The environment under the knife: A review of current Eco-surgical strategies and recommendations for Pakistan

The healthcare sector at its core is based on the fundamentals belief to do no harm and bring about betterment in the lives of the people. Paradoxically, hospitals are one of the leading contributors to pollution, greenhouse gas (GHG) emissions and toxic waste material worldwide. Surgical care delivery is quite resource intensive, consuming significant amount of energy and equipment as well as producing large quantities of waste. With climate change being a global priority, it is crucial that hospitals re-evaluate the environmental impact of such practices. The current review was planned to identify areas of improvement in surgical care in terms of sustainability, as well as describe efficient and innovative strategies for hospitals in Pakistan to lessen their impact on the environment. The implementation of the 5 R’s strategy for surgical care (Reduce, Reuse, Recycle, Rethink and Research) as well as general measures to improve energy efficiency, waste management and inter-sectoral collaboration will provide significant benefits to the environment and advance efforts to creating a more sustainable future for surgical healthcare in Pakistan.

PakSurg: The first trainee-lead model for multicenter surgical research collaboration in Pakistan

We describe creation and piloting of the PakSurg Collaborative, devised via integration of existing trainee-led collaborative models in the United Kingdom with the resource-limited surgical care in Pakistan. This is the first trainee-lead surgical research collaborative in Pakistan, established by the student-lead Surgery Interest Group from the Aga Khan University. The project involved creation of a model that included a steering committee comprising of five teams which worked in conjunction with collaborators from multiple hospitals. To facilitate this collaboration, a comprehensive and cost-efficient study management pathway was developed. The PakSurg Collaborative has the potential to deliver methodologically robust, high-quality, multicenter surgical evidence from Pakistan. This nationally representative data could inform evidence-based surgical guidelines, potentially translating into improved outcomes for patients undergoing surgery.

Patient Safety Culture in Nurses in Karawang, Indonesia: A Cross-Sectional Study

Patient safety is crucial for health care quality and is one of the major parameters monitored by all health care organizations around the world. Nurses play a critical role in improving the quality of care and patient safety because they take care of patients for the full 24 hours and engage with families and other health professionals. Thus, this study aimed to identify patient safety culture and its associated factors among nurses in Karawang, Indonesia. This study was conducted using a cross-sectional design. It was estimated that 220 participants would be needed to have confidence in the results at a medium-effect size. A convenience sampling technique was applied to select participants. This study used the Hospital Survey on Patient Safety Culture questionnaire. Linear regression analyses were used to investigate the factors associated with patient safety culture. Most of the nurses (52.79%) had a nursing diploma and 7% had been married. Approximately 70% were nurses at the level 1 to 3 range. The mean score was 3.05 (SD = 1.43). The highest domains score was teamwork (4.03, SD = 1.76), and the lowest score was reporting patients’ safety events (2.21, SD = 1.43). Gender, education level, and working unit contributed significantly to the variance in patient safety culture and the R-squared was 28.8%. This study found that patient safety culture among nurses was moderate. Therefore, in order to improve patient safety, a training program for nurses is needed alongside strategies to improve professional communication.

‘Coming home does not mean that the injury has gone’—exploring the lived experience of socioeconomic and quality of life outcomes in post-discharge trauma patients in urban India

Trauma results in long-term socioeconomic outcomes that affect quality of life (QOL) after discharge. However, there is limited research on the lived experience of these outcomes and QOL from low – and middle-income countries. The aim of this study was to explore the different socioeconomic and QOL outcomes that trauma patients have experienced during their recovery. We conducted semi-structured qualitative interviews of 21 adult trauma patients between three to eight months after discharge from two tertiary-care public hospitals in Mumbai, India. We performed thematic analysis to identify emerging themes within the range of different experiences of the participants across gender, age, and mechanism of injury. Three themes emerged in the analysis. Recovery is incomplete—even up to eight months post discharge, participants had needs unmet by the healthcare system. Recovery is expensive—participants struggled with a range of direct and indirect costs and had to adopt coping strategies. Recovery is intersocial—post-discharge socioeconomic and QOL outcomes of the participants were shaped by the nature of social support available and their sociodemographic characteristics. Provisioning affordable and accessible rehabilitation services, and linkages with support groups may improve these outcomes. Future research should look at the effect of age and gender on these outcomes.

Antibody levels and protection after Hepatitis B vaccine in adult vaccinated healthcare workers in northern Uganda

Hepatitis B vaccine has contributed to the reduction in hepatitis B virus infections and chronic disease globally. Screening to establish extent of vaccine induced immune response and provision of booster dose are limited in most low-and-middle income countries (LMICs). Our study investigated the extent of protective immune response and breakthrough hepatitis B virus infections among adult vaccinated healthcare workers in selected health facilities in northern Uganda. A cross-sectional study was conducted among 300 randomly selected adult hepatitis B vaccinated healthcare workers in Lira and Gulu regional referral hospitals in northern Uganda. Blood samples were collected and qualitative analysis of Hepatitis B surface antigen (HBsAg), Hepatitis B surface antigen antibody (HBsAb), Hepatitis B envelop antigen (HBeAg), Hepatitis B envelop antibody (HBeAb) and Hepatitis B core antibody (HBcAb) conducted using ELISA method. Quantitative assessment of anti-hepatitis B antibody (anti-HBs) levels was done using COBAS immunoassay analyzer. Multiple logistic regression was done to establish factors associated with protective anti-HBs levels (≥ 10mIU/mL) among adult vaccinate healthcare workers at 95% level of significance. A high proportion, 81.3% (244/300) of the study participants completed all three hepatitis B vaccine dose schedules. Two (0.7%, 2/300) of the study participants had active hepatitis B virus infection. Of the 300 study participants, 2.3% (7/300) had positive HBsAg; 88.7% (266/300) had detectable HBsAb; 2.3% (7/300) had positive HBeAg; 4% (12/300) had positive HBeAb and 17.7% (53/300) had positive HBcAb. Majority, 83% (249/300) had a protective hepatitis B antibody levels (≥10mIU/mL). Hepatitis B vaccine provides protective immunity against hepatitis B virus infection regardless of whether one gets a booster dose or not. Protective immune response persisted for over ten years following hepatitis B vaccination among the healthcare workers.

Competencies for Nurses Regarding Psychosocial Care of Patients With Cancer in Africa: An Imperative for Action

Psychosocial care is considered an important component of quality cancer care. Individuals treated for cancer can experience biologic or physical, emotional, spiritual, and practical consequences (eg, financial), which have an impact on their quality of living. With the establishment of cancer centers in Africa, there is growing advocacy regarding the need for psychosocial care, given the level of unmet supportive care needs and high emotional distress reported for patients. Nurses are in an ideal position to provide psychosocial care to patients with cancer and their families but must possess relevant knowledge and skills to do so. Across Africa, nurses are challenged in gaining the necessary education for psychosocial cancer care as programs vary in the amount of psychosocial content offered. This perspective article presents competencies regarding psychosocial care for nurses caring for patients with cancer in Africa. The competencies were adapted by expert consensus from existing evidenced-based competencies for oncology nurses. They are offered as a potential basis for educational program planning and curriculum development for cancer nursing in Africa. Recommendations are offered regarding use of these competencies by nursing and cancer program leaders to enhance the quality of care for African patients with cancer and their family members. The strategies emphasize building capacity of nurses to engage in effective delivery of psychosocial care for individuals with cancer and their family members.

The acceptability of delayed consent for prehospital emergency care research in the Western Cape province of South Africa

Background
Informed consent is an essential prerequisite for enrolling patients into a study. Obtaining informed consent in an emergency is complex and often impossible. Delayed consent has been suggested for emergency care research. This study aims to determine the acceptability of prehospital emergency care research with delayed consent in the Western Cape community of South Africa.

Methods
This study was an online survey of a stratified, representative sample of community members in the Western Cape province of South Africa. We calculated a powered sample size to be 385, and a stratified sampling method was employed. The survey was based on similar studies and piloted. Data were analysed descriptively.

Results
A total of 807 surveys were returned. Most respondents felt that enrolment into prehospital research would be acceptable if it offered direct benefit to them (n = 455; 68%) or if their condition was life-threatening and the research would identify improved treatment for future patients with a similar condition (n = 474; 70%). Similar results were appreciable when asked about the participation of their family member (n = 445; 66%) or their child (n = 422; 62%) regarding direct prospects of benefit. Overwhelmingly, respondents indicated that they would prefer to be informed of their own (n = 590; 85%), their family member’s (n = 593; 84%) or their child’s (n = 587; 86%) participation in a study immediately or as soon as possible. Only 35% (n = 283) agreed to retention data of deceased patients without the next of kin’s consent.

Conclusion
We report majority agreement of respondents for emergency care research with delayed consent if the interventions offered direct benefit to the research participant, if the participant’s condition was life-threatening and the work held the prospect of benefit for future patients, and if the protocol for delayed consent was approved by a human research ethics committee. These results should be explored using qualitative methods.

We Asked the Experts: The Tropical Surgeon: Everywhere in Chains But Not Imprisoned

Surgical practice in the tropics very much reminds one of the famous quote attributed to Jean-Jacques Rousseau: “Man is born free, but he is everywhere in chains”. The numerous and onerous challenges of tropical surgical practice are the metaphorical chains that bog down the tropical surgeon.

Poor government funding of health care and very low health insurance coverage in the tropics make surgery materials rarely available in operating theatres, necessitating patients having to buy these materials out-of-pocket (OOP), even in emergencies. The majority of patients cannot afford surgery materials OOP, owing to widespread poverty. This prolongs decision-to-incision time, consequently increasing perioperative morbidity and mortality.

Most hospitals depend on fuel-powered generators for electricity, due to epileptic power supply in the tropics. Cost of fuel is high, and most underfunded public hospitals cannot afford this expense sustainably. It is common for patients’ relatives to provide fuel to power generators for surgeries, especially in emergencies [1]. Surgeries are performed using lamps, phone torchlights or even sunlight. Even when power is available, operating theatres are poorly lit and lack basic supplies like running water, oxygen, functional anaesthesia machines, and even pulse oximeters [1]. It is common for surgeries to be postponed or cancelled because there is no oxygen or power supply in the operating theatre.

Unavailability of blood/blood products remains a significant cause of delayed decision-to-operating room time in the tropics. The bulk of blood donations are by replacement donors, who are usually patients’ relatives and friends. A patient may not have blood if his/her relative/friend has not donated, even for emergency procedures. These relatives often cannot afford the cross-match test, or are unable to donate due to blood incompatibility, or ineligibility, for various reasons.

Poor staffing is a perennial problem, resulting in surgical residents working for prolonged hours. Cumulative work hours of up to 123 h/week have been reported [2]. It is normal to have one house officer, one surgery registrar, and one specialist registrar on-call every day of the week in many surgical units in the tropics. These long work hours correlate with high rates of burnout, reduced quality of life, morbidity, and, in extreme cases, mortality, amongst surgical residents [2].

Even fewer than surgeons in the tropics, are anaesthetists. The anaesthetist-to-patient ratio is as low as 1:300,000, compared to 1;10,000 in developed countries [3]. Most of the available anaesthetists are employed in tertiary hospitals, leaving surgeons in secondary and private hospitals without much anaesthetist support [3]. This contributes to third-phase delay in the provision of surgical care in the tropics, whilst “waiting for the anaesthetist”, who may be unavailable. Surgeon-administered spinal anaesthesia and ketamine for emergency operations are commonplace, with an assistant monitoring the patient with a stethoscope attached to the patient’s chest and manually checking the vital signs at intervals, owing to non-functional or unavailable monitors [1, 3]. The surgeon in the tropics improvises many unavailable surgery equipment pieces, from using face towels as abdominal mops, to Foley’s catheter as chest tube.

Few functional operating theatres complement staff shortages in the tropics. In many hospitals, it is normal to find only one functional operating theatre, where all surgical cases, irrespective of specialty, are performed. Emergency surgeries are thus delayed, and elective procedures, often postponed or cancelled. These factors contribute significantly to high-case fatality rates (even from common, treatable surgical conditions) and reduced operative volumes in the tropics. Only 6% of the estimated 313 million surgical procedures undertaken globally each year occur in the tropics [4].

Aside from the challenges of practice, tropical surgeons lack motivation to undertake research due to a combination of lack of resources, poor funding, and other systemic factors. These factors force the tropical surgeon to do the researches that he can do, and not necessarily the researches that he should do. The outputs are mostly low-impact research works, which are at best published in local journals that are constrained by poor funding/subscription, infrequent publishing, long review times, and even longer times between acceptance and publication. Overtime, the tropical surgeon preferentially drops the pen for the scalpel.

Despite these challenges, the tropical surgeon has refused to be bogged down and has continued pushing the frontiers of surgical practice across different surgical specialties. Tropical surgeons are performing open heart surgeries, renal transplantations, minimal access general surgery, gynaecology and oncology operations, separation of conjoined twins, many major and complex hepatic, pancreatic, paediatric, plastic, and neurosurgeries, amongst several others, even with improvisations and local adaptations.

Outside of the theatre, many tropical surgeons have distinguished themselves as heads and members of different local, regional, and international health and surgical bodies/organisations, advancing the development of surgical care in their areas of influence. In the area of research, the recently published pragmatic multicentre factorial randomised controlled trial (RCT) testing measures to reduce surgical site infection in low- and middle-income countries (FALCON) is the largest RCT ever conducted across LMICs in the field of surgery. It was funded by the United Kingdom National Institute for Health Research (NIHR) and undertaken in 54 hospitals in seven countries, across three continents [5]. FALCON is an excellent example of how global collaboration can significantly address the challenges of, and improve surgical practice in the tropics.

There is an urgent need for concerted local and global efforts at finding solutions to the myriad of challenges bedevilling tropical surgical practice, if universal access to safe and affordable surgical care is to be improved. Public economic policies that engender economic growth and development would benefit health care delivery in the tropics. Government funding of health care should increase. This would guarantee availability of surgical supplies and equipment and improve infrastructural support in hospitals. Health insurance coverage should be optimised, and health-related savings encouraged amongst those not covered by health insurance. Public–private partnerships in public health care and funding of researches that impact tropical surgical practice are beneficial. These much and more were recommended by the Lancet Commission on Global Surgery, launched in 2014 to address the crucial gaps in access to surgical care in resource-poor countries [4]. Six years after the Commission published her Report, there is still a lot to be desired. It is time for a global re-awakening.

A qualitative study of barriers and facilitators to adequate environmental health conditions and infection control for healthcare workers in Malawi

The burden of healthcare-associated infections (HAIs) is greater in low- and middle-income countries than in high-income countries. Inadequate environmental health (EH) conditions and work systems contribute to HAIs in countries like Malawi. We collected qualitative data from 48 semi-structured interviews with healthcare workers (HCWs) from 45 healthcare facilities (HCFs) across Malawi and conducted a thematic analysis. The facilitators of infection prevention and control (IPC) practices in HCFs included disinfection practices, patient education, and waste management procedures. HCWs reported barriers such as lack of IPC training, bottlenecks in maintenance and repair, hand hygiene infrastructure, water provision, and personal protective equipment. This is one of the most comprehensive assessments to date of IPC practices and environmental conditions in Malawian HCFs in relation to HCWs. A comprehensive understanding of barriers and facilitators to IPC practices will help decision-makers craft better interventions and policies to support HCWs to protect themselves and their patients.

Cost Evaluation of Minimally Invasive Tissue Sampling (MITS) Implementation in Low- and Middle-Income Countries

Background
Low- and middle-income countries (LMICs) face disproportionately high mortality rates, yet the causes of death in LMICs are not robustly understood, limiting the effectiveness of interventions to reduce mortality. Minimally invasive tissue sampling (MITS) is a standardized postmortem examination method that holds promise for use in LMICs, where other approaches for determining cause of death are too costly or unacceptable. This study documents the costs associated with implementing the MITS procedure in LMICs from the healthcare provider perspective and aims to inform resource allocation decisions by public health decisionmakers.

Methods
We surveyed 4 sites in LMICs across Sub-Saharan Africa and South Asia with experience conducting MITS. Using a bottom-up costing approach, we collected direct costs of resources (labor and materials) to conduct MITS and the pre-implementation costs required to initiate MITS.

Results
Initial investments range widely yet represent a substantial cost to implement MITS and are determined by the existing infrastructure and needs of a site. The costs to conduct a single case range between $609 and $1028 per case and are driven by labor, sample testing, and MITS supplies costs.

Conclusions
Variation in each site’s use of staff roles and testing protocols suggests sites conducting MITS may adapt use of resources based on available expertise, equipment, and surveillance objectives. This study is a first step toward necessary examinations of cost-effectiveness, which may provide insight into cost optimization and economic justification for the expansion of MITS.