Providers.

BACKGROUND: The Surgical Safety Checklist (SSC) has been shown to reduce perioperative complications across global health systems. We sought to assess perceptions of the SSC and suggestions for its improvement among medical students, trainees, and early career providers. METHODS: From July to September 2019, a survey assessing perceptions of the SSC was disseminated through InciSioN, the International Student Surgical Network comprising medical students, trainees, and early career providers pursuing surgery. Individuals with ≥2 years of independent practice after training were excluded. Respondents were categorized according to any clinical versus solely non-clinical SSC exposure. Logistic regression was used to evaluate associations between clinical/non-clinical exposure and promoting future use of the SSC, adjusting for potential confounders/mediators: training level, human development index, and first perceptions of the SSC. Thematic analysis was conducted on suggestions for SSC improvement. RESULTS: Respondent participation rate was 24%. Three hundred and eighteen respondents were included in final analyses; 215 (67%) reported clinical exposure and 190 (60%) were promoters of future SSC use. Clinical exposure was associated with greater odds of promoting future SSC use (aOR 1.81 95% CI [1.03-3.19], p = 0.039). A greater proportion of promoters reported "Improved Operating Room Communication" as a goal of the SSC (0.21 95% CI [0.15-0.27]-vs.-0.12 [0.06-0.17], p = 0.031), while non-promoters reported the SSC goals were "Not Well Understood" (0.08 95% CI [0.03-0.12]-vs.-0.03 [0.01-0.05], p = 0.032). Suggestions for SSC improvement emphasized context-specific adaptability and earlier formal training. CONCLUSIONS: Clinical exposure to the SSC was associated with promoting its future use. Earlier formal clinical training may improve perceptions and future use among medical students, trainees, and early career providers.

Implementation Challenges Using a Novel Method for Collecting Patient-Reported Outcomes After Injury.

BACKGROUND: Monitoring longitudinal patient-reported outcomes after injury is important for comprehensive trauma care. Current methodologies are resource-intensive and struggle to engage patients. MATERIALS AND METHODS: Patients ≥18 y old admitted to the trauma service were prospectively enrolled. The following inclusion criteria were used: emergency operation, ICU length of stay ≥2 midnights, or hospital length of stay ≥4 d. Validated and customized questionnaires were administered using a novel internet-based survey platform. Three-month follow-up surveys were administered. Contextual field notes regarding barriers to enrollment/completion of surveys and challenges faced by participants were recorded. RESULTS: Forty-seven patients were eligible; 26 of 47 (55%) enrolled and 19 of 26 (73%) completed initial surveys. The final sample included 14 (74%) men and 5 (26%) women. Primary barriers to enrollment included technological constraints and declined participation. Contextual field notes revealed three major issues: competing hospital tasks, problems with technology, and poor engagement. The average survey completion time was 43 ± 27 min-21% found this too long. Seventy-four percent reported the system "easy to use" and 95% reported they would "very likely" or "definitely" respond to future surveys. However, 10 of 26 (38%) patients completed 3-mo follow-up. CONCLUSIONS: Despite a well-rated internet-based survey platform, study participation remained challenging. Lack of email access and technological issues decreased enrollment and the busy hospitalization posed barriers to completion. Despite a thoughtful operational design and implementation plan, the trauma population presented a challenging group to engage. Next steps will focus on optimizing engagement, broadening access to survey reminders, and enhancing integration into clinical workflows.

Qualitative outcomes of Clean Cut: implementation lessons from reducing surgical infections in Ethiopia.

BACKGROUND: Clean Cut is a six month, multi-modal, adaptive intervention aimed at reducing surgical infections through improving six critical perioperative processes: 1) handwashing/skin preparation, 2) surgical gown/drape integrity, 3) antibiotic administration, 4) instrument sterility, 5) gauze counts, and 6) WHO Surgical Safety Checklist use. The aim of this study was to elucidate themes across Clean Cut implementation sites in Ethiopia to improve implementation at future hospitals. METHODS: We conducted semi-structured interviews of 20 clinicians involved in Clean Cut at four hospitals. Participation was limited to Clean Cut team members and included surgeons, anesthetists, operating room (OR) nurses, ward nurses, OR managers, quality improvement personnel, and hospital administrators. Audio recordings were transcribed and coded using qualitative software. A codebook was inductively and iteratively derived between two researchers, tested for inter-rater reliability, and applied to all transcripts. We conducted thematic analysis to derive our final qualitative results. RESULTS: The interviews revealed barriers and facilitators to the implementation of Clean Cut, as well as strategies for future implementation sites. Key barriers included material resource limitations, feelings of job burden, existing gaps in infection prevention education, and communication errors during data collection. Common facilitators included strong hospital leadership support, commitment to improved patient outcomes, and organized Clean Cut training sessions. Future strategies include resource assessments, creating a sense of responsibility among staff, targeted training sessions, and incorporating new standards into daily routine. CONCLUSIONS: The findings of this study highlight the importance of engaging hospital leadership, providers and staff in quality improvement programs, and understanding their work contexts. The identified barriers and facilitators will inform future initiatives in the field of perioperative infection prevention.

Cougar (Puma concolor) Injury in the United States.

INTRODUCTION: Human encounters with the cougar (Puma concolor) are rare in the United States but may be fatal. METHODS: We performed a retrospective analysis of cougar attacks in the United States. We asked Fish and Wildlife Department officials from the 16 states in which cougars are known to live to identify all verified cougar attacks recorded in state history. Variables describing the human victim, cougar, and conditions surrounding the attack were recorded. The Fisher exact test was used for comparison. RESULTS: Ten states reported 74 cougar attacks from 1924 to 2018. Persons less than 18 y of age were heavily represented among victims; 48% were <18 y old, and 35% were less than 10 y old. Attacks were more common in the summer and fall months. Most attacks occurred during daylight hours. The head, neck, and chest were the most common anatomic sites of injury. Sixteen (46%) victims were hospitalized after being attacked, among the 35 victims with these data available. Eleven (15%) attacks were fatal among 71 reports with this information. None of the hospitalized victims died (P=0.02). No victim variables were predictive of death. CONCLUSIONS: Cougar attacks are uncommon but can be fatal. Attacks commonly affect children and young adults, although all age groups are at risk of attack and death. Most attacks occur during the daytime in the summer and fall. As development and recreational activities put humans in closer contact with cougars, establishing validated public health messaging is critical to minimize injurious encounters.

Surgical deserts in California: an analysis of access to surgical care.

BACKGROUND: Areas of minimal access to surgical care, often called "surgical deserts", are of particular concern when considering the need for urgent surgical and anesthesia care. We hypothesized that California would have an appropriate workforce density but that physicians would be concentrated in urban areas, and surgical deserts would exist in rural counties. METHODS: We used a benchmark of six general surgeons, six orthopedists, and eight anesthesiologists per 100,000 people per county to define a "desert". The number and location of these providers were obtained from the Medical Board of California for 2015. ArcGIS, version 10.3, was used to geocode the data and were analyzed in Redivis. RESULTS: There were a total of 3268 general surgeons, 3188 orthopedists, and 5995 anesthesiologists in California in 2015, yielding a state surgeon-to-population ratio of 7.2, 6.7, and 10.2 per 100,000 people, respectively; however, there was wide geographic variability. Of the 58 counties in California, 18 (31%) have a general surgery desert, 27 (47%) have an orthopedic desert, and 22 (38%) have an anesthesiology desert. These counties account for 15%, 25%, and 13% of the state population, respectively. Five, seven, and nine counties, respectively, have none in the corresponding specialty. CONCLUSIONS: Overall, California has an adequate ratio of surgical and anesthesia providers to population. However, because of their uneven distribution, significant surgical care deserts exist. Limited access to surgical and anesthesia providers may negatively impact patient outcome in these counties.

The association between angioembolization and splenic salvage for isolated splenic injuries.

BACKGROUND: Recent data suggest improved splenic salvage rates when angioembolization (AE) is routinely employed for high-grade splenic injuries; however, protocols and salvage rates vary among centers. MATERIALS/METHODS: Adult patients with isolated splenic injuries were identified using the National Trauma Data Bank, 2013-2014. Patients were excluded if they underwent immediate splenectomy or died in the emergency department. To characterize patterns of AE, trauma centers were grouped into quartiles based on frequency of AE use. Unadjusted analyses and mixed-effects logistical regression controlling for center effects were performed. RESULTS: Five thousand and ninety three adult patients were identified. Overall, 705 (13.8%) underwent AE and 290 (5.7%) required a splenectomy. In unadjusted comparisons, splenectomy rates were lower for patients with severe spleen injuries who underwent AE (7% versus 11%, P = 0.02). In mixed-effect logistical regression patients with severe splenic injuries undergoing AE had a lower odds ratio (OR) for splenectomy (OR = 0.67, P = 0.04). Patients treated at centers in the highest quartile of AE use had a lower OR for splenectomy (OR = 0.58, P = 0.02). CONCLUSIONS: The use of AE in patients with isolated severe splenic injuries is associated with decreased splenectomy rates. There is an association between centers that perform AE frequently and reduced splenectomy rates.

An Update on Fatalities Due to Venomous and Nonvenomous Animals in the United States (2008-2015).

INTRODUCTION: To review recent (2008-2015) United States mortality data from deaths caused by nonvenomous and venomous animals and compare with historical data. METHODS: The Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database was queried to return all animal-related fatalities between 2008 and 2015. Mortality frequencies for animal-related fatalities were calculated using the estimated 2011 United States population. Inclusion criteria included all mortalities that were a consequence of bite, contact, attack, or envenomation (International Classification of Diseases 10th revision codes W53-W59 and X20-X29). RESULTS: There were 1610 animal-related fatalities, with the majority from nonvenomous animals (4.8 deaths per 10 million persons annually). The largest proportion of animal-related fatalities was due to "other mammals," largely composed of horses and cattle. Deaths attributable to Hymenoptera (hornets, wasps, and bees) account for 29.7% of the overall animal-related fatalities and have been steady over the last 20 years. Dog-related fatality frequencies are stable, although the fatality frequency of 4.6 deaths per 10 million persons among children 4 years of age or younger was nearly 4-fold greater than in the other age groups. CONCLUSIONS: Appropriate education and prevention measures aimed at decreasing injury from animals should be directed at the high-risk groups of agricultural workers and young children with dogs. Public policy and treatment pricing should align to ensure adequate available medication for those at risk of anaphylaxis from stings from Hymenoptera.

Clinical update on management of pancreatic trauma.

BACKGROUND: Pancreatic injury is rare and optimal diagnosis and management is still debated. The aim of this study was to review the existing data and consensus on management of pancreatic trauma. METHODS: Systematic literature review until May 2018. RESULTS: Pancreas injury is reported in 0.2-0.3% of all trauma patients. Severity is scored by the organ injury scale (OIS), with new scores including physiology needing validation. Diagnosis is difficult, clinical signs subtle, and imaging by ultrasound (US) and computed tomography (CT) non-specific with <60% sensitivity for pancreatic duct injury. MRCP and ERCP have superior sensitivity (90-100%) for detecting ductal disruption. Early ERCP with stent is a feasible approach for initial management of all branch-duct and most main-duct injuries. Distal pancreatectomy (±splenectomy) may be required for a transected gland distal to the major vessels. Early peripancreatic fluid collections are common in ductal injuries and one-fifth may develop pseudocysts, of which two-thirds can be managed conservatively. Non-operative management has a high success rate (50-75%), even in high-grade injuries, but associated with morbidity. Mortality is related to associated injuries. CONCLUSION: Pancreatic injuries are rare and can often be managed non-operatively, supported by percutaneous drainage and ductal stenting. Distal pancreatectomy is the most common operative procedure.

A geospatial evaluation of timely access to surgical care in seven countries.

OBJECTIVE: To assess the consistent availability of basic surgical resources at selected facilities in seven countries. METHODS: In 2010-2014, we used a situational analysis tool to collect data at district and regional hospitals in Bangladesh (n = 14), the Plurinational State of Bolivia (n = 18), Ethiopia (n = 19), Guatemala (n = 20), the Lao People's Democratic Republic (n = 12), Liberia (n = 12) and Rwanda (n = 25). Hospital sites were selected by pragmatic sampling. Data were geocoded and then analysed using an online data visualization platform. Each hospital's catchment population was defined as the people who could reach the hospital via a vehicle trip of no more than two hours. A hospital was only considered to show consistent availability of basic surgical resources if clean water, electricity, essential medications including intravenous fluids and at least one anaesthetic, analgesic and antibiotic, a functional pulse oximeter, a functional sterilizer, oxygen and providers accredited to perform surgery and anaesthesia were always available. FINDINGS: Only 41 (34.2%) of the 120 study hospitals met the criteria for the provision of consistent basic surgical services. The combined catchments of the study hospitals in each study country varied between 3.3 million people in Liberia and 151.3 million people in Bangladesh. However, the combined catchments of the study hospitals in each study country that met the criteria for the provision of consistent basic surgical services were substantially smaller and varied between 1.3 million in Liberia and 79.2 million in Bangladesh. CONCLUSION: Many study facilities were deficient in the basic infrastructure necessary for providing basic surgical care on a consistent basis.

Costs and Financial Burden of Initial Hospitalizations for Firearm Injuries in the United States, 2006-2014.

OBJECTIVES: To quantify the inflation-adjusted costs associated with initial hospitalizations for firearm-related injuries in the United States. METHODS: We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample to identify patients admitted for firearm-related injuries from 2006 to 2014. We converted charges from hospitalization to costs, which we inflation-adjusted to 2014 dollars. We used survey weights to create national estimates. RESULTS: Costs for the initial inpatient hospitalization totaled $6.61 billion. The largest proportion was for patients with governmental insurance coverage, totaling $2.70 billion (40.8%) and was divided between Medicaid ($2.30 billion) and Medicare ($0.40 billion). Self-pay individuals accounted for $1.56 billion (23.6%) in costs. CONCLUSIONS: From 2006 to 2014, the cost of initial hospitalizations for firearm-related injuries averaged $734.6 million per year. Medicaid paid one third and self-pay patients one quarter of the financial burden. These figures substantially underestimate true health care costs. Public health implications. Firearm-related injuries are costly to the US health care system and are particularly burdensome to government insurance and the self-paying poor.