Quality improvement activities for surgical services at district hospitals in developing countries and perceived barriers to quality improvement: findings from Ghana and the scientific literature.

BACKGROUND: Most quality improvement (QI) activities in developing countries, established with funds from external donors, are focused on specific diseases or outreach programs, such as family planning or child survival. District hospitals in developing countries serve as the primary entry point for patients with surgical problems in developing countries, yet little is known about the extent to which formal QI activities for surgical services are present in these settings or the perceptions of hospital staff about the barriers to improving quality in this setting. This study aimed to document surgical QI efforts at district hospitals and perceived barriers to improving quality in a developing country-Ghana. It also provides a summary of the existing published scientific literature concerning surgical QI in developing countries. METHODS: A survey team visited 10 government district hospitals in Ghana, one in each of Ghana's 10 regions. The number and type of QI activities (surgical and nonsurgical) at these district hospitals and the perspectives of hospital staff regarding the steps required to improve the quality of surgical services in their facility were recorded. RESULTS: Of the 10 hospitals assessed, nine reported having some type of QI activity, ranging from satisfaction surveys to assessing quality of infection prevention. Only one hospital reported having QI activity addressing surgical care. To improve the quality of surgical care, seven hospitals reported the need for trained specialists in surgery, obstetrics, and gynecology. Six cited the need for an appropriately equipped operating theater and recovery ward. The primary barrier to achieving these recommendations, cited by 70 % of the hospitals, was the inability to recruit and retain qualified specialists with surgical skills. CONCLUSIONS: For Ghana to improve significantly the quality of surgical care provided in its district hospitals, greater emphasis is needed for continuous, systematic QI monitoring and for solving the problems identified. Increasing the number of appropriately trained surgical care providers is essential to strengthen the quality of surgical services in district hospitals. These findings likely apply to other resource-limited countries as well. Increased attention to improving the quality of surgical services at district hospitals in developing countries is urgently needed.

In the eyes of the beholder:assessment by clients on healthcare delivery in a large teaching hospital in Ghana.

BACKGROUND: Improving quality of health care delivery is a primary goal of all health care institutions. Health care systems face challenges in providing quality health care to the citizenry due to rising health care cost and clients demanding higher standards of care. OBJECTIVES: The study aimed at finding out clients' perceptions of the quality of health care delivery at the tertiary care level in Ghana, using the Central Outpatient Department (COPD) of the largest teaching hospital in Ghana as a case study. STUDY DESIGN: Overall 665 clients were selected through systematic random sampling procedure over a four-week period, between September and October 2010. Clients were interviewed after a visit to the COPD of the hospital during the survey period using a structured questionnaire.Two focus group discussions were held for clients during the period. RESULTS: Majority of clients (56%) were females and most (84%) were clients coming for review. During the focus group discussion, clients'considered one hour as the mean maximum time they would like to wait while seeking medical help,however, more than half of clients (51.9%)waited for over an hour (after registration) to see a doctor. About 86% had their condition explained to them and 87% were physically examined. In all, 83% of clients were satisfied, and 6% very satisfied with care given at the COPD. Clients however, considered poor attitude of some health workers, long waiting times,late starting times of clinic, uncomfortable physical environment and inadequate staff as being detrimental to the effective delivery of quality healthcare. CONCLUSION: Overall quality of health care as measured by the indicators used were generally perceived to be high except with client waiting time for services, lack of directional signs in the hospital and an uncomfortable waiting area at the COPD. There were concerns about attitude of some staff and late starting times of outpatient clinics. These when addressed would further improve quality.

Assessment of surgical and obstetrical care at 10 district hospitals in Ghana using on-site interviews.

BACKGROUND: For most of the population in Africa, district hospitals represent the first level of access for emergency and essential surgical services. The present study documents the number and availability of surgical and obstetrical care providers as well as the types of surgical and obstetrical procedures being performed at 10 first-referral district hospitals in Ghana. MATERIALS AND METHODS: After institutional review board and governmental approval, a study team composed of Ghanaian and American surgeons performed on-site surveys at 10 district hospitals in 10 different regions of Ghana in August 2009. Face-to-face interviews were conducted documenting the numbers and availability of surgical and obstetrical personnel as well as gathering data relating to the number and types of procedures being performed at the facilities. RESULTS: A total of 68 surgical and obstetrical providers were interviewed. Surgical and obstetrical care providers consisted of Medical Officers (8.5%), nurse anesthetists (6%), theatre nurses (33%), midwives (50.7%), and others (4.5%). Major surgical cases represented 37% of overall case volumes with cesarean section as the most common type of major surgical procedure performed. The most common minor surgical procedures performed were suturing of lacerations or episiotomies. CONCLUSIONS: The present study demonstrates that there is a substantial shortage of adequately trained surgeons who can perform surgical and obstetrical procedures at first-referral facilities. Addressing human resource needs and further defining practice constraints at the district hospital level are important facets of future planning and policy implementation.

Validation of the World Health Organization tool for situational analysis to assess emergency and essential surgical care at district hospitals in Ghana.

BACKGROUND: The World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (hereafter called the WHO Tool) has been used in more than 25 countries and is the largest effort to assess surgical care in the world. However, it has not yet been independently validated. Test-retest reliability is one way to validate the degree to which tests instruments are free from random error. The aim of the present field study was to determine the test-retest reliability of the WHO Tool. METHODS: The WHO Tool was mailed to 10 district hospitals in Ghana. Written instructions were provided along with a letter from the Ghana Health Services requesting the hospital administrator to complete the survey tool. After ensuring delivery and completion of the forms, the study team readministered the WHO Tool at the time of an on-site visit less than 1 month later. The results of the two tests were compared to calculate kappa statistics for each of the 152 questions in the WHO Tool. The kappa statistic is a statistical measure of the degree of agreement above what would be expected based on chance alone. RESULTS: Ten hospitals were surveyed twice over a short interval (i.e., less than 1 month). Weighted and unweighted kappa statistics were calculated for 152 questions. The median unweighted kappa for the entire survey was 0.43 (interquartile range 0-0.84). The infrastructure section (24 questions) had a median kappa of 0.81; the human resources section (13 questions) had a median kappa of 0.77; the surgical procedures section (67 questions) had a median kappa of 0.00; and the emergency surgical equipment section (48 questions) had a median kappa of 0.81. CONCLUSIONS: Hospital capacity survey questions related to infrastructure characteristics had high reliability. However, questions related to process of care had poor reliability and may benefit from supplemental data gathered by direct observation. Limitations to the study include the small sample size: 10 district hospitals in a single country. Consistent and high correlations calculated from the field testing within the present analysis suggest that the WHO Tool for Situational Analysis is a reliable tool where it measures structure and setting, but it should be revised for measuring process of care.

Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool.

OBJECTIVES: To survey infrastructure characteristics, personnel, equipment and procedures of surgical, obstetric and anaesthesia care in 17 hospitals in Ghana. METHODS: The assessment was completed by WHO country offices using the World Health Organization Tool for Situational Analysis to Assess Emergency and Essential Surgical Care, which surveyed infrastructure, human resources, types of surgical interventions and equipment in each facility. RESULTS: Overall, hospitals were well equipped with general patient care and surgical supplies. The majority of hospitals had a basic laboratory (100%), running water (94%) and electricity (82%). More than 75% had the basic supplies needed for general patient care and basic intra-operative care, including sterilization. Almost all hospitals were able to perform major surgical procedures such as caesarean sections (88%), herniorrhaphy (100%) and appendectomy (94%), but formal training of providers was limited: a few hospitals had a fully qualified surgeon (29%) or obstetrician (36%) available. CONCLUSIONS: The greatest barrier to improving surgical care at district hospitals in Ghana is the shortage of adequately trained medical personnel for emergency and essential surgical procedures. Important future steps include strengthening their number and qualifications.

Management of oesophageal atresia in a developing country: Is primary repair forbidden?

BACKGROUND: The aim of the study was to evaluate the outcomes of initial surgical procedures for oesophageal atresia at our institution. Primary repair of oesophageal atresia at our centre was perceived to be associated with a high mortality rate. In view of this, almost all patients seen since January 2014 were offered initial surgery for staged repair. MATERIALS AND METHODS: A retrospective review of records of infants with oesophageal atresia seen at the centre from January 2007 to December 2014 was used in this study. RESULTS: Eighty-five cases of oesophageal atresia were seen over the study period. Of these, 74 (87.1) had surgery performed. Surgical outcome was, however, indicated in 67 of the 74, with overall survival rate of 40.3%. Among the 67 patients, early primary repair was performed in 24 (35.8%) with a survival rate of 45.8% (11 patients). Totally, 12 (17.9%) of the 67 had initial procedure for delayed primary repair, with a survival rate of 16.7% (2 patients). The remaining 31 (46.3%) patients had initial surgery for staged repair, with survival rate of 45.2% (14 patients). There was no association between the type of surgery and the surgical outcome (χ2 = 3.396, df = 2, P = 0.183). CONCLUSION: The overall surgical survival rate of 40.3% for oesophageal atresia at our institution is low. This study did not show any difference in the survival rate of 45.8% and 45.2% associated with primary repair and staged repair respectively.

The daily water, sodium and potassium excretion in urine of Ghanaian children aged 5 to 12 years.

AIM: The aim of the study was to determine the daily losses of water, sodium and potassium in the urine of Ghanaian children who presented to the paediatric surgery unit of the Korle-Bu teaching hospital. METHODS: The urine of 74 Ghanaian children (51 male, 23 female) who presented to the Paediatric surgery unit of the Korle-Bu teaching hospital between June 1997 and January 1999 was collected over a 24 hour period and analysed to determine the volume, sodium and potassium content. RESULT: 74 children between the ages of 5 and 12 years with a mean age of 9 years were involved in the study. The mean daily urinary volume was 1136.8ml (95% confidence interval 1097.7 to 1176.0) with a range of 400 to 2400ml. The sodium excreted was 108.6mmol per day (confidence interval 105.3 to 111.9) with a range of 39.8 to 231.9mmol per day while the potassium excreted was 24.7mmol (confidence interval 23.7 to 25.7mmol) and a range of 6.25 to 69.9mmol per day. CONCLUSION: This study showed that children between 5 and 12 years in a ward lose a mean of 1136.8ml of water per day, 4.6mmol per kilogram of sodium per day, and 1mmol per kg per day of potassium in their urine.

Complications of hypospadias surgery: Experience in a tertiary hospital of a developing country.

BACKGROUND: Over 300 different operations have been described for the management of hypospadias. In recent times, the numbers of operations used in various centres have gradually reduced as the principles necessary to ensure adequate cosmetic and functional results with minimum complications are better understood. The aim of this article was to review the different types of operations used for managing hypospadias in a tertiary hospital in a developing country, to analyse the complications of surgery and discuss the factors that contribute to complications. MATERIALS AND METHODS: Patient folders, theatre, and ward records were used to obtain the required information. The age at surgery, types of hypospadias at presentation, types of operations done and complications were analysed. RESULTS AND CONCLUSION: With three main types of operations, tubularised incised plate urethroplasty and meatal advancement and glanuloplasty incorporated for anterior hypospadias (glanular, coronal, subcoronal, distal, midpenile), and lateral based flap urethroplasty for posterior hypospadias (proximal penile, penoscrotal, scrotal, perineal), most hypospadias were corrected with acceptable complication rates.

Hand hygiene practices and resources in a teaching hospital in Ghana.

INTRODUCTION: Nosocomial infections have long been neglected in Sub-Saharan Africa, and hand hygiene (HH) is usually neglected in hospital settings. This study aimed to provide baseline data on HH compliance among health workers and HH resources in a large West African teaching hospital. METHODOLOGY: A cross-sectional, unobtrusive observational study assessed personal and care-related HH compliance among doctors and nurses and HH resources in 15 service provision centres of the Korle-Bu Teaching Hospital (KBTH), Ghana, in 2011. Data was collected with an infection prevention checklist and health worker HH compliance form, based on World Health Organization guidelines. RESULTS: Care-related HH compliance of doctors and nurses was low and basic HH resources were deficient in all 15 service centres. Care-related HH compliance among doctors ranged from 9.2% to 57% and 9.6% to 54% among nurses. HH compliance was higher when risk was perceived to be higher (i.e., in the emergency and wound dressing/treatment rooms and labour wards). The neonatal intensive care unit (NICU) showed the highest level of compliance among health workers. Facilities for HH, particularly alcohol hand rub and liquid soap dispensers were shown to be deficient. CONCLUSIONS: Care-related HH compliance among doctors and nurses in this large West African hospital is low; however, the NICU, which had implemented HH interventions, had better HH compliance. HH intervention programs should be designed and promoted in all service centres. Also, the introduction of alcohol-based hand rubs as an accessible and effective HH alternative in Korle-Bu Teaching Hospital is recommended.

Parasitic infestations requiring surgical interventions.

Parasitic infestation is common in developing countries especially in Africa. Children are often more vulnerable to these infections. Many health problems result from these infestations, including malnutrition, iron-deficiency anemia, surgical morbidities, and even impaired cognitive function and educational achievement. Surgical intervention may be needed to treat serious complications caused by some of these parasites. Amoebic colitis and liver abscess caused by protozoan infections; intestinal obstruction, biliary infestation with cholangitis and liver abscess, and pancreatitis caused by Ascaris lumbricoides; biliary obstruction caused by Faschiola; hepatic and pulmonary hydatid cysts caused by Echinococcus granulosus and multilocularis are examples. Expenditure of medical care of affected children may cause a great burden on many African governments, which are already suffering from economic instability. The clinical presentation, investigation, and management of some parasitic infestations of surgical relevance in African children are discussed in this article.

Gastroschisis: a multi-centre comparison of management and outcome.

BACKGROUND: Anecdotal evidence and a handful of literature reports suggest that the outcome for infants born with gastroschisis in many African countries is poor when compared to Western nations. We wished to evaluate current management strategies and outcomes in African and Western units that treat infants with gastroschisis. PATIENTS AND METHODS: We conducted a retrospective review of case-notes for infants with gastroschisis who presented to a hospital between 1 January 2004 and 31 December 2007. There were five participating centres, divided for analysis into an African cohort (three centres) and a Western cohort (two centres). RESULTS: Fewer infants presented to a hospital with gastroschisis in the African cohort when compared to the Western cohort, particularly when the size of catchment area of each hospital was taken into account. The physiological state of the infant on presentation and management strategy varied widely between centres. Primary closure, preformed silo and surgical silo with delayed closure were all utilised in the African cohort. Use of the preformed silo and delayed abdominal wall closure was the strategy of choice in the Western cohort. The 30-day mortality was 23% and 1% respectively. This primary outcome measure varied considerably in the African cohort but was the same in the two Western units. CONCLUSIONS: Gastroschisis in the African cohort was characterised by fewer infants presenting to a hospital and a more variable outcome when compared to the Western cohort. A detailed epidemiological study to determine the incidence of gastroschisis in African countries may provide valuable information. In addition, interventions such as prompt resuscitation, safe neonatal transfer, the use of the preformed silo and parenteral nutrition could improve outcomes in infants with gastroschisis.

Assessing the surgical and obstetrics-gynecology workload of medical officers: findings from 10 district hospitals in Ghana.

HYPOTHESIS: Surgical and obstetrics-gynecology (Ob-Gyn) workload of medical officers (MOs) is substantial and may inform policies for training investment and surveillance to strengthen surgical care at district hospitals in Ghana. DESIGN: Observational study. SETTING: Academic research. PARTICIPANTS: Using standardized criteria, 12 trained on-site observers assessed the surgical and Ob-Gyn workload of MOs at 10 district hospitals in each of 10 administrative regions in Ghana, West Africa. The number of patients seen by MOs and the time spent managing each patient were recorded. According to each patient's diagnosis, the encounters were categorized as medical/nonsurgical, Ob-Gyn, or surgical. MAIN OUTCOME MEASURES: The proportions of patients having Ob-Gyn and surgical conditions and the time expended providing care to Ob-Gyn and surgical patients. RESULTS: Of the observed patient encounters, 1600 (64.5%) were classified as medical or nonsurgical, 514 (20.7%) as Ob-Gyn, and 368 (14.8%) as surgical (9.0% nontrauma and 5.8% trauma). The most common diagnosis among Ob-Gyn patients was obstetric complication requiring cesarean section. The most common diagnosis among surgical patients was inguinal hernia. Medical officers devoted 24.8% of their time to managing Ob-Gyn patients and 18.9% to managing surgical patients (which included 5.4% for the management of traumatic injuries). CONCLUSIONS: Surgical and Ob-Gyn patients represent a substantial proportion of the workload among MOs at district hospitals in Ghana. Strategies to increase surgical capacity at these facilities must include equipping MOs with the appropriate training and resources to address the significant surgical and Ob-Gyn workload they face.

Surgical training and experience of medical officers in Ghana's district hospitals.

PURPOSE: To document the quality of training and experience of those who care for patients undergoing surgery and emergency obstetrical procedures at 10 government district hospitals in Ghana. METHOD: A study team composed of Ghanaian and U.S. surgeons visited 10 district hospitals in 10 different regions of Ghana in August 2009. On-site interviews were conducted documenting the formal and informal training and the experience of the medical officers (MOs) performing in surgical facilities in these hospitals. RESULTS: Fourteen of the 17 MOs working at these facilities were available for interviews. All 14 had completed two years of housemanship, which is similar to a rotating internship. Only one had obtained any formal surgical training beyond the housemanship, although all were responsible for performing major surgical procedures. The formal training under qualified supervision during the housemanship was limited; the mean number of the most common major surgical procedures performed during training ranged from four to eight, depending on the procedure. CONCLUSIONS: Even though formal general surgical residency training in Ghana is well developed, graduates of these programs are not working in the district hospitals surveyed. The majority of surgical services provided at the district hospital are provided by MOs, who would benefit from more comprehensive training and ongoing supervision. To help meet the challenge of a shortage of physicians working at district hospitals, the authors present alternative approaches to care described in the literature that involve nonphysician midlevel health providers.

Pneumatic reduction of intussusception in children at Korle Bu Teaching Hospital: an initial experience.

BACKGROUND: Intussusception is a common abdominal emergency in children which necessitates prompt diagnosis and management. Nonsurgical methods of managing this condition are rapidly gaining popularity with fluoroscopic-guided pneumatic reduction being one of such methods that has been used with great success in many countries. We present our initial experience with fluoroscopic-guided pneumatic reduction of intussusception at Korle Bu Teaching Hospital which is also the first time the technique has been used in Ghana. MATERIALS AND METHODS: A total of 18 children were enrolled in the study between August 2007 and February 2008 at Korle Bu Teaching Hospital, Accra, Ghana. Patients were given air enema under fluoroscopic-guidance using locally assembled equipment. The intraluminal pressure was monitored with a pressure gauge and was not permitted to go above 120 mmHg. A total of three attempts of 3 min each were allowed. RESULTS: There were 12 males and 6 females. The average age of the patients was 8.3 months (SD= 3 months). Twelve (67%) of the cases were reduced successfully while 6 (33%) failed to reduce. A majority of those that did not reduced had symptoms for at least 2 days. Bowel perforation occurred in three (16.7%) cases. CONCLUSION: Pneumatic reduction of intussusception is a cost-effective and rapid method of management of intussusception. It however has limitations like high reported rate of bowel perforation and limited ability to identify lead points. The benefits however seem to outweigh these challenges, such as fluoroscopic-guided pneumatic reduction has a very high success rate. Fluoroscopic guided pneumatic reduction should be considered as one of the primary modes of reduction in Ghana and other neighbouring countries that are yet to practice it.