Single incision laparoscopic surgery from a caribbean perspective.

Conventional laparoscopy with multiple ports has recently gained a strong foothold in the Caribbean, but single incision laparoscopic surgery (SILS) has lagged behind. In this paper, we compare the data on SILS and conventional multi-port laparoscopy in the English-speaking Caribbean.

The economic impact of hospitalization for diabetic foot infections in a Caribbean nation.

CONTEXT: Foot infection is the most common complication of diabetes mellitus in the Caribbean. Diabetic foot infections place a heavy burden on health care resources in the Caribbean. OBJECTIVE: To evaluate the treatment-related costs for diabetic foot infections in a Caribbean nation. METHODS: We identified all patients with diabetic foot infections in a 730-bed hospital serving a catchment population of approximately 400,000 persons from June 1, 2011 through July 31, 2012. The following data were collected: details of infection, antibiotic usage, investigations performed, number of physician consultations, details of operative treatment, and duration of hospitalization. Total charges were tallied to determine the final cost for inhospital treatment of diabetic foot infections. RESULTS: There were 446 patients hospitalized with diabetic foot infections, yielding approximately 0.75% annual risk for patients with diabetes to develop foot infections. The mean duration of hospitalization was 22.5 days. Sixteen patients (3.6%) were treated conservatively without an operative procedure and 430 (96.4%) required some form of operative intervention. There were 885 debridements, 193 minor amputations and 60 major amputations, 7102 wound dressings, 2763 wound cultures, and 27,015 glucometer measurements. When the hospital charges were tallied, a total of US $13,922,178 (mean, US $31,216) were spent to treat diabetic foot infections in these 446 patients during 1 year at this hospital. CONCLUSIONS: Each year, the government of Trinidad and Tobago spends US $85 million, or 0.4% of their gross domestic product, solely to treat patients hospitalized for diabetic foot infections. With this level of national expenditure and the anticipated increase in the prevalence of diabetes, it is necessary to revive the call for investment in preventive public health strategies.

Infection control practice in the operating room: staff adherence to existing policies in a developing country.

CONTEXT: Infection control interventions are important for containing surgery-related infections. For this reason, the modern operating room (OR) should have well-developed infection control policies. The efficacy of these policies depends on how well the OR staff adhere to them. There is a lack of available data documenting adherence to infection control policies. OBJECTIVE: To evaluate OR staff adherence to existing infection control policies in Jamaica. METHODS: We administered a questionnaire to all OR staff to assess their training, knowledge of local infection control protocols, and practice with regard to 8 randomly selected guidelines. Adherence to each guideline was rated with fixed-choice items on a 4-point Likert scale. The sum of points determined the adherence score. Two respondent groups were defined: adherent (score > 26) and nonadherent (score ≤ 26). We evaluated the relationship between respondent group and age, sex, occupational rank, and time since completion of basic medical training. We used χ(2) and Fisher exact tests to assess associations and t tests to compare means between variables of interest. RESULTS: The sample comprised 132 participants (90 physicians and 42 nurses) with a mean age of 36 (standard deviation ± 9.5) years. Overall, 40.1% were adherent to existing protocols. There was no significant association between the distribution of adherence scores and sex (p = 0.319), time since completion of basic training (p = 0.595), occupational rank (p = 0.461), or age (p = 0.949).Overall, 19% felt their knowledge of infection control practices was inadequate. Those with working knowledge of infection control practices attained it mostly through informal communication (80.4%) and self-directed research (62.6%). CONCLUSION: New approaches to the problem of nonadherence to infection control guidelines are needed in the Caribbean. Several unique cultural, financial, and environmental factors influence adherence in this region, in contrast to conditions in developed countries.

From the patient's perspective: is there a need to improve the quality of informed consent for surgery in training hospitals?

OBJECTIVE: This study was performed to evaluate the presurgical informed consent process at a training hospital in Jamaica. METHODS: A postoperative survey was administered to all consecutive able and willing adult patients who underwent the presurgical informed consent process with surgical residents during a 5-week period. Information was collected on patient demographics and patients' perception and satisfaction with the informed consent process. RESULTS: There were 210 surveys completed. Patients were unaware of the training status of the physician involved with their presurgical informed consent process in 48% of cases. Nineteen (9%) patients were instructed to sign a consent document without any discussion. An attempt was made to secure a signature after some discussion with the remaining 191 patients. Patients reported that details of the operation were discussed 74% of the time; potential benefits of the surgery, 72% of the time; potential morbidity, 84% of the time; potential mortality, 19% of the time; predicted postoperative course, 49% of the time; projected recovery, 26% of the time; and other treatment options, 33% of the time. Forty-five patients believed that they were instructed to sign the consent document with minimal discussion. At termination of the consent process, only 70% of the 210 patients reported that they signed the consent form voluntarily. Overall, 67% of patients thought the current informed consent process was unsatisfactory. CONCLUSION: The current informed consent process in use in the surgical training program at the University Hospital of the West Indies requires improvement to meet expected ethical and legal standards.

Cost-benefit comparison of hemodialysis access creation in a developing country and North American centres.

OBJECTIVE: It has been suggested that vascular access operations should only be performed in high-volume centres to ensure good outcomes. Vascular access operations have been routinely performed in the Cayman Islands since 2005. However, with an estimated population of 45,000 persons, only a small number of patients require vascular access in any given interval. A cost-benefit analysis of this practice was performed. METHODS: All patients who had vascular access operations over four years were retrospectively identified. Two groups were defined - the local group, who had operations performed by surgeons in the Cayman Islands, and the offshore group, who were transferred off the island and had operations overseas. Cumulative cost, morbidity, patency and failure rates were compared. Significance was considered present with a two-tailed P≤0.05. RESULTS: There were 14 patients in the local group and 22 in the offshore group. The mean cost of access creation was 6.9 times greater in the offshore group (US$26,883.36 versus US$3,913.33; P<0.001). The likelihood of the use of arteriovenous grafts was significantly greater in the offshore group (P=0.04). When therapeutic outcomes were compared, there were no differences in primary or secondary failure, primary or secondary patency, or overall access-specific morbidity. CONCLUSIONS: In the present setting, vascular access creation exceeded all the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. Compared with overseas centres, this is being achieved at a significantly lower cost, with a greater likelihood of native fistula use and similar therapeutic outcomes.

Occupational hazard: treating cocaine body packers in Caribbean countries.

Body packing is a common method of smuggling cocaine where individuals ingest several drug-filled parcels for transport. When identified by the authorities, body packers are usually taken to hospital for evaluation. There are several points during management of these patients when the health care team may be placed at risk. We explore the hazards encountered during the management of these patients in developing Caribbean nations.