A qualitative study examining the health system's response to COVID-19 in Sierra Leone.

The paper examines the health system's response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013-16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients' experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients' livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

Access to quality care after injury in Northern Malawi: results of a household survey.

BACKGROUND: Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury. METHODS: We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked. RESULTS: Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142). CONCLUSION: Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.

Novel application of multi-facility process map analysis for rapid injury care health system assessment in Northern Malawi.

OBJECTIVES: We used the process mapping method and Three Delays framework, to identify and visually represent the relationship between critical actions, decisions and barriers to access to care following injury in the Karonga health system, Northern Malawi. DESIGN: Facilitated group process mapping workshops with summary process mapping synthesis. SETTING: Process mapping workshops took place in 11 identified health system facilities (one per facility) providing injury care for a population in Karonga, Northern Malawi. PARTICIPANTS: Fifty-four healthcare workers from various cadres took part. RESULTS: An overall injury health system summary map was created using those categories of action, decision and barrier that were sometimes or frequently reported. This provided a visual summary of the process following injury within the health system. For Delay 1 (seeking care) four barriers were most commonly described (by 8 of 11 facilities) these were 'cultural norms', 'healthcare literacy', 'traditional healers' and 'police processes'. For Delay 2 (reaching care) the barrier most frequently described was 'transport'-a lack of timely affordable emergency transport (formal or informal) described by all 11 facilities. For Delay 3 (receiving quality care) the most commonly reported barrier was that of 'physical resources' (9 of 11 facilities). CONCLUSIONS: We found our novel approach combining several process mapping exercises to produce a summary map to be highly suited to rapid health system assessment identifying barriers to injury care, within a Three Delays framework. We commend the approach to others wishing to conduct rapid health system assessments in similar contexts.

Strengthening ethics committees for health-related research in sub-Saharan Africa: a scoping review.

OBJECTIVE: Health-related research in sub-Saharan Africa (SSA) has grown over the years. However, concerns have been raised about the state of research ethics committees (RECs). This scoping review examines the literature on RECs for health-related research in SSA and identifies strategies that have been applied to strengthen the RECs. It focuses on three aspects of RECs: regulatory governance and leadership, administrative and financial capacity and technical capacity of members. DESIGN: A scoping review of published literature, including grey literature, was conducted using the Joanna Briggs Institute approach. DATA SOURCES: BioOne, CINAHL, Embase (via Ovid), Education Abstracts, Global Health, Google Scholar, Jstor, OpenEdition (French), Philosopher's Index, PsycINFO, PubMed, Science Citation and Expanded Index (Web of Science), reference lists of included studies and specific grey literature sources. ELIGIBILITY CRITERIA: We included empirical studies on RECs for health-related research in SSA, covering topics on REC leadership and governance, administrative and financial capacity and the technical capacity of REC members. We included studies published between 01 January 2000 and 18 February 2022 and written in English, French, Portuguese or Swahili. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened the records. Data were extracted by one reviewer and cross-checked by another. Owing to the heterogeneity of included studies, thematic analysis was used. RESULTS: We included 54 studies. The findings show that most RECs in SSA work under significant administrative and financial constraints, with few opportunities for capacity building for committee members. This has an impact on the quality of reviews and the overall performance of RECs. Although most countries have national governance systems for RECs, they lack regulations on accountability, transparency and monitoring of RECs. CONCLUSIONS: This review provides a comprehensive overview of the literature on RECs for health-related research in SSA and contributes to our understanding of how RECs can be strengthened.

Access to care following injury in Northern Malawi, a comparison of travel time estimates between Geographic Information System and community household reports.

INTRODUCTION: Injuries disproportionately impact low- and middle-income countries like Malawi. The Lancet Commission on Global Surgery's indicators include the population proportion accessing laparotomy and open fracture care, key trauma interventions, within two hours. The "Golden Hour" for receiving facility-based resuscitation also guides injury care system strengthening. Firstly, we estimated the proportion of the local population able to reach primary, secondary and tertiary facility care within two and one hours using Geographic Information System (GIS) analysis. Secondly, we compared community household-reported with GIS-estimated travel time. METHODS: Using information from a Health and Demographic Surveillance Site (Karonga, Malawi) on road network, facility location, and local staff-estimated travel speeds, we used a GIS-generated friction surface to calculate the shortest travel time from all households to each facility serving the population. We surveyed community households who reported travel time to their preferred, closest, government secondary and tertiary facilities. For recently injured community members, time to reach facility care was recorded. To assess the relationship between community household-reported travel time and GIS-estimated travel time, we used linear regression to generate a proportionality constant. To assess associations and agreement between injured patient-reported and GIS-estimated travel time, we used Kendall rank and Cohen's kappa tests. RESULTS: Using GIS, we estimated 79.1% of households could reach any secondary facility, 20.5% the government secondary facility, and 0% the government tertiary facility, within two hours. Only 28.2% could reach any secondary facility within one hour, 0% for the government secondary facility. Community household-reported travel time exceeded GIS-estimated travel time. The proportionality constant was 1.25 (95%CI 1.21-1.30) for the closest facility, 1.28 (95%CI 1.23-1.34) for the preferred facility, 1.45 (95%CI 1.33-1.58) for the government secondary facility, and 2.12 (95%CI 1.84-2.41) for tertiary care. Comparing injured patient-reported with GIS-estimated travel time, the correlation coefficient was 0.25 (SE 0.047) and Cohen's kappa was 0.15 (95%CI 0.078-0.23), suggesting poor agreement. DISCUSSION: Most households couldn't reach government secondary care within recognised thresholds indicating poor temporal access. Since GIS-estimated travel time was shorter than community-reported travel time, the true proportion may be lower still. GIS derived estimates of population emergency care access in similar contexts should be interpreted accordingly.

Economic Case for Scale-up of the WHO Surgical Safety Checklist at the National Level in Sub-Saharan Africa.

OBJECTIVES: To evaluate the economic case for nationwide scale-up of the World Health Organization (WHO) Surgical Safety Checklist using cost-effectiveness and benefit-cost analyses. BACKGROUND: The Checklist improves surgical outcomes but the economic case for widespread use remains uncertain. For perioperative quality improvement interventions to compete successfully against other worthwhile health and nonhealth interventions for limited government resources they must demonstrate cost-effectiveness and positive societal benefit. METHODS: Using data from 3 countries, we estimated the benefits as the total years of life lost (YLL) due to postoperative mortality averted over a 3 year period; converted the benefits to dollar equivalent values using estimates of the economic value of an additional year of life expectancy; estimated total implementation costs; and determined incremental cost-effectiveness ratio (ICER) and benefit-cost ratio (BCR). Costs are reported in international dollars using Word Bank purchasing power parity conversion factors at 2016 price-levels. RESULTS: In Benin, Cameroon, and Madagascar ICERs were: $31, $138, and $118 per additional YLL averted; and BCRs were 62, 29, and 9, respectively. Sensitivity analysis demonstrated that the associated mortality reduction and increased usage due to Checklist scale-up would need to deviate approximately 10-fold from published data to change our main interpretations. CONCLUSIONS: According to WHO criteria, Checklist scale-up is considered "very cost-effective" and for every $ 1 spent the potential return on investment is $9 to $62. These results compare favorably with other health and nonhealth interventions and support the economic argument for investing in Checklist scale-up as part of a national strategy for improving surgical outcomes.

Use of Feedback Data to Reduce Surgical Site Infections and Optimize Antibiotic Use in Surgery: A Systematic Scoping Review.

OBJECTIVE: Surgical site infection (SSI) prevention remains significant, particularly in the era of antimicrobial resistance. Feedback on practices and outcomes is known to be key to reduce SSI rates and optimize antibiotic usage. However, the optimal method, format and frequency of feedback for surgical teams remains unclear. The objective of the study is to understand how data from surveillance and audit are fed back in routine surgical practice. METHODS: A systematic scoping review was conducted, using well-established implementation science frameworks to code the data. Two electronic health-oriented databases (MEDLINE, EMBASE) were searched to September 2019. We included studies that assessed the use of feedback as a strategy either in the prevention and management of SSI and/or in the use of antibiotics perioperatively. RESULTS: We identified 21 studies: 17 focused on SSI rates and outcomes and 10 studies described antimicrobial stewardship for SSI (with some overlap in focus). Several interventions were reported, mostly multimodal with feedback as a component. Feedback was often provided in written format (62%), either individualized (38%) or in group (48%). Only 25% of the studies reported that feedback cascaded down to the frontline perioperative staff. In 65% of the studies, 1 to 5 implementation strategies were used while only 5% of the studies reported to have utilized more than 15 implementation strategies. Among studies reporting antibiotic usage in surgery, most (71%) discussed compliance with surgical antibiotic prophylaxis. CONCLUSIONS: Our findings highlight the need to provide feedback to all levels of perioperative care providers involved in patient care. Future research in this area should report implementation parameters in more detail.

Surgical Antibiotic Prophylaxis in an Era of Antibiotic Resistance: Common Resistant Bacteria and Wider Considerations for Practice.

The increasing incidence of antimicrobial resistance (AMR) presents a global crisis to healthcare, with longstanding antimicrobial agents becoming less effective at treating and preventing infection. In the surgical setting, antibiotic prophylaxis has long been established as routine standard of care to prevent surgical site infection (SSI), which remains one of the most common hospital-acquired infections. The growing incidence of AMR increases the risk of SSI complicated with resistant bacteria, resulting in poorer surgical outcomes (prolonged hospitalisation, extended durations of antibiotic therapy, higher rates of surgical revision and mortality). Despite these increasing challenges, more data are required on approaches at the institutional and patient level to optimise surgical antibiotic prophylaxis in the era of antibiotic resistance (AR). This review provides an overview of the common resistant bacteria encountered in the surgical setting and covers wider considerations for practice to optimise surgical antibiotic prophylaxis in the perioperative setting.

Conceptualising sustainability in the surgical work of non-governmental organisations in low and middle-income countries : a scoping review protocol.

INTRODUCTION: Sustainability remains poorly defined in global surgery, yet is, nevertheless, crucial to the work of non-governmental organisations (NGOs) in low- and middle-income countries (LMICs) aimed at strengthening access to, and quality of, surgical and anaesthesia care. The objective of this protocol is to outline a scoping review that maps what is known in the literature about sustainability in NGO surgical work in LMICs. METHODS: The application of Arksey and O'Malley's six-stage methodological framework is described: identifying research questions; identifying relevant publications; selecting publications; charting the data; reporting results; and stakeholder consultation. The review will include all study designs, as well as editorials, commentaries, sources of unpublished studies and grey literature. Three electronic databases will be searched. Two reviewers will use predefined and iteratively refined selection criteria based on the 'Population-Concept-Context' framework to independently screen titles and abstracts of citations from the search. Disagreements will be resolved together by the reviewers. Full-text screening will also be carried out independently by two reviewers. Disagreements at this stage will be resolved with a third party. The search strategy for grey literature will include searching in ProQuest Dissertations and Theses and the websites listed in a surgical NGO database. Further relevant citations will be identified by screening the reference lists of the included papers. ETHICS AND DISSEMINATION: This review will undertake a secondary analysis of data already collected and does not require ethical approval. The results will be disseminated through journals and conferences targeting surgical NGO stakeholders and global health academics.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

BACKGROUND: Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. RESULTS: For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. CONCLUSION: Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone.

INTRODUCTION: The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone. METHODS: Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis. RESULTS: From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. CONCLUSION: The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.

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.

Assessing trauma care systems in low-income and middle-income countries: a systematic review and evidence synthesis mapping the Three Delays framework to injury health system assessments.

BACKGROUND: The large burden of injuries falls disproportionately on low/middle-income countries (LMICs). Health system interventions improve outcomes in high-income countries. Assessing LMIC trauma systems supports their improvement. Evaluating systems using a Three Delays framework, considering barriers to seeking (Delay 1), reaching (Delay 2) and receiving care (Delay 3), has aided maternal health gains. Rapid assessments allow timely appraisal within resource and logistically constrained settings. We systematically reviewed existing literature on the assessment of LMIC trauma systems, applying the Three Delays framework and rapid assessment principles. METHODS: We conducted a systematic review and narrative synthesis of articles assessing LMIC trauma systems. We searched seven databases and grey literature for studies and reports published until October 2018. Inclusion criteria were an injury care focus and assessment of at least one defined system aspect. We mapped each study to the Three Delays framework and judged its suitability for rapid assessment. RESULTS: Of 14 677 articles identified, 111 studies and 8 documents were included. Sub-Saharan Africa was the most commonly included region (44.1%). Delay 3, either alone or in combination, was most commonly assessed (79.3%) followed by Delay 2 (46.8%) and Delay 1 (10.8%). Facility assessment was the most common method of assessment (36.0%). Only 2.7% of studies assessed all Three Delays. We judged 62.6% of study methodologies potentially suitable for rapid assessment. CONCLUSIONS: Whole health system injury research is needed as facility capacity assessments dominate. Future studies should consider novel or combined methods to study Delays 1 and 2, alongside care processes and outcomes.

Improving nursing documentation for surgical patients in a referral hospital in Freetown, Sierra Leone: protocol for assessing feasibility of a pilot multifaceted quality improvement hybrid type project.

BACKGROUND: There is an urgent need to improve quality of care to reduce avoidable mortality and morbidity from surgical diseases in low- and middle-income countries. Currently, there is a lack of knowledge about how evidence-based health system strengthening interventions can be implemented effectively to improve quality of care in these settings. To address this gap, we have developed a multifaceted quality improvement intervention to improve nursing documentation in a low-income country hospital setting. The aim of this pilot project is to test the intervention within the surgical department of a national referral hospital in Freetown, Sierra Leone. METHODS: This project was co-developed and co-designed by in-country stakeholders and UK-based researchers, after a multiple-methodology assessment of needs (qualitative, quantitative), guided by a participatory 'Theory of Change' process. It has a mixed-method, quasi-experimental evaluation design underpinned by implementation and improvement science theoretical approaches. It consists of three distinct phases-(1) pre-implementation(project set up and review of hospital relevant policies and forms), (2) intervention implementation (awareness drive, training package, audit and feedback), and (3) evaluation of (a) the feasibility of delivering the intervention and capturing implementation and process outcomes, (b) the impact of implementation strategies on the adoption, integration, and uptake of the intervention using implementation outcomes, (c) the intervention's effectiveness For improving nursing in this pilot setting. DISCUSSION: We seek to test whether it is possible to deliver and assess a set of theory-driven interventions to improve the quality of nursing documentation using quality improvement and implementation science methods and frameworks in a single facility in Sierra Leone. The results of this study will inform the design of a large-scale effectiveness-implementation study for improving nursing documentation practices for patients throughout hospitals in Sierra Leone. TRIAL REGISTRATION: Protocol version number 6, date: 24.12.2020, recruitment is planned to begin: January 2021, recruitment will be completed: December 2021.

Development and use of clinical vignettes to assess injury care quality in Northern Malawi.

BACKGROUND: It is known that outcomes after injury care in low-and-middle income countries (LMICs) are poorer than those in high income countries. However, little is known about healthcare provider competency to deliver quality injury care in these settings. We developed and used clinical vignettes to evaluate injury care quality in an LMIC setting. METHOD: Four serious injury scenarios, developed from agreed best practice, testing diagnostic and management skills, were piloted with high and low-income setting clinicians. Scenarios were used with primary and referral facility clinicians in Malawi. Participants described their clinical course of action (assessment, diagnostic, treatment and management approaches) for each scenario, registering one point per agreed best practice response. Mean percentage total scores were calculated and univariable and multivariable comparison made across provider groups, facility types, injury care frequency and training level. RESULTS: Fourteen Doctors, 51 Clinical Officers, 20 Medical Assistants from 11 facilities participated. Mean percentage total vignette scores varied significantly with clinician provider group (Doctors 63.1% vs Clinical Officers 49.6%, p<0.001, Clinical Officers vs Medical Assistants 39.4% p=0.001). Important care aspects most frequently included or omitted were: following chest injury, 88.2% reported chest drain insertion, 7.1% checked for tracheal deviation; following penetrating abdominal injury and shock, 98.8% secured IV access, 0% mentioned tranexamic acid; following severe head injury, 88.2% proposed CT or neurosurgical transfer, 7.1% ensured normotension; and following isolated open lower leg fracture, 90.1% arranged orthopaedic consultation, 2.4% assessed distal neurological status. CONCLUSION: These clinical vignettes proved easy to use and collected rich data. This supports their use for assessing and monitoring clinical care quality in other similar settings.

Implementation Strategies and the Uptake of the World Health Organization Surgical Safety Checklist in Low and Middle Income Countries: A Systematic Review and Meta-analysis.

OBJECTIVES: To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact. BACKGROUND: The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood. METHODS: We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034). RESULTS: We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52). CONCLUSIONS: The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community.

Staff recognition and its importance for surgical service delivery: a qualitative study in Freetown, Sierra Leone.

We examined the views of providers and users of the surgical system in Freetown, Sierra Leone on processes of care, job and service satisfaction and barriers to achieving quality and accessible care, focusing particularly on the main public tertiary hospital in Freetown and two secondary and six primary sites from which patients are referred to it. We conducted interviews with health care providers (N = 66), service users (n = 24) and people with a surgical condition who had chosen not to use the public surgical system (N = 13), plus two focus groups with health providers in primary care (N = 10 and N = 10). The overall purpose of the study was to understand perceptions on processes of and barriers to care from a variety of perspectives, to recommend interventions to improve access and quality of care as part of a larger study. Our research suggests that providers perceive their relationships with patients to be positive, while the majority of patients see the opposite: that many health workers are unapproachable and uncaring, particularly towards poorer patients who are unable or unwilling to pay staff extra in the form of informal payments for their care. Many health care providers note the importance of lack of recognition shown to them by their superiors and the health system in general. We suggest that this lack of recognition underlies poor morale, leading to poor care. Any intervention to improve the system should therefore consider staff-patient relations as a key element in its design and implementation, and ideally be led and supported by frontline healthcare workers.

Perinatal outcomes of cesarean deliveries in Sierra Leone: A prospective multicenter observational study.

OBJECTIVE: To analyze the indications for cesarean deliveries and factors associated with adverse perinatal outcomes in Sierra Leone. METHODS: Between October 2016 and May 2017, patients undergoing cesarean delivery performed by medical doctors and associate clinicians in nine hospitals were included in a prospective observational study. Data were collected perioperatively, at discharge, and during home visits after 30 days. RESULTS: In total, 1274 cesarean deliveries were included of which 1099 (86.3%) were performed as emergency surgery. Of the 1376 babies, 261 (19.0%) were perinatal deaths (53 antepartum stillbirths, 155 intrapartum stillbirths, and 53 early neonatal deaths). Indications with the highest perinatal mortality were uterine rupture (45 of 55 [81.8%]), abruptio placentae (61 of 85 [71.8%]), and antepartum hemorrhage (8 of 15 [53.3%]). In the group with cesarean deliveries performed for obstructed and prolonged labor, a partograph was filled out for 212 of 425 (49.9%). However, when completed, babies had 1.81-fold reduced odds for perinatal death (95% confidence interval 1.03-3.18, P-value 0.041). CONCLUSION: Cesarean deliveries in Sierra Leone are associated with an exceptionally high perinatal mortality rate of 190 per 1000 births. Late presentation in the facilities and lack of adequate fetal monitoring may be contributing factors.

Task-Sharing for Emergency Neurosurgery: A Retrospective Cohort Study in the Philippines.

OBJECTIVE: The safety and effectiveness of task-sharing (TS) in neurosurgery, delegating clinical roles to non-neurosurgeons, is not well understood. This study evaluated an ongoing TS model in the Philippines, where neurosurgical workforce deficits are compounded with a large neurotrauma burden. METHODS: Medical records from emergency neurosurgical admissions to 2 hospitals were reviewed (January 2015-June 2018): Bicol Medical Center (BMC), a government hospital in which emergency neurosurgery is chiefly performed by general surgery residents (TS providers), and Mother Seton Hospital, an adjacent private hospital where neurosurgery consultants are the primary surgeons. Univariable and multivariable linear and logistic regression compared provider-associated outcomes. RESULTS: Of 214 emergency neurosurgery operations, TS providers performed 95 and neurosurgeons, 119. TS patients were more often male (88.4% vs. 73.1%; P = 0.007), younger (mean age, 27.6 vs. 50.5 years; P < 0.001), and had experienced road traffic accidents (69.1% vs. 31.4%; P < 0.001). There were no significant differences between Glasgow Coma Scale (GCS) scores on admission. Provider type was not associated with mortality (neurosurgeons, 20.2%; TS, 17.9%; P = 0.68), reoperation, or pneumonia. No significant differences were observed for GCS improvement between admission and discharge or in-hospital GCS improvement, including or excluding inpatient deaths. TS patients had shorter lengths of stay (17.3 days vs. 24.4 days; coefficient, -6.67; 95% confidence interval, -13.01 to -0.34; P < 0.05) and were more likely to undergo tracheostomy (odds ratio, 3.1; 95% confidence interval, 1.30-7.40; P = 0.01). CONCLUSIONS: This study, one of the first to examine outcomes of neurosurgical TS, shows that a strategic TS model for emergency neurosurgery produces comparable outcomes to the local neurosurgeons.

Using the Knowledge to Action Framework to Describe a Nationwide Implementation of the WHO Surgical Safety Checklist in Cameroon.

BACKGROUND: Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention. METHODS: A collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams' reactions, learning and behavior change; and tertiary outcomes were perioperative teams' acceptability of the checklist. RESULTS: Three hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5-5.5, range 3-7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16-25) to 56% (95% CI, 49-63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87-95); risk assessment for difficult intubation was 79% (95% CI, 73-85): risk assessment for blood loss was 88% (95% CI, 83-93) use of pulse oximetry was 93% (95% CI, 90-97); antibiotic administration was 95% (95% CI, 91-98); surgical counting was 89% (95% CI, 84-93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5-5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%. CONCLUSIONS: This study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.