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Development of a Clinical Prediction Model for In‐hospital Mortality from the South African Cohort of the African Surgical Outcomes Study
AbstractBackgroundData on the factors that influence mortality after surgery in South Africa are scarce, and neither these data nor data on risk‐adjusted in‐hospital mortality after surgery are routinely collected. Predictors related to the context or setting of surgical care delivery may also provide insight into variation in practice. Variation must be addressed when planning for improvement of risk‐adjusted outcomes. Our objective was to identify the factors predicting in‐hospital mortality after surgery in South Africa from available data.MethodsA multivariable logistic regression model was developed to identify predictors of 30‐day in‐hospital mortality in surgical patients in South Africa. Data from the South African contribution to the African Surgical Outcomes Study were used and included 3800 cases from 51 hospitals. A forward stepwise regression technique was then employed to select for possible predictors prior to model specification. Model performance was evaluated by assessing calibration and discrimination. The South African Surgical Outcomes Study cohort was used to validate the model.ResultsVariables found to predict 30‐day in‐hospital mortality were age, American Society of Anesthesiologists Physical Status category, urgent or emergent surgery, major surgery, and gastrointestinal‐, head and neck‐, thoracic‐ and neurosurgery. The area under the receiver operating curve or c‐statistic was 0.859 (95% confidence interval: 0.827–0.892) for the full model. Calibration, as assessed using a calibration plot, was acceptable. Performance was similar in the validation cohort as compared to the derivation cohort.ConclusionThe prediction model did not include factors that can explain how the context of care influences post‐operative mortality in South Africa. It does, however, provide a basis for reporting risk‐adjusted perioperative mortality rate in the future, and identifies the types of surgery to be prioritised in quality improvement projects at a local or national level.
Quality of recovery after total hip and knee arthroplasty in South Africa: a national prospective observational cohort study
Abstract Background Encouraged by the widespread adoption of enhanced recovery protocols (ERPs) for elective total hip and knee arthroplasty (THA/TKA) in high-income countries, our nationwide multidisciplinary research group first performed a Delphi study to establish the framework for a unified ERP for THA/TKA in South Africa. The objectives of this second phase of changing practice were to document quality of patient recovery, record patient characteristics and audit standard perioperative practice. Methods From May to December 2018, nine South African public hospitals conducted a 10-week prospective observational study of patients undergoing THA/TKA. The primary outcome was ‘days alive and at home up to 30 days after surgery’ (DAH30) as a patient-centred measure of quality of recovery incorporating early death, hospital length of stay (LOS), discharge destination and readmission during the first 30 days after surgery. Preoperative patient characteristics and perioperative care were documented to audit practice. Results Twenty-one (10.1%) out of 207 enrolled patients had their surgery cancelled or postponed resulting in 186 study patients. No fatalities were recorded, median LOS was 4 (inter-quartile-range (IQR), 3–5) days and 30-day readmission rate was 3.8%, leading to a median DAH30 of 26 (25–27) days. Forty patients (21.5%) had pre-existing anaemia and 24 (12.9%) were morbidly obese. In the preoperative period, standard care involved assessment in an optimisation clinic, multidisciplinary education and full-body antiseptic wash for 67 (36.2%), 74 (40.0%) and 55 (30.1%) patients, respectively. On the first postoperative day, out-of-bed mobilisation was achieved by 69 (38.1%) patients while multimodal analgesic regimens (paracetamol and Non-Steroid-Anti-Inflammatory-Drugs) were administered to 29 patients (16.0%). Conclusion Quality of recovery measured by a median DAH30 of 26 days justifies performance of THA/TKA in South African public hospitals. That said, perioperative practice, including optimisation of modifiable risk factors, lacked standardisation suggesting that quality of patient care and postoperative recovery may improve with implementation of ERP principles. Notwithstanding the limited resources available, we anticipate that a change of practice for THA/TKA is feasible if ‘buy-in’ from the involved multidisciplinary units is obtained in the next phase of our nationwide ERP initiative. Trial registration The study was registered with ClinicalTrials.gov (NCT03540667).
A Multicenter, Cross-Sectional Quality Improvement Project: The Perioperative Implementation of a Hypertension Protocol by Anesthesiologists
BACKGROUND: Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of lifestyle modification for the management of hypertension. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. The study objective was for anesthesiologists to identify patients at the preoperative visit with previously undiagnosed or poorly controlled chronic hypertension and follow a simple management algorithm. METHODS: In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis and management of chronic hypertension. This was a multicenter, cross-sectional quality improvement project in 7 hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult in-patients had 2 sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated BP device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease had their surgery postponed and were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm in the diagnosis and management of hypertension. An 80% adherence rate was considered successful implementation. The secondary outcome was the adherence to the algorithm at discharge. RESULTS: Two hundred ninety-eight patients were screened for hypertension. One hundred six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline BP readings, 43 (40.6%) had stage 1, 22 (20.8%) stage 2, and 4 (3.8%) stage 3 hypertension, respectively. The adherence rate by the anesthesiologist in initiating treatment according to the algorithm was 89 of 106 (84.0%; 95% confidence interval [CI, 77.0–91.0). There was full adherence to the algorithm in 59 of 106 (55.5%; 95% CI, 46.2–65.1) at the time of discharge from hospital. CONCLUSIONS: Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multidisciplinary team.
Risks to healthcare workers following tracheal intubation of patients with COVID‐19: a prospective international multicentre cohort study
SummaryHealthcare workers involved in aerosol‐generating procedures, such as tracheal intubation, may be at elevated risk of acquiring COVID‐19. However, the magnitude of this risk is unknown. We conducted a prospective international multicentre cohort study recruiting healthcare workers participating in tracheal intubation of patients with suspected or confirmed COVID‐19. Information on tracheal intubation episodes, personal protective equipment use and subsequent provider health status was collected via self‐reporting. The primary endpoint was the incidence of laboratory‐confirmed COVID‐19 diagnosis or new symptoms requiring self‐isolation or hospitalisation after a tracheal intubation episode. Cox regression analysis examined associations between the primary endpoint and healthcare worker characteristics, procedure‐related factors and personal protective equipment use. Between 23 March and 2 June 2020, 1718 healthcare workers from 503 hospitals in 17 countries reported 5148 tracheal intubation episodes. The overall incidence of the primary endpoint was 10.7% over a median (IQR [range]) follow‐up of 32 (18–48 [0–116]) days. The cumulative incidence within 7, 14 and 21 days of the first tracheal intubation episode was 3.6%, 6.1% and 8.5%, respectively. The risk of the primary endpoint varied by country and was higher in women, but was not associated with other factors. Around 1 in 10 healthcare workers involved in tracheal intubation of patients with suspected or confirmed COVID‐19 subsequently reported a COVID‐19 outcome. This has human resource implications for institutional capacity to deliver essential healthcare services, and wider societal implications for COVID‐19 transmission.
The association between preoperative anemia and postoperative morbidity in pediatric surgical patients: A secondary analysis of a prospective observational cohort study
AbstractBackgroundThe prevalence of anemia in the South African pediatric surgical population is unknown. Anemia may be associated with increased postoperative complications. We are unaware of studies documenting these findings in patients in low‐ and middle‐income countries (LMICs).AimThe primary aim of this study was to describe the association between preoperative anemia and 26 defined postoperative complications, in noncardiac pediatric surgical patients. Secondary aims included describing the prevalence of anemia and risk factors for intraoperative blood transfusion.MethodThis was a secondary analysis of the South African Paediatric Surgical Outcomes Study, a prospective, observational surgical outcomes study. Inclusion criteria were all consecutive patients aged between 6 months and <16 years, presenting to participating centers during the study period who underwent elective and nonelective noncardiac surgery and had a preoperative hemoglobin recorded. Exclusion criteria were patients aged <6 months, undergoing cardiac surgery, or without a preoperative Hb recorded. To determine whether an independent association existed between preoperative anemia and postoperative complications, a hierarchical stepwise logistic regression was conducted.ResultsThere were 1094 eligible patients. In children in whom a preoperative Hb was recorded 46.2% had preoperative anemia. Preoperative anemia was independently associated with an increased risk of any postoperative complication (odds ratio 2.0, 95% confidence interval: 1.3‐3.1, P = .002). Preoperative anemia (odds ratio 3.6, 95% confidence interval: 1.8‐7.1, P < .001) was an independent predictor of intraoperative blood transfusion.ConclusionPreoperative anemia had a high prevalence in a LMIC and was associated with increased postoperative complications. The main limitation of our study is the ability to generalize the results to the wider pediatric surgical population, as these findings only relate to children in whom a preoperative Hb was recorded. Prospective studies are required to determine whether correction of preoperative anemia reduces morbidity and mortality in children undergoing noncardiac surgery.
Delphi prioritization and development of global surgery guidelines for the prevention of surgical-site infection
Abstract Background Most clinical guidelines are developed by high-income country institutions with little consideration given to either the evidence base for interventions in low- and middle-income countries (LMICs), or the specific challenges LMIC health systems may face in implementing recommendations. The aim of this study was to prioritize topics for future global surgery guidelines and then to develop a guideline for the top ranked topic. Methods A Delphi exercise identified and prioritized topics for guideline development. Once the top priority topic had been identified, relevant existing guidelines were identified and their recommendations were extracted. Recommendations were shortlisted if they were supported by at least two separate guidelines. Following two voting rounds, the final recommendations were agreed by an international guideline panel. The final recommendations were stratified by the guideline panel as essential (baseline measures that should be implemented as a priority) or desirable (some hospitals may lack these resources at present, in which case they should plan for future implementation). Results Prevention of surgical-site infection (SSI) after abdominal surgery was identified as the highest priority topic for guideline development. The international guideline panel reached consensus on nine essential clinical recommendations for prevention of SSI. These included recommendations concerning preoperative body wash, use of prophylactic antibiotics, decontamination of scrub teams' hands, use of antiseptic solutions for surgical site preparation and perioperative supplemental oxygenation. In addition, three desirable clinical recommendations and four recommendations for future research were agreed. Conclusion This process led to the development of a global surgery guideline for the prevention of SSI that is both clinically relevant and implementable in LMICs.
Africa’s critical care capacity before COVID-19
Critical care capabilities in affluent countries have been overwhelmed by the 2019 novel coronavirus disease (COVID-19) pandemic. Data from the African Surgical Outcomes Study (ASOS)1 suggests that this critical care crisis will be significantly worse in Africa.