Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in ...illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.
Abstract
Five billion people lack timely, affordable access to surgery. A large proportion of these are children. Qualitative research investigating the barriers to surgical care for children and ...ways of overcoming them is lacking. This study focused on children with hernia, a very common paediatric surgical condition for which surgery is the only effective treatment. The main aim of this qualitative study was to explore barriers to surgical care for children and identify potential solutions. Data were collected from parents of children with hernia and from health care providers at Soroti Regional Referral Hospital in eastern Uganda. Parents’ experiences, motives and barriers when accessing care were explored. The health care providers’ knowledge, perceptions and practices relating to children with hernia were investigated. The data were analysed using thematic content analysis. Traditional beliefs and gender inequality were considered major issues. Possible solutions included partnering with the local community in efforts to increase knowledge and acceptability in the community in general and by parents in particular. A formation of a surgical team dedicated to the management of children with surgical conditions was suggested as way to improve quality and increase volume of surgery for children.
The mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, ...governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures.
This prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data.
Among the 546 patients, 111 (20.3%) had femur fractures and their median IQR length of hospitalization was 27 days 14, 36 days. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained.
Femur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.
Abstract
Background
The epidemiology and cost of surgical care delivery in low-and middle-income countries (LMICs) is poorly understood. This study characterizes the cost of surgical care, rate of ...catastrophic medical expenditure and medical impoverishment, and impact of surgical hospitalization on patients’ households at Soroti Regional Referral Hospital (SRRH), Uganda.
Methods
We prospectively collected demographic, clinical, and cost data from all surgical inpatients and caregivers at SRRH between February 2018 and January 2019. We conducted and thematically analyzed qualitative interviews to discern the impact of hospitalization on patients’ households. We employed the chi-square, t-test, ANOVA, and Bonferroni tests and built regression models to identify predictors of societal cost of surgical care. Out of pocket spending (OOPS) and catastrophic expenses were determined.
Results
We encountered 546 patients, mostly male (62%) peasant farmers (42%), at a median age of 22 years; and 615 caregivers, typically married (87%), female (69%), at a median age of 35 years. Femur fractures (20.4%), soft tissue infections (12.3%), and non-femur fractures (11.9%) were commonest. The total societal cost of surgical care was USD 147,378 with femur fractures (USD 47,879), intestinal obstruction (USD 18,737) and non-femur fractures (USD 10,212) as the leading contributors. Procedures (40%) and supplies (12%) were the largest components of societal cost. About 29% of patients suffered catastrophic expenses and 31% were medically impoverished.
Conclusion
Despite free care, surgical conditions cause catastrophic expenses and impoverishment in Uganda. Femur fracture is the most expensive surgical condition due to prolonged hospitalization associated with traction immobilization and lack of treatment modalities with shorter hospitalization.
Abstract Background Surgical care delivery is poorly understood in resource-limited settings. To effectively move toward universal health coverage, there is a critical need to understand surgical ...care delivery in developing countries. This study aims to identify the barriers and facilitators of surgical care delivery at Soroti Regional Referral Hospital in Uganda. Methods In this mixed methods study, we (1) applied the Surgeons OverSeas’ Personnel, Infrastructure, Procedures, Equipment, and Supplies tool to assess surgical capacity; (2) retrospectively reviewed inpatient records; (3) conducted four semistructured focus group discussions with 18 purposively sampled providers involved in perioperative care; and (4) observed the perioperative process of care using a time and motion approach. Descriptive statistics were generated from quantitative data. Qualitative data were thematically analyzed. Results The Personnel, Infrastructure, Procedures, Equipment, and Supplies survey revealed severe deficiencies in workforce ( P -score = 14) and infrastructure ( I -score = 5). Equipment, supplies, and procedures were generally available. Male and female wards were overbooked 83% and 60% of the time, respectively. Providers identified lack of space, patient overload, and superfluous patients' attendants as barriers to surgical care. Workforce challenges were tackled using teamwork and task sharing. Inadequate equipment and processes were addressed using improvisations. All observed subjects ( n = 31) received interventions. The median decision-to-intervention time was 2.5 h (IQR, 0.4, 21.4). However, 48% of subjects experienced delays. Median decision-to-intervention delay was 14.8 h (IQR, 0.9, 26.6). Conclusions Despite severe workforce and physical infrastructural deficiencies at Soroti Regional Referral Hospital, providers are adjusting and innovating to deliver surgical care.
ObjectiveThis study investigated the surgical services for children at the highest levels of the public healthcare sector in Uganda. The aim was to determine volumes and types of procedure performed ...and the patients and the human resource involved.DesignThe study was a facility-based, record review.SettingThe study was carried out at the National Referral Hospital, all 14 regional referral hospitals and 14 general hospitals in Uganda, representing the highest levels of hospital in the public healthcare sector.ParticipantsThe subjects were children <18 years who underwent major surgery in the study hospitals during 2013 and 2014.ResultsThe study hospitals contribute with an average annual rate of paediatric surgery at 22.0 per 100 000 paediatric population. This is a fraction of the estimated need. Most of the procedures were performed for congenital anomalies (n=3111, 39.4%), inflammation and infection (n=2264, 28.7%) and trauma (n=1210, 15.3%). Specialist surgeons performed 60.3% (n=4758) of the procedures, and anaesthesia was administered by specialist physician anaesthetists in 11.6% (n=917) of the cases.ConclusionsA variety of paediatric surgical procedures are performed in a relatively decentralised system throughout Uganda. Task shifting and task sharing of surgery and anaesthesia are widespread: a large proportion of surgical procedures was carried out by non-specialist physicians, with anaesthesia mostly delivered by non-physician anaesthetists. Reinforcing the capacity and promoting the expansion of the health facilities studied, in particular the general hospitals and regional referral hospitals, could help reduce the immense unmet need for surgical services for children in Uganda.
Blood and blood products are essential in the management of injuries, medical illnesses, and childbirth. Chronic shortages in the blood supply perpetuates the high levels of morbidity and mortality ...from injury and treatable diseases. Patients in low- and middle-income countries are frequently unable to access blood units necessary for transfusion in a timely manner.
This study aimed to gain insight into the community and hospital factors that contribute to the observed insufficient supply of blood units available for transfusion at a regional referral hospital in rural Eastern Uganda.
A mixed-methods approach was utilized; community members were surveyed on knowledge, attitudes, and practices of blood donation and health professionals were queried on hospital factors affecting blood transfusions. Transfusion records were prospectively collected and analyzed, and the pathway of a single blood unit was observed and recorded.
Among the 82 community members that were surveyed, knowledge was poor (<50% correct) regarding age, weight, and volume of blood to be able to donate, but participants were overall knowledgeable on general characteristics that would exclude individuals from donating blood. Major themes elicited during qualitative interviews included a positive attitude towards and lack of information regarding blood donation. Health professionals expressed frustration in delayed testing of transfusion transmissible infections. The majority of blood transfusions were allocated to female patients (55.8%) and children under five years of age (33.2%).
Broadened inclusion and education of the general population in blood donation and increased outreach programs may be promising interventions to increase the blood supply at the Soroti Regional Referral Hospital. To reduce the current bottleneck seen in TTI testing, the feasibility and cost-effectiveness of local TTI testing technology should be investigated further.
Conjoined twins are rare congenital malformations that occur in identical twins who share both a placenta and an amniotic sac. If one twin dies, emergency separation is necessary to save the other ...twin.
A pair of conjoined twin girls, one stillborn and one alive, was referred to our facility 18 hours after delivery from a primary health facility. The twins were diagnosed at birth in a primigravida who had obstructed labor and were delivered by emergency cesarean section. They were joined at the lower chest and upper abdomen and had separate umbilical cords. Imaging studies to determine the extent of organ involvement in the twins were not conducted due to the unavailability of the necessary equipment at our facility. By the second day of life, the surviving twin showed sepsis and was given intravenous fluids and antibiotics. On the sixth day of life, they were taken to the operating room for separation. The twins shared part of the abdominal wall, part of the chest wall and had fused livers, all of which were separated. Following the operation, the surviving twin was treated for sepsis and received nutritional rehabilitation. After a hospital stay of six weeks she was discharged home.
An urgent operation to separate conjoined twins when one of them is stillborn is mandatory, even in a setting with limited diagnostic and surgical capabilities.
Background
The role of surgery in global health has gained greater attention in recent years. Approximately 1.8 billion children below 15 years live in low- and middle-income countries (LMIC). Many ...surgical conditions affect children. Therefore, paediatric surgery requires specific emphasis. Left unattended, the consequences can be dire. Despite this, there is a paucity of data regarding prevalence of surgical conditions in children in LMIC. The present objective was to investigate the prevalence of paediatric surgical conditions in children in a defined geographical area in Eastern Uganda.
Method
A cross-sectional study was carried out in the Iganga-Mayuge Health and Demographic Surveillance Site located in Eastern Uganda. Through a two-stage, cluster-based sampling process, 490 households from 49 villages were randomly selected, generating a study population of 1581 children. The children’s caregivers were interviewed, and the children were physically examined by two medical doctors to identify any surgical conditions.
Results
The interview was performed with 1581 children, and 1054 were physically examined. Among these, the overall prevalence of any surgical condition was 16.0 per cent (
n
= 169). Of these, 39 per cent had an unmet surgical need (66 of 169). This is equivalent to a 6.3 per cent prevalence of current unmet surgical need. The most common groups of surgical condition were congenital anomalies and trauma-related conditions.
Conclusion
Surgical conditions in children are common in eastern Uganda. The unmet need for surgery is high. With a growing population, the need for paediatric surgical capacity will increase even further. The health care system must be reinforced to provide services for children with surgical conditions if United Nations Sustainability Development Goal 3 is to be achieved by 2030.
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