Safety, productivity and predicted contribution of a surgical task-sharing programme in Sierra Leone.

BACKGROUND: Surgical task-sharing may be central to expanding the provision of surgical care in low-resource settings. The aims of this paper were to describe the set-up of a new surgical task-sharing training programme for associate clinicians and junior doctors in Sierra Leone, assess its productivity and safety, and estimate its future role in contributing to surgical volume. METHODS: This prospective observational study from a consortium of 16 hospitals evaluated crude in-hospital mortality over 5 years and productivity of operations performed during and after completion of a 3-year surgical training programme. RESULTS: Some 48 trainees and nine graduated surgical assistant community health officers (SACHOs) participated in 27 216 supervised operations between January 2011 and July 2016. During training, trainees attended a median of 822 operations. SACHOs performed a median of 173 operations annually. Caesarean section, hernia repair and laparotomy were the most common procedures during and after training. Crude in-hospital mortality rates after caesarean sections and laparotomies were 0·7 per cent (13 of 1915) and 4·3 per cent (7 of 164) respectively for operations performed by trainees, and 0·4 per cent (5 of 1169) and 8·0 per cent (11 of 137) for those carried out by SACHOs. Adjusted for patient sex, surgical procedure, urgency and hospital, mortality was lower for operations performed by trainees (OR 0·47, 95 per cent c.i. 0·32 to 0·71; P < 0·001) and SACHOs (OR 0·16, 0·07 to 0·41; P < 0·001) compared with those conducted by trainers and supervisors. CONCLUSION: SACHOs rapidly and safely achieved substantial increases in surgical volume in Sierra Leone.

Assessment of caesarean section and inguinal hernia repair as proxy indicators of total number of surgeries.

BACKGROUND: The traditional instruments used to assess surgical capacity in low-income countries require substantial amounts of time and resources, and have thus not been systematically used in this context. Proxy indicators have been suggested as a simpler method to estimate surgical volume. The aim of this study was to assess caesarean section and inguinal hernia repair as proxy indicators of the total number of surgeries performed per capita in a given region in Sierra Leone in sub-Saharan Africa. METHODS: Avaliable handwritten surgical data were compiled from 58 (96·7%) health institutions that performed WHO defined major surgery in Sierra Leone in 2012 (from Jan 1, to Dec 31). 24 152 surgical procedures were included in the study. Validity of proxy indicators was tested by logistic regression analyses with the rate of caesarean sections compared with total operations (% CS), hernia repairs (% HR), or both (% CS plus HR) as dependent variables and the operations per 100 000 capita as the covariate. FINDINGS: The number of operations per 100 000 capita for the 13 districts of Sierra Leone varied from 909 in the urban Western District to 32 in the rural district of Moyamba. There was a significant negative correlation between each of the proxy indicators and the number of operations per 100 000 capita. For changes in the operations per 100 000 capita of 100, we obtained an estimated odds ratio for the % CS proxy indicator of 0·675 (95% CI 0·520-0·876; p<0·01), % HR being 0·822 (0·688-0·983; p<0·05), and for % CS plus HR being 0·838 (0·731-0·962; p<0·05). INTERPRETATION: The unmet need for surgical services in Sierra Leone can be estimated by either of the three proxy indicators. However, it seems that % CS is more sensitive to small changes in operations per 100 000 capita compared with the % HR. There is no obvious added benefit of use of the combined proxy indicator. Although this study shows that proxy indicators are a promising method to evaluate surgical activity, this is a cross-sectional study and can thus only show correlation. Longitudinal studies would strengthen these findings. FUNDING: Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway, and CapaCare.

Surgery in the time of Ebola: how events impacted on a single surgical institution in Sierra Leone.

INTRODUCTION: The mortality and morbidity of Ebola extends far wider than those contracting the disease. Surgical activity in Sierra Leone has been severely disrupted by the epidemic. METHOD: This is a retrospective study examining the effect of the 2014-2015 Ebola virus epidemic on surgical activity in a Sierra Leone's main teaching hospital. RESULTS: The impact of national and local events on surgical provision is illustrated by the experience of Connaught Hospital, Freetown Sierra Leone. Surgical activity fell dramatically in August 2014, the month when the most health care workers died and continued to fall to just 3% of expected activity. Two of eight surgeons at Connaught Hospital died of Ebola. DISCUSSION: The example of Connaught Hospital serves as a graphic and poignant illustration of the difficulties faced by surgeons in low resource settings when dealing with the acute effects of a natural disaster. In any future epidemic, high levels of preparedness, training and protection, in addition to liaison with public health teams early in an epidemic, may allow surgeons to carry out at least some of their duties without the very high levels of personal risk seen here.In a country with so few specialists the loss of 25% is disastrous and will result in long term capacity reduction.

Evaluation of a point-of-care blood test for identification of Ebola virus disease at Ebola holding units, Western Area, Sierra Leone, January to February 2015.

Current Ebola virus disease (EVD) diagnosis relies on reverse transcription-PCR (RT-PCR) technology, requiring skilled laboratory personnel and technical infrastructure. Lack of laboratory diagnostic capacity has led to diagnostic delays in the current West African EVD outbreak of 2014 and 2015, compromising outbreak control. We evaluated the diagnostic accuracy of the EVD bedside rapid diagnostic antigen test (RDT) developed by the United Kingdom's Defence Science and Technology Laboratory, compared with Ebola virus RT-PCR, in an operational setting for EVD diagnosis of suspected cases admitted to Ebola holding units in the Western Area of Sierra Leone. From 22 January to 16 February 2015, 138 participants were enrolled. EVD prevalence was 11.5%. All EVD cases were identified by a positive RDT with a test line score of 6 or more, giving a sensitivity of 100% (95% confidence interval (CI): 78.2-100). The corresponding specificity was high (96.6%, 95% CI: 91.3-99.1). The positive and negative predictive values for the population prevalence were 79.0% (95% CI: 54.4-93.8) and 100% (95% CI: 96.7-100), respectively. These results, if confirmed in a larger study, suggest that this RDT could be used as a 'rule-out' screening test for EVD to improve rapid case identification and resource allocation.

Mass casualty incident training in a resource-limited environment.

BACKGROUND: A mass casualty incident (MCI) occurs when a disaster involves a large number of injured people, overwhelming the capacity of local emergency medical services. This article describes the planning and execution of a MCI workshop created for use in Sierra Leone, a low-income country. METHODS: Surgeons OverSeas (SOS), an international non-governmental organization, partnered with the Sierra Leone Office of National Security and Connaught Hospital to develop a 2-day MCI workshop designed to meet needs specific to their resource-limited environment. Pre- and post-course questionnaires were completed. Day 1 consisted of didactic teaching focused on triage principles, resource deployment, communication/operations and tabletop drills. On day 2 a mock MCI with performance assessments by independent observers was staged, followed by post-event debriefing. RESULTS: Pre-course questionnaires identified the following deficits: lack of triage training (29 per cent), and transportation (19 per cent) and communication (17 per cent) shortfalls. Only 11 per cent could define MCI. During the drill, on-scene and hospital triage was accurate in 28 (93 per cent) and 23 (77 per cent) of 30 casualties respectively. Systematic deficiencies identified included: transport issues, no accurate system for tracking victims, and undersized triage areas. Participants identified interagency coordination (63 of 136 responses; 46·3 per cent) and triage (32 of 136; 23·5 per cent) as the most valuable lessons learned. CONCLUSION: Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority.

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.

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.

Comparison of surgical care deficiencies between US civil war hospitals and present-day hospitals in Sierra Leone.

BACKGROUND: Surgery is rapidly becoming a part of public health initiatives in developing countries. METHODS: In collaboration with the Sierra Leone Ministry of Health and Sanitation, a team of local surgeons and surgeons from the organization Surgeons OverSeas (SOS) used the WHO Tool for Situational Analysis to Assess Emergency Surgical Care to quantify surgical capacity in Sierra Leone. These data were then compared to data collected from the Medical and Surgical History of the Civil War, a work documenting surgical care and hospitals during the US Civil War. RESULTS: There are 0.2 government hospital surgeons/100,000 people in Sierra Leone compared to 300 surgeons/100,000 soldiers in the Union Army. In Sierra Leone it is rare to have running water, fuel, anesthesia, and reliable X-rays. In comparison, US Civil War hospitals had reliable running water, fuel, and anesthesia. It is rare to manage open fractures, limb dislocations, amputations, and conditions requiring chest tubes in Sierra Leone, while these procedures were commonly employed in US Civil War hospitals. CONCLUSIONS: Government hospitals in present day Sierra Leone lack the infrastructure, personnel, supplies, and equipment to adequately provide emergency and essential surgical care. In a comparison of present day Sierra Leonean and US Civil War hospitals, the US Civil War facilities are equivalent and in many ways superior. It is hoped that such a comparison will aid advocacy efforts so that greater resources are devoted to improving emergency and essential surgical care in low- and middle-income countries.

Universal precautions and surgery in Sierra Leone: the unprotected workforce.

BACKGROUND: Surgical patients and healthcare workers in sub-Saharan Africa are at an increased risk of contracting HIV. Sierra Leone is one of the poorest countries in the world and has a documented HIV prevalence rate of 2%. Because surgeons and other healthcare staff in sub-Saharan Africa are at risk for HIV exposure from their patients, an assessment of protective supplies and equipment was considered essential. METHODS: A Society of International Humanitarian Surgeons team in cooperation with the Sierra Leonean Ministry of Health and Sanitation undertook a survey of HIV-protective supplies and equipment at government hospitals in Sierra Leone. The presence of eye protection, sterile gloves, aprons, functioning suction machines, and sharps containers was recorded and compared with a local mission hospital and a local private hospital. RESULTS: Only 20% of government hospitals in Sierra Leone have adequate stores of sterile gloves or eye protection. Suction pumps and aprons are available in only 30-40% of facilities, respectively, and only half have functioning sterilizers and sharps containers. The mission and private hospitals were fully stocked. CONCLUSIONS: Although surgical healthcare workers are at risk for exposure to HIV, resources for their protection at government hospitals in Sierra Leone are severely lacking. The Society of International Humanitarian Surgeons is developing a program to provide protective supplies and equipment to hospitals in Sierra Leone, but additional efforts by other organizations working to decrease the spread of HIV are essential.

Ebola Holding Units at government hospitals in Sierra Leone: evidence for a flexible and effective model for safe isolation, early treatment initiation, hospital safety and health system functioning.

The 2014-2015 West African outbreak of Ebola Virus Disease (EVD) claimed the lives of more than 11,000 people and infected over 27,000 across seven countries. Traditional approaches to containing EVD proved inadequate and new approaches for controlling the outbreak were required. The Ministry of Health & Sanitation and King's Sierra Leone Partnership developed a model for Ebola Holding Units (EHUs) at Government Hospitals in the capital city Freetown. The EHUs isolated screened or referred suspect patients, provided initial clinical care, undertook laboratory testing to confirm EVD status, referred onward positive cases to an Ebola Treatment Centre or negative cases to the general wards, and safely stored corpses pending collection by burial teams. Between 29th May 2014 and 19th January 2015, our five units had isolated approximately 37% (1159) of the 3097 confirmed cases within Western Urban and Rural district. Nosocomial transmission of EVD within the units appears lower than previously documented at other facilities and staff infection rates were also low. We found that EHUs are a flexible and effective model of rapid diagnosis, safe isolation and early initial treatment. We also demonstrated that it is possible for international partners and government facilities to collaborate closely during a humanitarian crisis.

Delayed primary realignment of posterior urethral rupture.

The treatment of acute posterior urethral rupture is controversial. Twelve patients who presented with acute posterior urethral rupture over a five-year period were treated by delayed primary realignment of the injury. The technique of this procedure and the outcome are the subject of this presentation. Eight patients had successful realignment without strictures. Two patients with strictures responded to simple dilatations with bougies and the other two had formal urethroplasty.

Fracture of the penis--diagnosis and management.

Fracture of the penis is an uncommon injury, but it occurs most commonly during over enthusiastic sexual intercourse. Diagnosis is not difficult but serious complications such as urethral rupture and corporo-urethral fistula may occur. Management should be by early surgical exploration, with evacuation of the haematoma and repair of the tear in the tunica albuginea in order to minimize the length of patient's stay in hospital and avoid complications such as penile deformity and painful penile erections.

An estimate of hernia prevalence in Sierra Leone from a nationwide community survey.

PURPOSE: A large number of unrepaired inguinal hernias is expected in sub-Saharan Africa where late presentation often results in incarceration, strangulation, or giant scrotal hernias. However, no representative population-based data are available to quantify the prevalence of hernias. We present data on groin masses in Sierra Leone to estimate prevalence, barriers to care, and associated disability. METHODS: A cluster randomized, cross-sectional household survey of 75 clusters of 25 households with 2 respondents each was designed to calculate the prevalence of and disability caused by groin hernias in Sierra Leone using a verbal head-to-toe examination. Barriers to hernia repairs were assessed by asking participants the main reason for delay in surgical care. RESULTS: Information was obtained from 3,645 respondents in 1,843 households, of which 1,669 (46%) were male and included in the study. In total, 117 males or 7.01% (95% CI 5.64-8.38) reported a soft or reducible swelling likely representing a hernia with four men having two masses. Of the 93.2% who indicated the need for health care, only 22.2% underwent a procedure, citing limited funds (59.0%) as the major barrier to care. On disability assessment, 20.2% were not able to work secondary to the groin swelling. CONCLUSIONS: The results indicate groin masses represent a major burden for the male population in Sierra Leone. Improving access to surgical care for adult patients with hernias and early intervention for children will be vital to address the burden of disease and prevent complications or limitations of daily activity.