Referral of District Level Operations to Regional Hospitals in South Africa.

INTRODUCTION: In South Africa, district hospitals have limited surgical capacity, and most surgical conditions are referred to higher-level facilities for definitive management. This study aims to identify the proportion, type, and volume of district-level general surgery referrals to two regional government hospitals in South Africa. MATERIALS AND METHODS: This was a retrospective analysis of secondary data collected on persons who underwent general surgery operations at two South African regional hospitals between January 1, 2016 and December 31, 2018. District-level operations were those included in the South African Department of Health District Health Package. Descriptive analyses were performed to determine the proportions of district-level general surgery referrals and operations. Multivariate analyses were performed to determine factors associated with district-level general surgery operations. RESULTS: A total of 9357 persons underwent general surgery operations. Of these, 5925 (63.3%) were district-level operations. The most common district-level operations were lower limb amputations (n = 1007; 17.0%), abscess drainage (n = 936; 15.8 %), appendectomy (n = 791; 13.4%), non-trauma emergency laparotomy (n = 666; 11.2%), and inguinal hernia repair (n = 574; 9.7%). In multivariate analysis, district-level operations were associated with emergency conditions (OR: 5.64, P < 0.001), trauma (OR: 1.43, P < 0.001) and male gender (OR: 2.35, P < 0.001). CONCLUSIONS: In South Africa, the majority of general surgery diseases treated at regional hospitals are district-level conditions. The definition of district-level conditions could be too broad, and a narrower basket of surgical care for district hospitals would focus training efforts on achievable targets. More resources are needed at regional hospitals to care for their additional surgical burden.

Trauma trends during COVID-19 alcohol prohibition at a South African regional hospital.

INTRODUCTION: The objective of this study was to examine the relationship between trauma volume and alcohol prohibition during the COVID-19 lockdown in South Africa. METHODS: This was a retrospective analysis of trauma volume from Worcester Regional Hospital in South Africa from 1 January to 28 December 2020. We compared total volume and incidence rates during five calendar periods; one when alcohol sales were allowed as per normal and four when alcohol sales were completely or partially banned. Poisson regression was used to model differences between alcohol ban and non-ban periods. RESULTS: During the first period (pre-COVID-19, no ban), the trauma admission rate was 95 per 100 days, compared to 39 during the second period (complete ban 1), 74 during the third period (partial ban 1), 40 during the fourth period (complete ban 2) and 105 during the fifth period (partial ban 2). There was a 59-69% decrease in trauma volume between the no ban and complete ban 1 periods. When alcohol sales were partially reinstated, trauma volume significantly increased by 83-90% then dropped again by 39-46% with complete ban 2. By the second half of 2020, when alcohol sales were partially allowed again (partial ban 2), trauma volume increased by 163-250%, thus returning to pre-COVID-19 levels. DISCUSSION AND CONCLUSIONS: Our study demonstrates a clear trend of decreased trauma volume during periods of complete alcohol prohibition compared to non- and partial alcohol bans. This finding suggests that temporary alcohol bans can be used to decrease health facility traffic during national emergencies.

We Asked the Experts: The Role of Rural Hospitals in Achieving Equitable Surgical Access in Low-Resourced Settings.

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.

Operative surgery at the district hospital.

Surgical disease is an important cause of preventable mortality and morbidity, but it is not clear how best to deliver surgical services to under-served rural populations in poorer countries. South Africa's policy is to restructure heath services, with district hospitals and health centres becoming the primary delivery vehicle for quality health care to all South Africans. Among other things this involves defining what services a district hospital should be expected to provide, including the district hospital service package (DHSP). Many felt that the list of district hospital surgical procedures is unrealistic, and it is not clear to what extent the package is deliverable. We therefore studied the operative surgery undertaken at district hospital level in a single region with well-organised primary health care services.