Evaluation of a digital triage platform in Uganda: A quality improvement initiative to reduce the time to antibiotic administration

Background
Sepsis is the leading cause of death in children under five in low- and middle-income countries. The rapid identification of the sickest children and timely antibiotic administration may improve outcomes. We developed and implemented a digital triage platform to rapidly identify critically ill children to facilitate timely intravenous antibiotic administration.

Objective
This quality improvement initiative sought to reduce the time to antibiotic administration at a dedicated children’s hospital outpatient department in Mbarara, Uganda.

Intervention and study design
The digital platform consisted of a mobile application that collects clinical signs, symptoms, and vital signs to prioritize children through a combination of emergency triggers and predictive risk algorithms. A computer-based dashboard enabled the prioritization of children by displaying an overview of all children and their triage categories. We evaluated the impact of the digital triage platform over an 11-week pre-implementation phase and an 11-week post-implementation phase. The time from the end of triage to antibiotic administration was compared to evaluate the quality improvement initiative.

Results
There was a difference of -11 minutes (95% CI, -16.0 to -6.0; p < 0.001; Mann-Whitney U test) in time to antibiotics, from 51 minutes (IQR, 27.0–94.0) pre-implementation to 44 minutes (IQR, 19.0–74.0) post-implementation. Children prioritized as emergency received the greatest time benefit (-34 minutes; 95% CI, -9.0 to -58.0; p < 0.001; Mann-Whitney U test). The proportion of children who waited more than an hour until antibiotics decreased by 21.4% (p = 0.007). Conclusion A data-driven patient prioritization and continuous feedback for healthcare workers enabled by a digital triage platform led to expedited antibiotic therapy for critically ill children with sepsis. This platform may have a more significant impact in facilities without existing triage processes and prioritization of treatments, as is commonly encountered in low resource settings.

Pragmatic multicentre factorial randomized controlled trial testing measures to reduce surgical site infection in low‐ and middle‐income countries: study protocol of the FALCON trial

Aim
Surgical site infection (SSI) is the commonest postoperative complication worldwide, representing a major burden for patients and health systems. Rates of SSI are significantly higher in low‐ and middle‐income countries (LMICs) but there is little high‐quality evidence on interventions to prevent SSI in LMICs.

Method
FALCON is a pragmatic, multicentre, 2 x 2 factorial, stratified randomized controlled trial, with an internal feasibility study, which will address the need for evidence on measures to reduce rates of SSI in patients in LMICs undergoing abdominal surgery. To assess whether either (1) 2% alcoholic chlorhexidine versus 10% povidone‐iodine for skin preparation, or (2) triclosan‐coated suture versus non‐coated suture for fascial closure, can reduce surgical site infection at 30‐days post‐surgery for each of (1) clean‐contaminated and (2) contaminated/dirty surgery. Patients with predicted clean‐contaminated or contaminated/dirty wounds with abdominal skin incision ≥ 5 cm will be randomized 1:1:1:1 between (1) 2% alcoholic chlorhexidine and noncoated suture, (2) 2% alcoholic chlorhexidine and triclosan‐coated suture, (3) 10% aqueous povidone–iodine and noncoated suture and (4) 10% aqueous povidone–iodine and triclosan‐coated suture. The two strata (clean‐contaminated versus contaminated/dirty wounds) are separately powered. Overall, FALCON aims to recruit 5480 patients. The primary outcome is SSI at 30 days, based on the Centers for Disease Control definition of SSI.

Conclusion
FALCON will deliver high‐quality evidence that is generalizable across a range of LMIC settings. It will influence revisions to international clinical guidelines, ensuring the global dissemination of its findings.

Beyond technology: review of systemic innovation stories in global surgery

Since the launch of the Lancet Commission on Global Surgery (LCOGS) in 2015, significant attention and interest have been invested in breaking down the barriers that prevent universal access to essential surgical, obstetric and anesthesia (SOA) services. Improving access to surgical care in low-resource areas, whether in low- and middle-income countries (LMICs) or within vulnerable populations in high-income countries (HICs), requires stakeholders to think outside of the box. Innovation, or the process of creatively resolving a problem, is a crucial strategy for addressing complex challenges in global health and global surgery. While technology has traditionally taken the spotlight, novel ideas that support surgical systems strengthening and advance the agenda of achieving access for all should also be highlighted. This narrative review will focus on the principal ideas and trends in global surgery innovation, stretching beyond habitual technological advancements. By centering the narrative around non-technological achievements, we will explore emerging ideas that are transforming infrastructures in health systems strengthening, financial capacity, advocacy, and research and partnerships. From the development of National Surgical, Obstetric, and Anesthesia Plans (NSOAPs) to the creation of collaborative authorship, systemic innovations have and will continue to improve the delivery and quality of essential surgical services in areas of need around the world.

Resuming elective surgeries in Corona pandemic from the perspective of a developing country

Since the COVID-19 pandemic, healthcare facilities have entered into a “crisis mode”. One of the measures used to allow hospitals to surge their capacity and serve the patient population with COVID-19 infection was the suspension of elective activity, most importantly elective surgery and other procedures. Now as the infection is fading, efforts are being made to resume elective surgical services keeping in mind the safety of the patient and health care workers. Resuming surgical services in developing countries is an uphill task.

Frugal innovation for global surgery: leveraging lessons from low- and middle-income countries to optimise resource use and promote value-based care

Limited or inconsistent access to necessary resources creates many challenges for delivering quality medical care in low- and middle-income countries (LMICs). These include funding and revenue, skilled clinical and allied health professionals, administrative expertise, reliable community infrastructure (eg water, electricity), functioning capital equipment and sufficient surgical supplies. Despite these challenges, some surgical care providers manage to provide cost effective, high quality care, offering lessons not only for other LMICs but also for high-income countries (HICs) that are working towards increasing value-based care. Examples would be how to optimise the consumption of resources, and reduce the environmental and public health burden of surgical care.

Owing to the liberal utilisation of capital equipment and single-use supplies, surgical care in HICs is increasingly recognised as a significant source of greenhouse gases and other environmental impacts that adversely affect human health. Regulations require many potentially reusable supplies and drugs to be discarded after single use. Supply manufacturers may label drugs or products as single-use to increase profit, reduce liability or facilitate regulatory approval. Many HICs struggle to increase the value of care while maximising quality and outcomes, and minimising cost and resource use.

Salome Maswime: dynamic leader in global surgery

As Associate Professor and Head of Global Surgery at the University of Cape Town (UCT), South Africa, Salome Maswime is aware of the scale of the job in front of her. “For me the big problem is the disconnect between health systems and clinical care in low and middle income countries, especially concerning surgical care. Outcomes are often poor, there being not enough focus on the quality of surgery, and how it relates to integrated health care and overarching health systems performance”, she explains. Maswime saw such shortcomings first hand in her clinical career in obstetrics and gynaecology, before she took up the new post as Head of Global Surgery at UCT in July, 2019.

Usability of Mobile Health Apps for Postoperative Care: Systematic Review

Background: Mobile health (mHealth) apps are increasingly used postoperatively to monitor, educate, and rehabilitate. The usability of mHealth apps is critical to their implementation.

Objective: This systematic review evaluates the (1) methodology of usability analyses, (2) domains of usability being assessed, and (3) results of usability analyses.

Methods: The A Measurement Tool to Assess Systematic Reviews checklist was consulted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline was adhered to. Screening was undertaken by 2 independent reviewers. All included studies were assessed for risk of bias. Domains of usability were compared with the gold-standard mHealth App Usability Questionnaire (MAUQ).

Results: A total of 33 of 720 identified studies were included for data extraction. Of the 5 included randomized controlled trials (RCTs), usability was never the primary end point. Methodology of usability analyses included interview (10/33), self-created questionnaire (18/33), and validated questionnaire (9/33). Of the 3 domains of usability proposed in the MAUQ, satisfaction was assessed in 28 of the 33 studies, system information arrangement was assessed in 11 of the 33 studies, and usefulness was assessed in 18 of the 33 studies. Usability of mHealth apps was above industry average, with median System Usability Scale scores ranging from 76 to 95 out of 100.

Conclusions: Current analyses of mHealth app usability are substandard. RCTs are rare, and validated questionnaires are infrequently consulted. Of the 3 domains of usability, only satisfaction is regularly assessed. There is significant bias throughout the literature, particularly with regards to conflicts of interest. Future studies should adhere to the MAUQ to assess usability and improve the utility of mHealth apps.

Barriers to surgery performed by non-physician clinicians in sub-Saharan Africa—a scoping review

Background
Sub-Saharan Africa (SSA) faces the highest burden of disease amenable to surgery while having the lowest surgeon to population ratio in the world. Some 25 SSA countries use surgical task-shifting from physicians to non-physician clinicians (NPCs) as a strategy to increase access to surgery. While many studies have investigated barriers to access to surgical services, there is a dearth of studies that examine the barriers to shifting of surgical tasks to, and the delivery of safe essential surgical care by NPCs, especially in rural areas of SSA. This study aims to identify those barriers and how they vary between surgical disciplines as well as between countries.

Methods
We performed a scoping review of articles published between 2000 and 2018, listed in PubMed or Embase. Full-text articles were read by two reviewers to identify barriers to surgical task-shifting. Cited barriers were counted and categorized, partly based on the World Health Organization (WHO) health systems building blocks.

Results
Sixty-two articles met the inclusion criteria, and 14 clusters of barriers were identified, which were assigned to four main categories: primary outcomes, NPC workforce, regulation, and environment and resources. Malawi, Tanzania, Uganda, and Mozambique had the largest number of articles reporting barriers, with Uganda reporting the largest variety of barriers from empirical studies only. Obstetric and gynaecologic surgery had more articles and cited barriers than other specialties.

Conclusion
A multitude of factors hampers the provision of surgery by NPCs across SSA. The two main issues are surgical pre-requisites and the need for regulatory and professional frameworks to legitimate and control the surgical practice of NPCs.

Hashtag Global Surgery: The Role of Social Media in Advancing the Field of Global Surgery

Introduction: Surgery is increasingly recognized as an indispensable part of healthcare, but lack of awareness about its cost-effectiveness and cross-cutting impact remain. Social media has become an important resource for healthcare professionals in a variety of settings due to its instant global reach in a non-discriminatory and low-threshold manner. In 2010, #globalsurgery was first used on Twitter to spread awareness, foster international collaborations, and raise voices of advocates around the world. Here, we examine the role of social media in the field of global surgery.

Methods: The use of #globalsurgery on Twitter was analyzed through Tweetreach from July 31 to December 31, 2018. Additional analysis of hashtags in Spanish, Japanese, Malay, and Portuguese was done to determine the number of tweets, retweets, impressions, and users using #globalsurgery or translated hashtags. Sentiment analysis was performed to determine the affective state of tweets.

Results: A total of 4,519 tweets and 15,861 retweets were posted by 4,449 different contributors. Tweets totalled 58,733,406 potential direct impressions and 46,560,293 potential amplified impressions, with potential reach of 11,272,014. English was the major language (99.47%), followed by Spanish (0.49%) and Japanese (0.04%). Portuguese and Malay hashtags were not used during the study period.

Conclusion: #globalsurgery provides an innovative way to overcome barriers and strengthen collaboration among advocates, and more effectively raise awareness about global surgery.

Oxygen availability in sub-Saharan African countries: a call for data to inform service delivery

Oxygen is central to the management of patients admitted to hospital with severe COVID-19. Furthermore, the availability of oxygen therapy is just as important for the management of other patients who are acutely ill. However, despite recognition from most health-care providers that oxygen is a fundamental component of a health-care system, it has not been a focus of health-care delivery in sub-Saharan African countries, as shown by the lack of data collected on oxygen availability.