Cost of postoperative sepsis in Vietnam

Despite improvements in medical care, the burden of sepsis remains high. In this study, we evaluated the incremental cost associated with postoperative sepsis and the impact of postoperative sepsis on clinical outcomes among surgical patients in Vietnam. We used the national database that contained 1,241,893 surgical patients undergoing seven types of surgery. We controlled the balance between the groups of patients using propensity score matching method. Generalized gamma regression and logistic regression were utilized to estimate incremental cost, readmission, and reexamination associated with postoperative sepsis. The average incremental cost associated with postoperative sepsis was 724.1 USD (95% CI 553.7–891.7) for the 30 days after surgery, which is equivalent to 28.2% of the per capita GDP in Vietnam in 2018. The highest incremental cost was found in patients undergoing cardiothoracic surgery, at 2,897 USD (95% CI 530.7–5263.2). Postoperative sepsis increased patient odds of readmission (OR = 6.40; 95% CI 6.06–6.76), reexamination (OR = 1.67; 95% CI 1.58–1.76), and also associated with 4.9 days longer of hospital length of stay among surgical patients. Creating appropriate prevention strategies for postoperative sepsis is extremely important, not only to improve the quality of health care but also to save health financial resources each year.

Prospective, observational study of perioperative critical incidents, anaesthesia and mortality in elective paediatric surgical patients at a national referral hospital in Niger

Aims: To describe perioperative critical incidents, the conduct of anaesthesia and perioperative mortality in elective paediatric surgery patients in a national referral hospital in Niger.

Methods: This is a prospective, observational study conducted from January to March 2018. All paediatric patients 15 years an younger, who underwent elective surgery in the Niamey National Hospital were included. The following variables were studied: age, sex, type of surgery, American Society of Anesthesiologists physical status (ASA PS) classification, monitoring system, anaesthesia technique, critical incidents, blood transfusion, analgesia, qualification of the anaesthesia practitioner, postoperative destination and mortality. Data were analysed with Excel 2007 and Epi Info 6™ (Centers for Disease Control and Prevention Atlanta, GA). The chi2 test was used for univariate associations with critical incidents. Statistical significance was considered if p < 0.05. Results: There were 231 (27.2%) paediatric patients of 849 surgical patients during the study period. Within the paediatric group, the mean age was 6 ± 4 years. The male:female sex ratio was 1.65. A full blood count was completed preoperatively in all patients. Three per cent of the patients received a preoperative blood transfusion. The most frequently performed surgery was abdominal (42.4%). Most patients were classified as ASA PS I (55%) and ASA PS II (45%). General anaesthesia was performed in 96.1% of cases and spinal anaesthesia in 3.9%. The median duration of general anaesthesia was 63 (interquartile range 45–90) minutes. There were 27 reported critical incidents (11.7%), ten of which occurred during induction (4.9%), five intraoperatively (2.2%) and 12 postoperatively (5.2%). Multimodal postoperative analgesia was used in 33.8% of these patients. One patient died in the postoperative period (0.43%). Conclusion: Perioperative critical incidents in paediatric surgical patients in Niger remain high. To improve this situation requires paediatric training of anaesthetic staff, and improved paediatric monitoring and the use of safer anaesthesia agents.

The structure, function and implementation of an outcomes database at a Ugandan secondary hospital: the Mbarara Surgical Services Quality Assurance Database

The Mbarara Surgical Services Quality Assurance Database (Mbarara SQUAD) is an outcomes database of surgical, obstetric and anaesthetic/critical care at Mbarara Regional Referral Hospital, a secondary referral hospital in southwestern Uganda. The primary scope of SQUAD is the assessment of the outcomes of care. The primary outcome is mortality. The aim is to improve the quality of care, guide allocation of resources and provide a platform for research. The target population includes all inpatients admitted for treatment to the surgery service, the obstetrics and gynaecology services, and the intensive care unit (ICU). Data collection was initiated in 2013 and closed in 2018. Data were extracted from patient charts and hospital logbooks. The database has over 50 000 patient encounters, including over 20 000 obstetrics and gynaecology admissions, 15 000 surgical admissions and 16 000 otolaryngology outpatient visits. Entries are coded using the International Classification of Diseases, Tenth Revision (ICD-10) for diagnoses, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for procedures. The completeness and accuracy of the data entry and the coding were validated. Governance of data use is by a local steering committee in Mbarara. The structure, function and implementation of this database may be relevant for similar hospital databases in low-income countries.

The impact of COVID-19 on healthcare-associated infections in intensive care units in low and middle income countries: International Nosocomial Infection Control Consortium (INICC) findings

Background
: This study examines the impact of the COVID-19 pandemic on healthcare-associated infection (HAI) incidence in low-to-middle-income countries (LMICs).

Methods
: Patients from 7 LMICs were followed during hospital intensive care unit (ICU) stays throughout January 2019 to May 2020. HAI rates were calculated using the INICC Surveillance Online System applying CDC-NHSN criteria. Pre-COVID-19 rates for 2019 were compared to COVID-19 era rates for 2020 for central line associated bloodstream infections (CLABs), catheter associated urinary tract infections (CAUTIs), ventilator associated events (VAEs), mortality and lengths of stay (LOS).

Results
: 7,775 patients were followed for 49,506 bed-days. 2019 to 2020 rate comparisons: 2.54 and 4.73 CLABSIs per 1,000 central line days (RR=1.85, p = 0.0006), 9.71 and 12.58 VAEs per 1,000 mechanical ventilator days (RR=1.29, p = 0.10), 1.64 and 1.43 CAUTIs per 1,000 urinary catheter days (RR=1.14; p = 0.69). Mortality rates were 15.2% and 23.2% for 2019 and 2020 (RR=1.42; p < 0.0001). Mean LOS were 6.02 and 7.54 days (RR=1.21, p < 0.0001). Discussion : This report documents a rise in HAI rates in 7 LMICs during the first 5 months of the COVID-19 pandemic and highlights the need to reprioritize and return to conventional infection prevention practices.

Lessons learnt from emergency medicine services during the COVID-19 pandemic: A case study of India and the United States

India and the United States have both witnessed a high burden of COVID-19 infections since the pandemic was declared in early 2020. However, the COVID-19 restrictions have met with mixed responses in India and the US. Despite recommendations to continue social isolation and personal hygiene measures, India has not been able to curb the rise in daily cases. Our findings demonstrate the difference in the manner by which India and the US differ in their emergency handling of patients. We conducted a thorough review of the existing protocols and data concerning emergency responses in India and the US. The triage and care of suspected COVID-19 positive patients is different across India and the US. We find that there is a shortage of oxygenation, vaccination and other essential supplies in India. Further, the US is able to triage patients through telemedicine and EMS before suspected COVID-19 patients arrive, which is less prevalent in India. Our study identifies the importance of the emergency department (ED) as a critical contributor to the prevention and care of suspected and confirmed COVID-19 patients. Hospitals in India have been struggling to accommodate a huge influx of patients during its second wave with the ED playing a key link in their COVID-19 response.

Performance in mortality prediction of SAPS 3 And MPM-III scores among adult patients admitted to the ICU of a private tertiary referral hospital in Tanzania: a retrospective cohort study

Background
Illness predictive scoring systems are significant and meaningful adjuncts of patient management in the Intensive Care Unit (ICU). They assist in predicting patient outcomes, improve clinical decision making and provide insight into the effectiveness of care and management of patients while optimizing the use of hospital resources. We evaluated mortality predictive performance of Simplified Acute Physiology Score (SAPS 3) and Mortality Probability Models (MPM0-III) and compared their performance in predicting outcome as well as identifying disease pattern and factors associated with increased mortality.

Methods
This was a retrospective cohort study of adult patients admitted to the ICU of the Aga Khan Hospital, Dar- es- Salaam, Tanzania between August 2018 and April 2020. Demographics, clinical characteristics, outcomes, source of admission, primary admission category, length of stay and the support provided with the worst physiological data within the first hour of ICU admission were extracted. SAPS 3 and MPM0-III scores were calculated using an online web-based calculator. The performance of each model was assessed by discrimination and calibration. Discrimination between survivors and non–survivors was assessed by the area under the receiver operator characteristic curve (ROC) and calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test.

Results
A total of 331 patients were enrolled in the study with a median age of 58 years (IQR 43-71), most of whom were male (n = 208, 62.8%), of African origin (n = 178, 53.8%) and admitted from the emergency department (n = 306, 92.4%). In- hospital mortality of critically ill patients was 16.1%. Discrimination was very good for all models, the area under the receiver-operating characteristic (ROC) curve for SAPS 3 and MPM0-III was 0.89 (95% CI [0.844–0.935]) and 0.90 (95% CI [0.864–0.944]) respectively. Calibration as calculated by Hosmer-Lemeshow goodness-of-fit test showed good calibration for SAPS 3 and MPM0-III with Chi- square values of 4.61 and 5.08 respectively and P–Value > 0.05.

Conclusion
Both SAPS 3 and MPM0-III performed well in predicting mortality and outcome in our cohort of patients admitted to the intensive care unit of a private tertiary hospital. The in-hospital mortality of critically ill patients was lower compared to studies done in other intensive care units in tertiary referral hospitals within Tanzania.

Resource Use, Availability and Cost in the Provision of Critical Care in Tanzania: A Systematic Review

Introduction

Critical care is essential in saving lives of critically ill patients, however, provision of critical care across lower resource settings can be costly, fragmented and heterogenous. Despite the urgent need to scale-up the provision of critical care, little is known about its availability and cost. Here, we aim to systematically review and identify reported resource use, availability and costs for the provision of critical care and the nature of critical care provision in Tanzania.

Methods

The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines; PROSPERO registration number: CRD42020221923. We searched Medline, Embase and global health databases. We included studies that reported on provision of critical care, cost and availability of resources used in the provision of critical care published after 2010. Costs were adjusted and reported in 2019 USD and TZS using the world bank GDP deflators.

Results

A total 31 studies were found to fulfil the inclusion and exclusion criteria. Critical care identified in Tanzania was categorised into: ICU delivered critical care and non-ICU critical care. The availability of ICU delivered critical care was limited to urban settings whereas non-ICU critical care was found in rural and urban settings. 15 studies reported on the costs of services related to critical care yet no study reported an average or unit cost of critical care. Costs of medication, equipment (e.g. oxygen, PPE), services, and human resources were identified as inputs to specific critical care services in Tanzania.

Conclusion

There is limited evidence on the resource use, availability and costs of critical care in Tanzania. There is a strong need for further empirical research on critical care resources availability, utilization and costs across specialties and hospitals of different level in LMICs like Tanzania to inform planning, priority setting and budgeting for critical care services.

Clinical Profile and Predictors of Mortality in Neonates Born With Non-Immune Hydrops Fetalis: Experience From a Lower-Middle-Income Country

Introduction
Hydrops fetalis (HF) is a life-threatening condition in which a fetus has an abnormal collection of fluid in the tissue around the lungs, heart, abdomen, or under the skin. Based on its pathophysiology, it is classified into immune and non-immune types. With the widespread use of anti-D immunoglobulin, non-immune HF has become more common, with an incidence of one in 1,700-3,000 live births. A multitude of fetal diseases with various causes can lead to non-immune HF. Due to the recent advances in prenatal diagnostic and therapeutic interventions together with improved neonatal intensive care, the diagnosis and subsequent management of HF have been refined. However, HF is still associated with a high mortality rate. A recent assessment of the literature found that there is a lack of data on prognostic variables in neonates with HF from low- and middle-income countries. In light of this, we sought to establish the etiologic causes, predictors of mortality, and eventual fate of newborns born non-immune HF at the Aga Khan University Hospital, Karachi during the 10-year period spanning January 2009-December 2019 in this retrospective analysis.

Methodology
For this study, we collected data from the computerized database and patient record files at the hospital on all infants with non-immune HF. Demographic data, postnatal interventions, clinical and laboratory findings, outcomes, and the results of comparison between HF patients who died and those who survived were analyzed.

Results
The incidence of non-immune HF at our hospital was 0.62/1,000 live births during the period under study, with 33 newborn babies diagnosed with non-immune HF from a total of 53,033 live-born deliveries. An etiologic factor was discovered in 17 (51.5%) neonates with non-immune HF while 16 (48.4%) were classified as those with unidentified etiology. The most common causes were cardiovascular and genetic syndromes, which resulted in 100% mortality. The overall mortality rate was 67%. The need for mechanical ventilation, surfactant therapy, and prolonged hospitalization were identified as independent risk factors of mortality.

Conclusion
Our study proves that the need for mechanical ventilation [moderate to severe hypoxic respiratory failure (HRF)] and prolonged hospitalization are strong predictors of poor outcomes in neonates with non-immune HF. Therefore, severe hydrops causing significant mortality can be anticipated based on the patients’ respiratory status and the need for escalated oxygen support.

ERAS Society Recommendations for Improving Perioperative Care in Low- and Middle-Income Countries Through Implementation of Existing Tools and Programs: An Urgent Need for the Surgical Safety Checklist and Enhanced Recovery After Surgery

The Lancet Commission and Global Surgery Foundation in 2015 highlighted the need for access to safe and affordable surgical and anesthetic care in low- and middle-income countries (LMICs) [1]. Patients that do have access to care in LMICs, however, have a higher risk of complications and mortality than in high-income countries (HICs). Ninety-six percent of all perioperative deaths worldwide occur in LMICs, and the economic impact of this is a staggering 2.6% of the combined gross domestic product of LMICs [1]. Although it is a common belief that the greatest contributors to adverse outcomes in LMICs are poor access to care and late presentation, deficits in the quality of accessible care are a substantial concern.

Following the Lancet Commission and the World Health Assembly Resolution 68.15, all member countries committed to developing a National, Surgical, Obstetric and Anaesthesia Plan (NSOAP) to assist in improving access to safe surgery and anesthesia [1]. The missing link in the NSOAP strategy is support for the implementation of standardized, evidence-based perioperative care guidelines and tools to measure guideline compliance and outcomes. This is crucial not only because of the need to improve perioperative care but as access to safe surgery and anesthesia improves, there is likely to be increased patient volume and pressure on the healthcare system to provide quality surgical care. A new set of tools need not be developed to improve perioperative care in LMICs. These tools already exist with evidence for their effectiveness. The Surgical Safety Checklist (SSC) and Enhanced Recovery After Surgery (ERAS) Program are two examples [2, 3]. Barriers to acceptance, adoption, and implementation of existing tools present the greatest hurdles that must be overcome to improve perioperative outcomes in LMICs.

The SSC is a communication tool used by the surgical team to confirm that appropriate actions are taken in the perioperative period to maintain patient safety. At the same time, the three pause points within the checklist include conversation prompts to ensure there is a shared understanding between the surgical team members. The SSC was designed to optimize its effectiveness in LMICs with a focus on influencing globally relevant outcomes using recommendations that are applicable and supported by the resources in LMICs. As a result, the use of the SSC has been shown to significantly reduce perioperative morbidity and mortality in LMICs as well as in HIC settings, and its impact may be larger when implemented well in LMICs [2].

Despite evidence of effectiveness, the acceptance and adoption of the SSC remain poor in LMICs with ranges between 20 and 40% when compared with facilities in HIC where rates of adoption range between 80 and 95% [4]. The reasons for this failed penetrance relate to a lack of resources and infrastructure for initial and ongoing implementation and audits and surgical hierarchies that may not support aspects of the SSC, such as encouraging all members of the team to vocalize concerns if they exist. The barriers to successful implementation are further exacerbated by checklist fatigue and similar factors that also lead to decreased meaningful use in HICs. The need for improved implementation of the SSC in LMICs has been recognized by global health organizations. With this increased focus on quality and safety initiatives and implementation, it is time to consider other strategies for improvement.

ERAS is another tool that has the potential to benefit LMICs with strategies that have demonstrated benefits across a variety of settings and clinical outcomes [3]. The ERAS program is based on implementation of evidence-based clinical practice guidelines performed by a multidisciplinary perioperative team, using tools to monitor and evaluate compliance to the guidelines and patient outcomes concurrently. Randomized trials of ERAS-based care vs traditional care conducted in HICs have shown a significant reduction in length of stay (20–40%) and complications (20–30%). Cost studies of ERAS have demonstrated a return-on-investment ratio up to 7.3 (i.e., a savings of $7.3 for every $1 invested), showing that ERAS is value-based surgery [3].

There are few established ERAS programs in LMICs, however, data from these centers demonstrate similar benefits to HICs [5]. Whether these benefits can be achieved at scale remains unknown, and the crux of the issue relates to how ERAS is applied in tertiary-university centers in LMICs compared to the district and regional levels. ERAS guidelines in their current format are specialty-specific, predominantly for elective procedures, and thus likely to be easily implemented in tertiary-university LMIC hospitals, which have similar subspecialty units. The implementation in these units will have the added benefit of facilitating the teaching and training of all perioperative team members.

The greatest unmet surgical and anesthetic need is, however, at the district and regional level in LMICs [1]. Unlike tertiary hospitals, surgery in these centers is often performed on an emergency basis by surgeons with no sub-specialty training. To address this gap, the ERAS® Society, in partnership with the World Bank and perioperative leaders in LMICs, has undertaken the development of a generic perioperative ERAS® Society guideline for elective and emergency surgery. This approach will integrate the SSC and be applied to patients undergoing a variety of operations including general and obstetrical surgery. These practices will focus on key ERAS measures such as patient education/engagement, avoidance of opioids and prolonged fasting, early mobilization, and early feeding. In addition to these guidelines, the ERAS® Society and World Bank are developing a tailored implementation program and monitoring tool to assess guideline compliance and patient outcomes specifically targeted to LMICs.

ERAS and the SSC share a similar quality that makes them well-suited for adoption in poorly resourced settings—that is their adaptability. Both tools are designed to be tailored to suit the context in which they will be adopted. Combining the NSOAP strategy with existing tools such as SSC and ERAS have the potential to provide a platform to improve the quality of surgical care in LMICs with improved patient outcomes and service efficiency, at scale, rapidly and make a significant contribution to addressing the unmet surgical and anesthetic need in LMICs.

Association between government policy and delays in emergent and elective surgical care during the COVID-19 pandemic in Brazil: a modeling study

Background
The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care.

Methods
Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil’s Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state.

Findings
Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog.

Interpretation
Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.