Tracheostomy Practices for Mechanically Ventilated Patients in Malawi.

BACKGROUND: Tracheostomy is used for patients who require prolonged mechanical ventilation. Extensive research has described the provision and optimal timing of tracheostomy, but very little describes tracheostomy utilization in low- and middle-income countries, particularly in sub-Saharan Africa. METHODS: This prospective cohort study describes patients admitted to the intensive care unit (ICU) of a tertiary hospital in Malawi who received tracheostomy versus those who did not, with a primary outcome of hospital mortality. We performed subgroup analysis of patients with severe head injuries. RESULTS: The analysis included 451 patients admitted to the study ICU between September 2016 and July 2018. Overall hospital mortality was 40% for patients who received tracheostomy and 63% for patients who did not. Logistic regression modeling revealed an odds ratio (OR) of 0.34 (95% CI 0.18-0.64) for hospital mortality among patients who received tracheostomy versus those who did not (p < 0.001). Standardized mortality ratio weighting revealed an odds ratio of 0.81 (95% CI 0.65-0.99, p < 0.001) for hospital death among patients who received tracheostomy versus those who did not. In the subgroup excluding severe head injury, both ICU (50%) and hospital mortality (75%) were higher overall, but hospital mortality was not more common for patients with tracheostomy versus without (OR 1.28, 95% CI 0.94-1.74, p = 0.104). CONCLUSIONS: Tracheostomy is not associated with hospital mortality in a Malawi ICU cohort, but these results are affected by the presence of head injury. Research may focus on home tracheostomy care given the lack of hospital discharge options for patients in austere settings.

High Elective Surgery Cancellation Rate in Malawi Primarily Due to Infrastructural Limitations.

BACKGROUND: The provision of safe and timely surgical care is essential to global health care. Low- and middle-income countries have a disproportionate share of the global surgical disease burden and struggle to provide care with the given resources. Surgery cancellation worldwide occurs for many reasons, which are likely to differ between high-income and low-income settings. We sought to evaluate the proportion of elective surgery that is cancelled and the associated reasons for cancellation at a tertiary hospital in Malawi. METHODS: This was a retrospective review of a database maintained by the Department of Anesthesiology at Kamuzu Central Hospital in Lilongwe, Malawi. Data were available from August 2011 to January 2015 and included weekday records for the number of scheduled surgeries, the number of cancelled surgeries, and the reasons for cancellation. Descriptive statistics were performed. RESULTS: Of 10,730 scheduled surgeries, 4740 (44.2%) were cancelled. The most common reason for cancellation was infrastructural limitations (84.8%), including equipment shortages (50.9%) and time constraints (33.3%). Provider limitations accounted for 16.5% of cancellations, most often due to shortages of anaesthesia providers. Preoperative medical conditions contributed to 26.3% of cancellations. CONCLUSION: This study demonstrates a high case cancellation rate at a tertiary hospital in Malawi, attributable primarily to infrastructural limitations. These data provide evidence that investments in medical infrastructure and prevention of workforce brain drain are critical to surgical services in this region.

Emergency-to-Elective Surgery Ratio: A Global Indicator of Access to Surgical Care.

BACKGROUND: Surgical care is essential to health systems but remains a challenge for low- and middle-income countries (LMICs). Current metrics to assess access and delivery of surgical care focus on the structural components of surgery and are not readily applicable to all settings. This study assesses a new metric for surgical care access and delivery, the ratio of emergent surgery to elective surgery (Ee ratio), which represents the number of emergency surgeries performed for every 100 elective surgeries. METHODS: A systematic search of PubMed and Medline was conducted for studies describing surgical volume and acuity published between 2006 and 2016. The relationship between Ee ratio and three national indicators (gross domestic product, per capital healthcare spending, and physician density) was analyzed using weighted Pearson correlation coefficients (r w) and linear regression models. RESULTS: A total of 29 studies with 33 datasets were included for analyses. The median Ee ratio was 14.6 (IQR 5.5-62.6), with a range from 1.6 to 557.4. For countries in sub-Saharan Africa the median value was 62.6 (IQR 17.8-111.0), compared to 9.4 (IQR 3.4-13.4) for the United States and 5.5 (IQR 4.4-10.1) for European countries. In multivariable linear regression, the per capita healthcare spending was inversely associated with the Ee ratio, with a 63-point decrease in the Ee ratio for each 1 point increase in the log of the per capita healthcare spending (regression coefficient ß = -63.2; 95% CI -119.6 to -6.9; P = 0.036). CONCLUSIONS: The Ee ratio appears to be a simple and valid indicator of access to available surgical care. Global health efforts may focus on investment in low-resource settings to improve access to available surgical care.