Think global, act local: Burn care in a resource-limited setting

The burden of burn injuries remains a major global health issue.1,2 Worldwide,millions of people suffer from burns and burn-related disabilities and deformities. Every year over 8 million people require medical attention due to burns. Burns cause an estimated loss of 8.5 million disability-adjusted life years (DALYs) each year due to premature death and disability.3 Five per cent of all injury-related deaths are caused by burns, which amounts to an estimated 120,000 deaths annually.4 Non-fatal burns are a leading cause of disability, which cause long-term physical and psychological problems.5,6 There are large differences in burn care worldwide.1 In high-income countries (HICs) major progress has been made in acute burn care over the past decades. With advancements made in the prevention of burns and treatments of wounds, the incidence of burns has decreased and the survival rate of patients has increased. The current mortality reported by HICs is 1.5%.7 This is in stark contrast to low- and middle-income countries (LMICs). In these countries the burden of burn incidence, mortality and morbidity remains high.1,8,9 The vast majority of all burns globally occur in LMICs. This is because people use open fires in daily life, for example for cooking, heating and agriculture. The incidence of burns in these countries is estimated to be 1.3 per 100,000 people, compared to 0.14 per 100,000 people in HICs.8,10 The few existing studies from LMICs show that poor populations are most at risk of sustaining burns, and that the majority of patients are children.1,2,9,11,12 The higher morbidity and mortality is a consequence of the fact that geographically isolated and economically disadvantaged populations have limited access to safe and timely burn care.2 Due to this lack of care, 95% of all fatal fire-related cases of mortality due to burns occurs in LMICs. Studies have estimated that the risk of child mortality due to burns is currently over seven times
higher in LMICs compared to HICs

The role of community health workers in the surgical cascade: a scoping review

Background
Community health workers (CHWs) can increase access to various primary healthcare services; however, their potential for improving surgical care is under-explored. We sought to assess the role of CHWs in the surgical cascade, defined as disease screening, linkage to operative care, and post-operative care. Given the well-described literature on CHWs and screening, we focused on the latter two steps of the surgical cascade.

Methods
We conducted a scoping review of the peer-reviewed literature. We searched for studies published in any language from January 1, 2000 to May 1, 2020 using electronic literature databases including Pubmed/MEDLINE, Web of Science, SCOPUS, and Google Scholar. We included articles on CHW involvement in linkage to operative care and/or post-operative surgical care. Narrative and descriptive methods were used to analyze the data.

Results
The initial search identified 145 articles relevant to steps in the surgical cascade. Ten studies met our inclusion criteria and were included for review. In linkage to care, CHWs helped increase surgical enrollment, provide resources for vulnerable patients, and build trust in healthcare services. Post-operatively, CHWs acted as effective monitors for surgical-site infections and provided socially isolated patients with support and linkage to additional services. The complex and wide-ranging needs of surgical patients illustrated the need to view surgical care as a continuum rather than a singular operative event.

Conclusion
While the current literature is limited, CHWs were able to maneuver complex medical, cultural, and social barriers to surgical care by linking patients to counseling, education, and community resources, as well as post-operative infection prevention services. Future studies would benefit from more rigorous study designs and larger sample sizes to further elucidate the role CHWs can serve in the surgical cascade.

Challenges Affecting Health Referral Systems in Low-And Middle-Income Countries: A Systematic Literature Review

Aims: Low and middle-income countries are still facing challenges of dysfunctional referral systems which have impaired health service provision. This review aimed at investigating these challenges to understand their nature, cause, and the impacts they have on health service provision.

Methods: Database search was made in Google scholar, ACM Library, PubMed health, and BMC public health, and a total of 123 papers were generated. Only 14 fitted the inclusion criteria. Inclusion criteria included studies that were both quantitative and qualitative addressing challenges facing referral systems or health referral systems, studies describing the barriers to effective referral systems, and studies describing factors that affect referral systems. The review only included studies conducted in LMICs and included literature between January 2010 and February 2021.

Findings: Results revealed that human resource and financial constraints, non-compliance, and communication are the key challenges affecting referral systems in LMICs.

Recommendation: Countries that are facing these challenges need to overhaul the system and improve end-to-end communication between hospitals, improve capacity specifically in referral and emergency units, and sensitizing patients on the adherence to emergency protocols.

Effect of COVID-19 pandemic lockdowns on planned cancer surgery for 15 tumour types in 61 countries: an international, prospective, cohort study

Background
Surgery is the main modality of cure for solid cancers and was prioritised to continue during COVID-19 outbreaks. This study aimed to identify immediate areas for system strengthening by comparing the delivery of elective cancer surgery during the COVID-19 pandemic in periods of lockdown versus light restriction.

Methods
This international, prospective, cohort study enrolled 20 006 adult (≥18 years) patients from 466 hospitals in 61 countries with 15 cancer types, who had a decision for curative surgery during the COVID-19 pandemic and were followed up until the point of surgery or cessation of follow-up (Aug 31, 2020). Average national Oxford COVID-19 Stringency Index scores were calculated to define the government response to COVID-19 for each patient for the period they awaited surgery, and classified into light restrictions (index 60). The primary outcome was the non-operation rate (defined as the proportion of patients who did not undergo planned surgery). Cox proportional-hazards regression models were used to explore the associations between lockdowns and non-operation. Intervals from diagnosis to surgery were compared across COVID-19 government response index groups. This study was registered at ClinicalTrials.gov, NCT04384926.

Findings
Of eligible patients awaiting surgery, 2003 (10·0%) of 20 006 did not receive surgery after a median follow-up of 23 weeks (IQR 16–30), all of whom had a COVID-19-related reason given for non-operation. Light restrictions were associated with a 0·6% non-operation rate (26 of 4521), moderate lockdowns with a 5·5% rate (201 of 3646; adjusted hazard ratio [HR] 0·81, 95% CI 0·77–0·84; p<0·0001), and full lockdowns with a 15·0% rate (1775 of 11 827; HR 0·51, 0·50–0·53; p<0·0001). In sensitivity analyses, including adjustment for SARS-CoV-2 case notification rates, moderate lockdowns (HR 0·84, 95% CI 0·80–0·88; p<0·001), and full lockdowns (0·57, 0·54–0·60; p<0·001), remained independently associated with non-operation. Surgery beyond 12 weeks from diagnosis in patients without neoadjuvant therapy increased during lockdowns (374 [9·1%] of 4521 in light restrictions, 317 [10·4%] of 3646 in moderate lockdowns, 2001 [23·8%] of 11 827 in full lockdowns), although there were no differences in resectability rates observed with longer delays.

Interpretation
Cancer surgery systems worldwide were fragile to lockdowns, with one in seven patients who were in regions with full lockdowns not undergoing planned surgery and experiencing longer preoperative delays. Although short-term oncological outcomes were not compromised in those selected for surgery, delays and non-operations might lead to long-term reductions in survival. During current and future periods of societal restriction, the resilience of elective surgery systems requires strengthening, which might include protected elective surgical pathways and long-term investment in surge capacity for acute care during public health emergencies to protect elective staff and services.

Funding
National Institute for Health Research Global Health Research Unit, Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, Medtronic, Sarcoma UK, The Urology Foundation, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research.

The impact of the COVID-19 pandemic on global neurosurgical education: a systematic review

The COVID-19 pandemic has disrupted neurosurgical training worldwide, with the shutdown of academic institutions and the reduction of elective surgical procedures. This impact has disproportionately affected LMICs (lower- and/or middle-income countries), already burdened by a lack of neurosurgical resources. Thus, a systematic review was conducted to examine these challenges and innovations developed to adapt effective teaching and learning for medical students and neurosurgical trainees. A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and The Cochrane Handbook of Systematic Reviews of Interventions. MEDLINE, PubMed, Embase and Cochrane databases were accessed, searching and screening literature from December 2019 to 5th December 2020 with set inclusion and exclusion criteria. Screening identified 1254 articles of which 26 were included, providing data from 96 countries. Twenty-three studies reported transition to online learning, with 8 studies also mentioned redeployment into COVID wards with 2 studies mentioning missed surgical exposure as a consequence. Of 7 studies conducted in LMICs, 3 reported residents suffering financial insecurities from reduced surgical caseload and recession. Significant global disruption in neurosurgical teaching and training has arisen from the COVID-19 pandemic. Decreased surgical exposure has negatively impacted educational provision. However, advancements in virtual technology have allowed for more affordable, accessible training especially in LMICs. Using this, initiatives to reduce physical and mental stress experienced by trainees should be paramount.

We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings

Access to safe and timely surgical care saves lives, but its multiple barriers in low- and middle-income countries (LMICs) contribute to high postoperative mortality [1]. In these settings, surgical health systems are fragile due to a shortage of supplies such as drugs, anesthesia equipment and oxygen, the maldistribution of surgical specialists, poor referral systems, and an inability to routinely track processes and outcomes indicators for quality improvement. The ongoing Covid-19 pandemic has heightened barriers to surgical care in LMICs with resultant increases in unmet surgical needs. On the other hand, the pandemic has revealed the great potentials of telehealth.

Telehealth, which is the provision of healthcare-related services over a distance using electronic and telecommunication technologies, has created solutions to leapfrog certain barriers to surgical care in LMICs. Long distance travel to reach facilities and extended waiting times to see specialists can be circumvented by phone and online consultations. These virtual visits are not only cost saving but can prevent critical delays in patient care. Remote consultations can take on various forms. Firstly, initial visits and preoperative instructions can be done through telehealth platforms from the comfort of patient homes. In certain low acuity and elective cases, video visits may make it possible to determine the need for an operation or the need for in-person visitation to assist surgical planning. Additionally, mobile apps, direct phone calls, and instant messaging are suitable for preoperative education and assisting patients in navigating barriers to surgical access in addition to using video chat platforms. Likewise, mHealth apps and real-time video features allow for postoperative follow-up including routine wound inspection and utilize community health workers, nurses, or general medical doctors located closer to the patient than the hospital that provided the surgical care. The addition of artificial intelligence technology to mHealth could aid these cadres to identify wound infections. In Rwanda, machine learning is being harnessed to detect postoperative wound infections in rural women after Cesarean sections [2]. Finally, outreach by surgeons to rural areas can be strengthened by remote preoperative consultations to identify appropriate operative candidates, provide virtual spaces for planning with local teams, and conduct postoperative follow-up. Therefore, telehealth maximizes the impact of visiting specialists and improves the quality of patient care.

Poor communication and referral networks between health facilities are major barriers to timely and quality access to surgical care in LMICs. Telehealth allows doctors and nurses in rural and primary care facilities to communicate quickly with surgeons at regional and tertiary hospitals. The mHealth app, Vula Mobile, is used ubiquitously by South African rural doctors and nurses to refer persons with surgical conditions to specialists at higher level hospitals. A 2019 study showed that one-third of acute orthopedic conditions were managed on this platform through expert advice without the need for transfer [3]. The median response time on the app was less than 30 minutes. In addition, metadata from mHealth referral apps can be used to track volumes, referral times, and patient flow, which might be used for quality improvement efforts. This type of telehealth platform shows promise and might be scaled-up in other LMICs to better link networks of non-specialist health care providers and surgeons.

If higher bandwidth is available, real-time video platforms, which allow for in-depth consultations and case discussions, can be used to overcome specialist shortages in LMICs. Virtual multi-disciplinary conferences are being used in South–South and North–South collaborations. For example, the Global Cancer Institute has a network of over 500 doctors from Africa, Asia, and Latin America who present cancer cases for discussion with US oncology experts [4].

The limited case mix at some LMIC training hospitals and the shortage of surgical subspecialists can impede the acquisition of certain operative skills. Telesurgery, or intra-operative tele-mentoring, is where a senior surgeon located remotely can give immediate and continuous feedback to the operating surgeon. Early attempts at South–South telesurgery collaborations have shown good patient outcomes [5].

Another telehealth innovation for skills acquisition is simulation, or the use of models to imitate the steps of an operation. Simulators can be high-fidelity units with computer animation or low-fidelity models made from inexpensive materials like cardboard boxes and graspers to learn three-dimensional techniques such as laparoscopic suturing and knot tying. Simulation has been shown to be particularly useful during the Covid-19 pandemic to augment training since elective operative volume has decreased in almost every country worldwide…

An Ethnographic Study of Nursing on a Surgery Ship Providing Humanitarian Care

Less than half the world’s population has access to essential health services (United Nations, 2020), the majority of whom live in low to middle-income countries (LMICs; Meara et al., 2015). The inability to access health services denies people a life of dignity. To bridge this current gap in the provision of health care, nongovernmental organisations are responding by deploying specialist, short term healthcare teams (Ng-Kamstra et al., 2016). Nurses, as the largest group of health professionals, provide care within those teams. Substantial literature is linked to nurses deployed in a disaster response situation, However, there is limited research into nurses’ roles within teams meeting a humanitarian response outside that urgent disaster context, and what their contribution brings. The purpose of this ethnographic study was to explore nursing involvement within humanitarian healthcare provision to generate insight into the area of humanitarian nursing in an acute, short term, nondisaster context and to extend the research literature surrounding this topic. The study was framed within the context of a faith-based nongovernmental organisation delivering specialist surgery on a civilian hospital ship. The aim was to advance the mission and purpose of humanitarian (nondisaster) nursing, providing a detailed description of the culture of nursing care in that setting. An interpretivist standpoint, influenced by a social constructivist theoretical position, was taken. Data were collected over 6 months, using participant observation, a reflection of artefacts, and the collective voice of volunteer nurses. Thematic analysis was conducted considering Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines. Findings elucidated nursing within the context of a community of nursing practice (CoNP), revealing four major themes: (1) “What drew us here?” (expressions of motivation), (2) “Who we are and how we do what we do” (expressions of engagement), (3) challenges (embracing change), and (4) development (expressions of transformation). This study contributes new knowledge by describing the culture of nursing and how nurses enact their care in a previously undescribed humanitarian context. Based on the analysis of findings, a professional practice model (PPM) named HHEALED was proposed. An in-depth application of the model was made to the specific organisational context framing the study. Recommendations arising from this study address nurses’ social and professional roles within humanitarian care that could further validate and strengthen policies and programs for the delivery of humanitarian health care for a mobile platform providing specialist surgical care.

Harvard Medical School Department of Global Health and Social Medicine COVID-19 seminar series: COVID and surgical, anesthetic and obstetric care

On May 21, 2020, the Harvard Program in Global Surgery and Social Change (PGSSC) hosted a webinar as part of the Harvard Medical School Department of Global Health and Social Medicine’s COVID-19 webinar series. The goal of PGSSC’s virtual webinar was to share the experiences of surgical, anesthesia, and obstetric (SAO) providers on the frontlines of the COVID pandemic, from both high-income countries (HICs), such as the United States and the United Kingdom, as well as low- and middle-income countries (LMICs). Providers shared not only their experiences delivering SAO care during this global pandemic, but also solutions and innovations they and their colleagues developed to address these new challenges. Additionally, the seminar explored the relationship between surgery and health system strengthening and pandemic preparedness, and outlined the way forward, including a roadmap for prioritization and investment in surgical system strengthening. Throughout the discussion, other themes emerged as well, such as the definition of elective surgery and its implications during a persistent global pandemic, the safe and ethical reintroduction of surgical services, and the social inequities exposed by the stress placed on health systems by COVID-19. These proceedings document the perspectives shared by participants through their invited lectures as well as through the panel discussion at the end of the seminar.

The practices of aseptic technique of perioperative nurses in operation room to prevent surgical site infection : integrative literature review

Surgical site infections are the most common preventable health care-associated infections. However, the complications of SSIs are associated with additional inpatient stay costs, morbidity, and mortality. Perioperative nurses must be well-educated and well-trained to perform aseptic technique for preventing SSIs as well as facilitating safe surgical procedures for patients. Aseptic technique practices involve the performance of hand hygiene, donning gloves, applying surgical attire, preoperative aseptic skin preparation, aseptic instrument preparation, and aseptic environment maintenance.

The thesis aims to explore which elements are related to the perioperative nurses’ practices in aseptic technique in operation room, regarding the prevention of SSIs and how these practices affect to the outcomes of SSIs.

The purpose of this thesis is to promote understanding and awareness of aseptic technique in operation room, which contributes to SSI prevention. Particularly, the study is beneficial for senior nursing students and graduated nurses as a holistic picture of aseptic technique for further specific research related to this topic.

A combination of qualitative and quantitative methods was executed in this literature review. The data search and collection processes are mainly from electronic databases as EBSCO, SAGE, and PubMed in association with the consideration of inclusion and exclusion criteria. The year publication was from 2010 to 2020 in order to meet the requirement of timely and update knowledge provision. Inductive content analysis was conducted to analyse collected data and generate appropriate categories relevant to research questions.

Regard of SSI prevention, double set of sterile gloves is recommended in clinical practice to decrease the possibility of inner gloving perforation and bacterial transmission inside out. Surgical hand rubbing with alcohol-based disinfection solution is more preferred than traditional scrubbing. Despite insufficient evidence, surgical attire, including gown, surgical headgear, and SMs is routinely recommended in clinical practice compliance. If necessary, hair removal with clippers is preferable than razors. Shoe covers, a back-and-forth technique in skin preparation, adhesive surgical drapes were supported by a very low level of evidence. Meanwhile, staff movements, door openings, temperature, and airflow have been suggested to affect the integrity of the sterile field by a moderate amount of evidence. A minor point was also pointed out that 30-47% of entries and exits from the OR are unnecessary.

Effective interventions in road traffic accidents among the young and novice drivers of low and middle-income countries: A scoping review

Problem considered
Road traffic accident (RTA) is the ninth leading cause of global mortality and are also contributes mortality rates among young adults aged 15–29 years. This paper aims to conduct a comprehensive review to provide evidence of effective interventions of RTA prevention among young adults.

Methods
Three databases, MEDLINE, Embase, and PsychINFO, were searched. Eligible articles were practical behavioural and technological interventions directly affecting young drivers. The quality assessment used critical appraisal tools from the Joanna Briggs Institute (JBI). A narrative approach was used to analyze data of the 1107 articles identified, 17 articles met the inclusion criteria. Six studies used a driving simulator; five studies were educational training interventions; one used an incentive and in-car GPS, and one video-based training. One intervention used a vehicle warning system. A motorcycle simulator intervention and two-hybrid interventions, a pc-training and field training, and a driving simulator and vehicle training were also identified.

Result
The Green Light for Life, a training program, was emphasized as it was a simple intervention, using parent influences to improve injury crash rates by 12.7% p < 0.001. Furthermore, RAPT, a driving simulator, improved gaze in the range of 52.1–70% p < 0.001, and HRT, a motorcycle simulator, showed 0.92, p < 0.001 proportion of hazard avoidance. Conclusion These interventions can provide important leads to be adapted and replicated in various settings globally, to improve RTA outcomes among young adults. Future research can adopt a qualitative approach to determine the willingness of use for these interventions and adherence to current interventions.