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BACKGROUND: Educating health professionals on patient safety can potentially reduce healthcare-associated harm. Patient safety courses have been incorporated into medical and nursing curricula in many high-income countries and their impact has been demonstrated in the literature through objective assessments. This study aimed to explore student perceptions about a patient safety course to assess its influence on aspiring health professionals at a personal level as well as to explore differences in areas of focus between medical and nursing students. METHODS: A dedicated patient safety course was introduced for year III medical and year II and IV nursing students at the Aga Khan University (2021-2022). As part of a post-course assessment, 577 participating students (184 medical and 393 nursing) wrote reflections on the course, detailing its influence on them. These free-text responses were thematically analyzed using NVivo. RESULTS: The findings revealed five major themes: acquired skills (clinical, interpersonal), understanding of medical errors (increased awareness, prevention and reduction, responding to errors), personal experiences with patient safety issues, impact of course (changed perceptions, professional integrity, need for similar sessions, importance of the topic) and course feedback (format, preparation for clinical years, suggestions). Students reported a lack of baseline awareness regarding the frequency and consequences of medical errors. After the course, medical students reported a perceptional shift in favor of systems thinking regarding error causality, and nursing students focused on human factors and error prevention. The interactive course format involving scenario-based learning was deemed beneficial in terms of increasing awareness, imparting relevant clinical and interpersonal skills, and changing perspectives on patient safety. CONCLUSIONS: Student perspectives illustrate the benefits of an early introduction of dedicated courses in imparting patient safety education to aspiring health professionals. Students reported a lack of baseline awareness of essential patient safety concepts, highlighting gaps in the existing curricula. This study can help provide an impetus for incorporating patient safety as a core component in medical and nursing curricula nationally and across the region. Additionally, patient safety courses can be tailored to emphasize areas identified as gaps among each professional group, and interprofessional education can be employed for shared learning. The authors further recommend conducting longitudinal studies to assess the long-term impact of such courses.
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Currículo , Segurança do Paciente , Pesquisa Qualitativa , Estudantes de Medicina , Estudantes de Enfermagem , Humanos , Estudantes de Enfermagem/psicologia , Estudantes de Medicina/psicologia , Masculino , Feminino , Erros Médicos/prevenção & controle , Atitude do Pessoal de Saúde , Arábia Saudita , Competência ClínicaRESUMO
OBJECTIVES: To evaluate nationwide pediatric critical care facilities and resources in Pakistan. DESIGN: Cross-sectional observational study. SETTING: Accredited pediatric training facilities in Pakistan. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A survey was conducted using the Partners in Health 4S (space, staff, stuff, systems) framework, via email or telephone correspondence. We used a scoring system in which each item in our checklist was given a score of 1, if available. Total scores were added up for each component. Additionally, we stratified and analyzed the data between the public and private healthcare sectors. Out of 114 hospitals (accredited for pediatric training), 76 (67%) responded. Fifty-three (70%) of these hospitals had a PICU, with a total of 667 specialized beds and 217 mechanical ventilators. There were 38 (72%) public hospitals and 15 (28%) private hospitals. There were 20 trained intensivists in 16 of 53 PICUs (30%), while 25 of 53 PICUs (47%) had a nurse-patient ratio less than 1:3. Overall, private hospitals were better resourced in many domains of our four Partners in Health framework. The Stuff component scored more than the other three components using analysis of variance testing ( p = 0.003). On cluster analysis, private hospitals ranked higher in Space and Stuff, along with the overall scoring. CONCLUSIONS: There is a general lack of resources, seen disproportionately in the public sector. The scarcity of qualified intensivists and nursing staff poses a challenge to Pakistan's PICU infrastructure.
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Cuidados Críticos , Hospitais Públicos , Humanos , Criança , Paquistão , Estudos Transversais , Inquéritos e QuestionáriosRESUMO
Covid-19 pandemic affected the health care systems globally. In many countries, healthcare services were overwhelmed by the huge number of Covid cases; hence, shifting the focus from locally endemic infectious diseases. Such a case presented to us that was initially managed along the lines of critical Covid pneumonia with steroids, Remdesivir, and supplemental oxygen for hypoxic respiratory failure. The patient also received Baricitinib, to which he was non-responsive and thus offered invasive mechanical ventilation. Post intubation, the patient was managed for Covid-associated ARDS with lung protective ventilation. He later also developed liver dysfunction, renal failure, coagulation derangements, and shock. Workup for malaria and dengue were negative. Later, Crimean Congo PCR was sent which came positive; a possible cause of progressive deterioration. In CCHF endemic areas, it is crucial to rule out the CCHF infection among patients presenting with critical Covid pneumonia due to similar clinical presentation in both the infections.
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COVID-19 , Coinfecção , Vírus da Febre Hemorrágica da Crimeia-Congo , Febre Hemorrágica da Crimeia , Masculino , Humanos , Febre Hemorrágica da Crimeia/complicações , Febre Hemorrágica da Crimeia/diagnóstico , Febre Hemorrágica da Crimeia/epidemiologia , Coinfecção/epidemiologia , Pandemias , COVID-19/terapia , COVID-19/epidemiologiaRESUMO
The ongoing coronavirus (COVID-19) infection causes severe respiratory dysfunction and has become an emergent issue for worldwide healthcare due to highly transmissible and contagious nature. Aerosol generating procedures such as tracheal intubation is of particularly high risk. This mandates some advice on processes and techniques required to protect staff and uniform approach during airway management. We hereby share our experience in development of an emergency response system to deal with COVID airway management at a frontline hospital which particularly consider the local demands and resources. This includes a change in working dynamics with 24/7 consultant coverage for emergent or urgent tracheal intubation of COVID patients at non-operating room locations. Other steps include prepackaging intubation baskets, availability of videolaryngoscope, standard personal protective equipment including powered air purifying respirator, and use of modified intubation checklist.
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To determine how often care is limited at the end of life and the factors that are associated with this decision, we reviewed the medical records of all patients that passed away in the intensive care units (ICU) of Aga Khan University. We found that a majority of patients had Do-Not-Resuscitate orders in place at the time of death. Our analysis yielded 6 variables that were associated with the decision to limit care. These are patient age, sex, duration of mechanical ventilation, Glasgow Coma Scale (GCS) ≤8 at any point during ICU stay, GCS ≤8 in the first 24 hours following ICU admission, and mean arterial pressure <65 mm of Hg while on vasopressors in the first 24 hours following ICU admission. These variables require further study and should be carefully considered during end of life discussions to allow for optimal management at the end of life.
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BACKGROUND: In response to the COVID-19 pandemic, concerted efforts were made by provincial and federal governments to invest in critical care infrastructure and medical equipment to bridge the gap of resource-limitation in intensive care units (ICUs) across Pakistan. An initial step in creating a plan toward strengthening Pakistan's baseline critical care capacity was to carry out a needs-assessment within the country to assess gaps and devise strategies for improving the quality of critical care facilities. METHODS: To assess the baseline critical care capacity of Pakistan, we conducted a series of cross-sectional surveys of hospitals providing COVID-19 care across the country. These hospitals were pre-identified by the Health Services Academy (HSA), Pakistan. Surveys were administered via telephonic and on-site interviews and based on a unique checklist for assessing critical care units which was created from the Partners in Health 4S Framework, which is: Space, Staff, Stuff, and Systems. These components were scored, weighted equally, and then ranked into quartiles. RESULTS: A total of 106 hospitals were surveyed, with the majority being in the public sector (71.7%) and in the metropolitan setting (56.6%). We found infrastructure, staffing, and systems lacking as only 19.8% of hospitals had negative pressure rooms and 44.4% had quarantine facilities for staff. Merely 36.8% of hospitals employed accredited intensivists and 54.8% of hospitals maintained an ideal nurse-to-patient ratio. 31.1% of hospitals did not have a staffing model, while 37.7% of hospitals did not have surge policies. On Chi-square analysis, statistically significant differences (p < 0.05) were noted between public and private sectors along with metropolitan versus rural settings in various elements. Almost all ranks showed significant disparity between public-private and metropolitan-rural settings, with private and metropolitan hospitals having a greater proportion in the 1st rank, while public and rural hospitals had a greater proportion in the lower ranks. CONCLUSION: Pakistan has an underdeveloped critical care network with significant inequity between public-private and metropolitan-rural strata. We hope for future resource allocation and capacity development projects for critical care in order to reduce these disparities.
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COVID-19 , Pandemias , Adulto , Cuidados Críticos , Estudos Transversais , Humanos , PaquistãoRESUMO
OBJECTIVE: To retrospectively review outcomes of a health provider-led infant circumcision programme in Pakistan. METHODS: Based on World Health Organization guidelines, we trained surgical technicians and midwives to perform circumcisions using the Plastibell device at two Indus Health Network facilities. Programme tools include a training manual for health providers, information brochures for families, an enrolment form and standardized forms for documenting details of the procedure and outcomes. Infants aged 1-92 days were eligible for the study. Health workers contacted families on days 1 and 7 after the procedure to record any adverse events. We compared the characteristics of infants experiencing adverse events with infants facing no complications using multivariate logistic regression. FINDINGS: Between August 2016 and August 2018, 2822 circumcised male infants with mean age 22.8 days were eligible for the study. Of these, 2617 infants (92.7%) were followed up by telephone interviews of caretakers. Older infants were more likely to experience adverse events than infants circumcised between 1-30 days of age: 31-60 days: adjusted odds ratio, aOR: 2.03; 95% confidence interval, CI: 1.31-3.15; 61-92 days: aOR: 2.14; 95% CI: 1.13-4.05. Minor adverse events (100 infants; 3.8%) included failure of the bell to shed (90 infants) and minimal bleeding (10 infants). Major adverse events (eight infants; 0.3%) included bleeding that required intervention (four infants), infection (three infants) and skin tear (one infant). CONCLUSION: Standardized training protocols and close monitoring enabled nonphysician health providers to perform safe circumcisions on infants aged three months or younger.
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Circuncisão Masculina , Adulto , Pessoal de Saúde , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Paquistão , Estudos Retrospectivos , Organização Mundial da Saúde , Adulto JovemRESUMO
BACKGROUND: Pakistan is a lower-middle-income country with a high burden of injuries. Karachi, its most populated city, lacks a trauma care system due to which trauma patients do not receive the required care. We conducted an assessment of the existing facilities for trauma care in Karachi. METHODS: Twenty-two tertiary and secondary hospitals from public and private sectors across Karachi were assessed. The Guidelines for Essential Trauma Care (GETC) tool was used to collect information about the availability of skills, knowledge, and equipment at these facilities. RESULTS: Among tertiary hospitals (n = 7), private sector hospitals had a better median (IQR) score, 90.4 (81.8-93.1), as compared to the public sector hospitals, 44.1 (29.3-75.8). Among secondary hospitals (n = 15), private sector hospitals had a better median (IQR) score, 70.3 (67.8-77.7), as compared to the public sector hospitals, 39.7 (21.9-53.3). DISCUSSION: This study identifies considerable deficiencies in trauma care in Karachi and provides objective data that can guide urgently needed reforms tailored to this city's needs. On a systems level, it delineates the need for a regulatory framework to define trauma care levels and designate selected hospitals across the city accordingly. Using these data, improvement in trauma care systems can be achieved through collaboration and partnership between public and private stakeholders.
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Serviços Médicos de Emergência , Hospitais Privados , Hospitais Públicos , Humanos , Paquistão , Setor PúblicoRESUMO
BACKGROUND: Intraoperative massive transfusion (MT) is common during liver transplantation (LT). A predictive model of MT has the potential to improve use of blood bank resources. STUDY DESIGN AND METHODS: Development and validation cohorts were identified among deceased-donor LT recipients from 2010 to 2016. A multivariable model of MT generated from the development cohort was validated with the validation cohort and refined using both cohorts. The combined cohort also validated the previously reported McCluskey risk index (McRI). A simple modified risk index (ModRI) was then created from the combined cohort. Finally, a method to translate model predictions to a population-specific blood allocation strategy was described and demonstrated for the study population. RESULTS: Of the 403 patients, 60 (29.6%) in the development and 51 (25.5%) in the validation cohort met the definition for MT. The ModRI, derived from variables incorporated into multivariable model, ranged from 0 to 5, where 1 point each was assigned for hemoglobin level of less than 10 g/dL, platelet count of less than 100 × 109 /dL, thromboelastography R interval of more than 6 minutes, simultaneous liver and kidney transplant and retransplantation, and a ModRI of more than 2 defined recipients at risk for MT. The multivariable model, McRI, and ModRI demonstrated good discrimination (c statistic [95% CI], 0.77 [0.70-0.84]; 0.69 [0.62-0.76]; and 0.72 [0.65-0.79], respectively, after correction for optimism). For blood allocation of 6 or 15 units of red blood cells (RBCs) based on risk of MT, the ModRI would prevent unnecessary crossmatching of 300 units of RBCs/100 transplants. CONCLUSIONS: Risk indices of MT in LT can be effective for risk stratification and reducing unnecessary blood bank resource utilization.
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Bancos de Sangue , Transfusão de Sangue , Cuidados Intraoperatórios , Transplante de Fígado , Modelos Biológicos , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de RiscoRESUMO
BACKGROUND: In 2016, the World Health Organization (WHO) strongly recommended the use of a high fraction of inspired oxygen (FiO2) in adult patients undergoing general anaesthesia to reduce the risk of surgical site infection (SSI). Since then, further trials have been published, trials included previously have come under scrutiny, and one article was retracted. We updated the systematic review on which the recommendation was based. METHODS: We performed a systematic literature search from January 1990 to April 2018 for RCTs comparing the effect of high (80%) vs standard (30-35%) FiO2 on the incidence of SSI. Studies retracted or under investigation were excluded. A random effects model was used for meta-analyses; the sources of heterogeneity were explored using meta-regression. RESULTS: Of 21 RCTs included, six were newly identified since the publication of the WHO guideline review; 17 could be included in the final analyses. Overall, no evidence for a reduction of SSI after the use of high FiO2 was found [relative risk (RR): 0.89; 95% confidence interval (CI): 0.73-1.07]. There was evidence that high FiO2 was beneficial in intubated patients [RR: 0.80 (95% CI: 0.64-0.99)], but not in non-intubated patients [RR: 1.20 (95% CI: 0.91-1.58); test of interaction; P=0.048]. CONCLUSIONS: The WHO updated analyses did not show definite beneficial effect of the use of high perioperative FiO2, overall, but there was evidence of effect of reducing the SSI risk in surgical patients under general anaesthesia with tracheal intubation. However, the evidence for this beneficial effect has become weaker and the strength of the recommendation needs to be reconsidered.
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Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Oxigênio/administração & dosagem , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Humanos , Tempo de Internação , Resultado do TratamentoRESUMO
BACKGROUND: Evidence-based guidelines from the World Health Organization (WHO) have recommended a high (80%) fraction of inspired oxygen (FiO2) to reduce surgical site infection in adult surgical patients undergoing general anaesthesia with tracheal intubation. However, there is ongoing debate over the safety of high FiO2. We performed a systematic review to define the relative risk of clinically relevant adverse events (AE) associated with high FiO2. METHODS: We reviewed potentially relevant articles from the WHO review supporting the recommendation, including an updated (July 2018) search of EMBASE and PubMed for randomised and non-randomised controlled studies reporting AE in surgical patients receiving 80% FiO2 compared with 30-35% FiO2. We assessed study quality and performed meta-analyses of risk ratios (RR) comparing 80% FiO2 against 30-35% for major complications, mortality, and intensive care admission. RESULTS: We included 17 moderate-good quality trials and two non-randomised studies with serious-critical risk of bias. No evidence of harm with high FiO2 was found for major AE in the meta-analysis of randomised trials: atelectasis RR 0.91 [95% confidence interval (CI) 0.59-1.42); cardiovascular events RR 0.90 (95% CI 0.32-2.54); intensive care admission RR 0.93 (95% CI 0.7-1.12); and death during the trial RR 0.49 (95% CI 0.17-1.37). One non-randomised study reported that high FiO2 was associated with major respiratory AE [RR 1.99 (95% CI 1.72-2.31)]. CONCLUSIONS: No definite signal of harm with 80% FiO2 in adult surgical patients undergoing general anaesthesia was demonstrated and there is little evidence on safety-related issues to discourage its use in this population.
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Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Oxigênio/administração & dosagem , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Humanos , Tempo de Internação , Resultado do TratamentoRESUMO
INTRODUCTION: Little is known about the state of resuscitation services in low- and middle-income countries (LMICs), including Nigeria, Africa's most populous country. We sought to assess the cardiopulmonary resuscitation (CPR) care in referral hospitals across Nigeria to better inform capacity-building initiatives. METHODS: We designed a survey to evaluate infrastructure, equipment, personnel, training, and clinical management, as no standardized instrument for assessing resuscitation in LMICs was available. We included referral teaching hospitals with a functioning intensive care unit (ICU) and a department of anaesthesiology. We pilot-tested our tool at four hospitals in Nigeria and recruited participants electronically via the Nigerian Society of Anaesthetists directory. RESULTS: Our survey included 17 hospitals (82% public, 12% private, 6% public-private partnership), although some questions include only a subset of these. We found that 20% (3 out of 15) of hospitals had a cardiac arrest response team system, 21% (3/14) documented CPR events, and 21% (3/14) reviewed such events for education and quality improvement. Most basic supplies were sufficient in the ICU (100% [15/15] availability of defibrillators, 94% [16/17] of adrenaline) but were less available in other departments. While 67% [10/15] of hospitals had a resuscitation training program, only 27% [4/15] had at least half their physicians trained in basic life support. CONCLUSION: In this first large-scale assessment of resuscitation care in Nigeria, we found progress in training centre development and supply availability, but a paucity of cardiac arrest response team systems. Our data indicate a need for improved capacity development, especially in documentation and continuous quality improvement, both of which are low-cost solutions.
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Reanimação Cardiopulmonar/estatística & dados numéricos , Hospitais de Ensino/estatística & dados numéricos , Fortalecimento Institucional , Reanimação Cardiopulmonar/educação , Equipamentos e Provisões Hospitalares/estatística & dados numéricos , Feminino , Saúde Global , Pesquisas sobre Atenção à Saúde , Arquitetura Hospitalar , Hospitais de Ensino/organização & administração , Humanos , Unidades de Terapia Intensiva , Masculino , Nigéria , Encaminhamento e ConsultaRESUMO
BACKGROUND: Patients undergoing liver transplantation frequently but inconsistently require massive blood transfusion. The ability to predict massive transfusion (MT) could reduce the impact on blood bank resources through customization of the blood order schedule. Current predictive models of MT for blood product utilization during liver transplantation are not generally applicable to individual institutions owing to variability in patient population, intraoperative management, and definitions of MT. Moreover, existing models may be limited by not incorporating cirrhosis stage or thromboelastography (TEG) parameters. METHODS: This retrospective cohort study included all patients who underwent deceased-donor liver transplantation at the Johns Hopkins Hospital between 2010 and 2014. We defined MT as intraoperative transfusion of > 10 units of packed red blood cells (pRBCs) and developed a multivariable predictive model of MT that incorporated cirrhosis stage and TEG parameters. The accuracy of the model was assessed with the goodness-of-fit test, receiver operating characteristic analysis, and bootstrap resampling. The distribution of correct patient classification was then determined as we varied the model threshold for classifying MT. Finally, the potential impact of these predictions on blood bank resources was examined. RESULTS: Two hundred three patients were included in the study. Sixty (29.6%) patients met the definition for MT and received a median (interquartile range) of 19.0 (14.0-27.0) pRBC units intraoperatively compared with 4.0 units (1.0-6.0) for those who did not satisfy the criterion for MT. The multivariable model for predicting MT included Model for End-stage Liver Disease score, whether simultaneous liver and kidney transplant was performed, cirrhosis stage, hemoglobin concentration, platelet concentration, and TEG R interval and angle. This model demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test P = .45) and good discrimination (c statistic: 0.835; 95% confidence interval, 0.781-0.888). A probability cutoff threshold of 0.25 was found to misclassify only 4 of 100 patients as unlikely to experience MT, with the majority such misclassifications within 4 units of the working definition for MT. For this threshold, a preoperative blood ordering schedule that allocated 6 units of pRBCs for those unlikely to experience MT and 15 for those who were likely to experience MT would prevent unnecessary crossmatching of 338 units/100 transplants. CONCLUSIONS: When clinical and laboratory parameters are included, a model predicting intraoperative MT in patients undergoing liver transplantation is sufficiently accurate that its predictions could guide the blood order schedule for individual patients based on institutional data, thereby reducing the impact on blood bank resources. Ongoing evaluation of model accuracy and transfusion practices is required to ensure continuing performance of the predictive model.
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Bancos de Sangue/estatística & dados numéricos , Transfusão de Sangue/métodos , Transplante de Fígado/métodos , Algoritmos , Estudos de Coortes , Doença Hepática Terminal/sangue , Doença Hepática Terminal/cirurgia , Feminino , Humanos , Cuidados Intraoperatórios , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Valor Preditivo dos Testes , Estudos Retrospectivos , Tromboelastografia , Resultado do TratamentoRESUMO
Use of an anesthesia information management system (AIMS) has been reported to improve accuracy of recorded information. We tested the hypothesis that analyzing the distribution of times charted on paper and computerized records could reveal possible rounding errors, and that this effect could be modulated by differences in the user interface for documenting certain event times with an AIMS. We compared the frequency distribution of start and end times for anesthesia cases completed with paper records and an AIMS. Paper anesthesia records had significantly more times ending with "0" and "5" compared to those from the AIMS (p < 0.001). For case start times, AIMS still exhibited end-digit preference, with times whose last digits had significantly higher frequencies of "0" and "5" than other integers. This effect, however, was attenuated compared to that for paper anesthesia records. For case end times, the distribution of minutes recorded with AIMS was almost evenly distributed, unlike those from paper records that still showed significant end-digit preference. The accuracy of anesthesia case start times and case end times, as inferred by statistical analysis of the distribution of the times, is enhanced with the use of an AIMS. Furthermore, the differences in AIMS user interface for documenting case start and case end times likely affects the degree of end-digit preference, and likely accuracy, of those times.
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Anestesia , Monitorização Intraoperatória/instrumentação , Sistemas de Informação em Salas Cirúrgicas , Anestesiologia , Coleta de Dados , Registros Eletrônicos de Saúde , Humanos , Monitorização Intraoperatória/métodos , Salas Cirúrgicas , Reprodutibilidade dos Testes , Projetos de Pesquisa , Estudos Retrospectivos , Software , Fatores de Tempo , Interface Usuário-ComputadorRESUMO
BACKGROUND: Anesthesia is integral to improving surgical care in low-resource settings. Anesthesia providers who work in these areas should be familiar with the particularities associated with providing care in these settings, including the types and outcomes of commonly performed anesthetic procedures. METHODS: The authors conducted a retrospective analysis of anesthetic procedures performed at Médecins Sans Frontières facilities from July 2008 to June 2014. The authors collected data on patient demographics, procedural characteristics, and patient outcome. The factors associated with perioperative mortality were analyzed. RESULTS: Over the 6-yr period, 75,536 anesthetics were provided to adult patients. The most common anesthesia techniques were spinal anesthesia (45.56%) and general anesthesia without intubation (33.85%). Overall perioperative mortality was 0.25%. Emergent procedures (0.41%; adjusted odds ratio [AOR], 15.86; 95% CI, 2.14 to 115.58), specialized surgeries (2.74%; AOR, 3.82; 95% CI, 1.27 to 11.47), and surgical duration more than 6 h (9.76%; AOR, 4.02; 95% CI, 1.09 to 14.88) were associated with higher odds of mortality than elective surgeries, minor surgeries, and surgical duration less than 1 h, respectively. Compared with general anesthesia with intubation, spinal anesthesia, regional anesthesia, and general anesthesia without intubation were associated with lower perioperative mortality rates of 0.04% (AOR, 0.10; 95% CI, 0.05 to 0.18), 0.06% (AOR, 0.26; 95% CI, 0.08 to 0.92), and 0.14% (AOR, 0.29; 95% CI, 0.18 to 0.45), respectively. CONCLUSIONS: A wide range of anesthetics can be carried out safely in resource-limited settings. Providers need to be aware of the potential risks and the outcomes associated with anesthesia administration in these settings.
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Anestesia/economia , Recursos em Saúde/economia , Missões Médicas/economia , Assistência ao Paciente/economia , Médicos/economia , Adolescente , Adulto , Idoso , Anestesia/métodos , Anestesia/tendências , Feminino , Recursos em Saúde/tendências , Humanos , Masculino , Missões Médicas/tendências , Pessoa de Meia-Idade , Assistência ao Paciente/métodos , Assistência ao Paciente/tendências , Médicos/tendências , Estudos Retrospectivos , Fatores de Tempo , Adulto JovemRESUMO
OBJECTIVE: To determine hospital costs and the adjusted risk of death associated with emergent versus elective surgery. BACKGROUND: Emergency surgery has a higher cost and worse outcomes compared with elective surgery. However, no national estimates of the excess burden of emergency surgery exist. METHODS: Nationwide Inpatient Sample (NIS) data from 2001 to 2010 were analyzed. Patients aged 18 years or older who underwent abdominal aortic aneurysm repair, coronary artery bypass graft, or colon resection for neoplasm were included. Using generalized linear models with propensity scores, cost differences for emergent versus elective admission were calculated for each procedure. Multivariable logistic regression was performed to investigate the adjusted odds of mortality comparing elective and emergent cases. Discharge-level weights were applied to analyses. RESULTS: A total of 621,925 patients, representing a weighted population of 3,057,443, were included. The adjusted mean cost difference for emergent versus elective care was $8741.22 (30% increase) for abdominal aortic aneurysm repair, $5309.78 (17% increase) for coronary artery bypass graft, and $7813.53 (53% increase) for colon resection. If 10% of the weighted estimates of emergency procedures had been performed electively, the cost benefit would have been nearly $1 billion, at $996,169,160 (95% confidence interval [CI], $985,505,565-$1,006,834,104). Elective surgery patients had significantly lower adjusted odds of mortality for all procedures. CONCLUSIONS: Even a modest reduction in the proportion of emergent procedures for 3 conditions is estimated to save nearly $1 billion over 10 years. Preventing emergency surgery through improved care coordination and screening offers a tremendous opportunity to save lives and decrease costs.
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Aneurisma Aórtico/cirurgia , Colectomia/economia , Ponte de Artéria Coronária/economia , Procedimentos Cirúrgicos Eletivos/economia , Serviço Hospitalar de Emergência/economia , Custos de Cuidados de Saúde , Adulto , Idoso , Idoso de 80 Anos ou mais , Aneurisma Aórtico/economia , Neoplasias do Colo/economia , Neoplasias do Colo/cirurgia , Emergências/economia , Feminino , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estados Unidos , Adulto JovemRESUMO
BACKGROUND: Burn injury is an important yet under-researched area in Pakistan. The objective of this study was to determine the characteristics and associated outcomes of burn injury patients presenting to major emergency departments in Pakistan. METHODS: Pakistan National Emergency Department Surveillance (Pak-NEDS) was a pilot active surveillance conducted between November 2010 and March 2011. Information related to patient demographics, mode of arrival, cause of burn injury, and outcomes was analyzed for this paper. Data were entered using Epi Info and analyzed using SPSS v.20. Ethical approval was obtained from all participating sites. RESULTS: There were 403 burn injury patients in Pak-NEDS, with a male to female ratio 2:1. About 48.9% of the burn injury patients (n = 199) were between 10 - 29 years of age. There was no statistically significant difference between unintentional and intentional burn injury patients except for body part injured (p-value 0.004) and ED disposition (p-value 0.025). Among 21 patients who died, most were between 40 - 49 years of age (61.9%) and suffered from fire burns (81%). CONCLUSION: Burn injuries are a burden on emergency rooms in Pakistan. We were able to demonstrate the significant burden of burn injuries that is not addressed by specialized burn centers.
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Queimaduras/epidemiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Acidentes/estatística & dados numéricos , Adolescente , Adulto , Distribuição por Idade , Ambulâncias/estatística & dados numéricos , Criança , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Paquistão/epidemiologia , Vigilância da População , Distribuição por Sexo , Centros de Atenção Terciária/estatística & dados numéricos , Índices de Gravidade do Trauma , Violência/estatística & dados numéricos , Adulto JovemRESUMO
PURPOSE: To determine the incidence, characteristics, disposition, and economic burden of emergency department (ED) visits for ophthalmic trauma in the United States (US). DESIGN: Retrospective study. METHODS: The Nationwide Emergency Department Sample was used to calculate and characterize ED visits for ophthalmic trauma in the US from 2009 to 2018. Linear regression was used to estimate trends in annual incidence and mean inflation-adjusted ED charges. Logistic regression was used to assess variables associated with inpatient admission. RESULTS: There were over 7.3 million ED visits for ophthalmic trauma in the US over the 10 years, with an annual incidence of 233 per 100,000 population. Patients were predominantly male (65 %), 21-44 years old (39 %), and from low-income households (56 %). Only 1 % of patients were hospitalized. Older age, male sex, metropolitan teaching hospitals, and trauma centers were associated with significantly higher odds of inpatient admission. The mean inflation-adjusted ED charge per visit more than doubled over the decade ($1,333 to $3,187) with total charges exceeding $14 billion. Superficial injuries (44 %) and eyelid/orbit wounds (20 %) accounted for the majority of visits. Orbital floor fractures (4 %) and open globe injuries (2 %) accounted for a minority of visits but were responsible for most admissions (49 % and 29 %, respectively) and the highest mean ED charge ($7,157 and $6,808, respectively). CONCLUSIONS: Ophthalmic trauma represents an increasingly significant burden to EDs in the US. Preventive efforts should target young males from low socioeconomic backgrounds. Strategies to improve outpatient access and redirect non-urgent injuries may help alleviate costs.
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Serviço Hospitalar de Emergência , Traumatismos Oculares , Humanos , Masculino , Estados Unidos/epidemiologia , Adulto Jovem , Adulto , Feminino , Estudos Retrospectivos , Traumatismos Oculares/epidemiologia , Traumatismos Oculares/terapia , Hospitalização , Centros de TraumatologiaRESUMO
OBJECTIVE: To assess if limiting elective surgeries during specific pandemic phases significantly affected COVID-19 incidence among operating room (OR) staff. STUDY DESIGN: Retrospective cohort study. Place and Duration of the Study: Operation Theatre (OT), The Aga Khan University Hospital, Karachi, Pakistan, from May 2020 to 2021. METHODOLOGY: This retrospective study compared two pandemic waves: Wave 1, during which elective surgeries were restricted (REL), and Wave 2, during which elective surgeries were continued routinely (EL). Exposure levels were measured based on OR activity. Incidence rates were calculated per 100 OR staff, per 100 ORs, and per 100 surgeries for both Groups. RESULTS: No statistically significant difference emerged in COVID-19 incidence among OR staff between REL (13.8 per 100 staff) and EL (14.4 per 100 staff) Groups (p = 0.825). However, the EL Group exhibited a significantly lower incidence risk per running OR (5.6 per 100 ORs vs. REL's 12 per 100 ORs, p <0.001). Additionally, the EL Group showed a lower incidence per 100 surgeries (1.5 vs. REL's 2.9, p <0.002). CONCLUSION: Restricting elective surgeries during the early pandemic phase did not significantly reduce COVID-19 incidence among OR staff. Infections were primarily linked to interactions with colleagues and the community, emphasising the need for a balanced pandemic response considering patient care and the consequences of surgery restrictions. KEY WORDS: COVID-19 infection, Operating room staff, COVID-19 waves, COVID-19 transmission, Hospital epidemiology, Pandemic response.
Assuntos
COVID-19 , Procedimentos Cirúrgicos Eletivos , Salas Cirúrgicas , SARS-CoV-2 , Centros de Atenção Terciária , Humanos , COVID-19/prevenção & controle , COVID-19/epidemiologia , COVID-19/transmissão , Paquistão/epidemiologia , Estudos Retrospectivos , Incidência , Controle de Infecções/métodos , Masculino , Feminino , Adulto , Pandemias , Pessoal de SaúdeRESUMO
INTRODUCTION: Improvement in burn injury data collections and the quality of databanks has allowed meaningful study of the epidemiologic trends in burn care. The study assessed factors associated with disposition of burn injury patients from emergency department accounting for pre-hospital care and emergency care. METHODS: This prospective observational pilot study of the South Asia Burn Registry project was conducted at selected public sector burn centers in Bangladesh and Pakistan (September 2014 - January 2015). All age groups with an initial presentation to the burn centers were enrolled. Descriptive and regression analysis is presented. RESULTS: A total of 2749 patients were enrolled. The mean age was 21.7 ± 18.0 years, 55.3% were males, and about a quarter were children < 5 years. About 46.9% of the females were housewives. Scald burns were common among children (67.6%) while flame burns were common among adults (44.3%). About 75% of patients were brought in via non-ambulance mode of transport. More than 55% of patients were referrals from other facilities or clinics. The most common first aid given pre-hospital was the use of water or oil. About 25% were admitted for further care. The adjusted odds of being admitted compared to being sent home were highest for children < 5 yrs, those with higher total body surface area burnt, having arrived via ambulance, scald and electrical burn, having an associated injury and inhalational injury. CONCLUSION: The study provides insight into emergency burn care and associated factors that influenced outcomes for patients with burn injuries.