Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study

Abstract
Introduction: In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India.

Methods: We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality.

Results: A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP100bpm) and bradycardia (HR<60bpm), hypoxia (SpO220brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality.

Conclusion: The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.

The landscape of academic global surgery: a rapid review

Interest in academic global surgery, which comprises clinical, educational, and research collaborations to improve surgical care between academic surgeons in high-income countries and low- and middle-income countries (LMICs) and their corresponding academic institutions, has grown over the years. However, there is no collective knowledge of academic global surgery. Thus, this review aims to understand the current landscape of academic global surgery and discuss future directions. A rapid review, a streamlined approach, was conducted to identify and summarize emerging studies systematically. The keywords applied in the search strategy were “global surgery” and “academic programs”. The total number of retrieved articles in PubMed was 390, and after the investigation, 20 articles were extensively reviewed for the result section. According to the results, this study provided findings regarding: (I) perceptions of residents, faculty, and surgical program directors toward academic global surgery programs, (II) key program characteristics of implemented academic global surgery programs, and (III) evaluation results of available academic global surgery programs. We also drew lessons and challenges for a useful guide for future academic global surgery research and the development of optimal educational programs. This review identified a small but rich set of information on academic global surgery. Further research and discussion are needed on how to successfully incorporate the academic global surgery program into medical institutions

Assessing Patient Safety Culture: Application of the Safety Attitudes Questionnaire in a Kenyan Setting

Background:
Patient safety has recently been declared a global health priority. Achievement and sustenance of a culture of patient safety require a regular and timely assessment of the organization. The Safety Attitudes Questionnaire is a patient safety culture assessment tool whose usefulness has been established in countries, but a few studies have been published from Africa, more so, in Kenyan settings.

Objective:
To evaluate the reliability of the Safety Attitudes Questionnaire in assessing the patient safety culture in a Kenyan setting and to assess healthcare workers’ perceptions of patient safety culture.

Methods:
A descriptive quantitative approach was utilized whereby the Safety Attitudes Questionnaire was administered to 241 healthcare workers in two public hospitals. The Cronbach’s α was calculated to determine the internal consistency of the SAQ. Descriptive and inferential statistics were used to analyze and describe the data on patient safety culture.

Results:
The total scale Cronbach’s alpha of the SAQ was 0.86, while that of the six dimensions was 0.65 to 0.90. The overall mean score of the total SAQ was 65.8 (9.9). Participants had the highest positive perception for Job Satisfaction with a mean score of 78.3 (16.1) while the lowest was evaluated for Stress Recognition with a mean score of 53.8 (28.6).

Conclusion:
The SAQ demonstrated satisfactory internal consistency and is suitable for use in the Kenyan context. The perception of patient safety culture in the Kenyan hospital is below international recommendations. There is a need for implementation of strategies for the improvement of the organization culture in Kenyan hospitals.

Towards a framework approach to integrating pathways for infection prevention and antibiotic stewardship in surgery: a qualitative study from India and South Africa

Background The surgical pathway remains a hard to reach, critical target for antimicrobial stewardship (AMS) and infection prevention and control (IPC). We investigated the drivers for surgical AMS and IPC, across cardiovascular and thoracic surgery (CVTS) and gastrointestinal surgery teams in two academic hospitals in South Africa (SA) and India. Materials and methods An ethnographic observational study of IPC and AMS was conducted (July 2018–August 2019), with data gathered from 190 hours of non-participant observations (138 India, 60 SA); face-to-face interviews with patients (6 India, 7 South Africa), and healthcare professionals (HCPs) (44 India, 61 SA); and, in-depth patient case studies (4 India, 2 SA). A grounded theory approach aided by Nvivo 11 software, analyzed the emerging themes. An iterative and recursive process of moving between the coded data and the higher-level themes, ensured saturation of the themes. The multiple modes of enquiry enabled cross-validation and triangulation of findings. Results Across surgical pathways, multiple barriers exist impeding effective IPC and AMS practices. The existing, implicit roles of HCPs (including nurses, and senior surgeons) are overlooked as interventions target junior doctors, bypassing the opportunity for integrating care across the surgical team members. Critically, the ownership of decisions remains with the operating surgeons and entrenched hierarchies restrict the integration of other HCPs in IPC and AMS. Conclusions IPC and AMS are not integrated in surgery. Identifying the implicit existing HCPs roles in IPC and AMS is critical and will facilitate the development of effective and transparent processes across the surgical team for IPC and AMS. Developing a framework approach that includes nurse leadership, empowering pharmacists and engaging surgical leads is essential for integrated care.

Patterns of neurosurgical conditions at a major government hospital in Cambodia

Background: Low- and middle-income countries (LMICs) have a growing and largely unaddressed neurosurgical burden. Cambodia has been an understudied country regarding the neurosurgical pathologies and case volume. Rapid infrastructure development with noncompliance of safety regulations has led to increased numbers of traumatic injuries. This study examines the neurosurgical caseload and pathologies of a single government institution implementing the first residency program in an effort to understand the neurosurgical needs of this population. Methods: This is a longitudinal descriptive study of all neurosurgical admissions at the Department of Neurosurgery at Preah Kossamak Hospital (PKH), a major government hospital, in Phnom Penh, Cambodia, between September 2013 and June 2018. Results: 5490 patients were admitted to PKH requiring neurosurgical evaluation and care. Most of these admissions were cranial injuries related to road traffic accidents primarily involving young men compared to women by approximately 4:1 ratio. Spinal pathologies were more evenly distributed in age and gender, with younger demographics more commonly presenting with traumatic injuries, while the older with degenerative conditions. Conclusions: Despite increased attention and efforts over the past decade, Cambodia’s neurosurgical burden mirrors that of other LMICs, with trauma affecting most patients either on the road or at the workplace. Currently, Cambodia has 34 neurosurgeons to address the growing burden of a country of 15 million with an increasing life expectancy of 69 years of age, stressing the importance of better public health policies and urgency for building capacity for safe and affordable neurosurgical care.