O. C. Nwanna-Nzewunwa1, M. Ajiko2, F. Kirya2, J. Epodoi2, F. Kabagenyi2, I. Feldhaus1, R. A. Dicker1, C. Juillard1 1University Of California – San Francisco,Center For Global Surgical Studies,San Francisco, CA, USA 2Soroti Regional Referral Hospital,Surgery,Soroti, SOROTI, Uganda
Introduction: Thirty percent of the global disease burden is surgical; yet, 71% of the world’s population lacks access to basic surgery. As a key component of universal health coverage, there is a critical need for a comprehensive assessment of existing surgical care. This study uses a mixed methods approach to evaluate the barriers and facilitators of quality surgical care delivery at a regional referral hospital in rural Uganda.
Methods: From 1st May to 22nd June 2015, we conducted quantitative and qualitative research activities to assess emergency surgical care at a regional referral hospital. The Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) tool from Surgeons OverSeas was used to evaluate surgical capacity. We reviewed hospital records from 1st May to 22nd June , 2015 to determine surgical inpatient volume and occupancy rates. Emergency surgical care processes were observed prospectively over 53 consecutive days using time-and-motion methodology. Descriptive statistical analyses were conducted on all quantitative components. Thematic analysis was conducted on four semi-structured focus group discussions with 18 purposively sampled providers involved in the process of surgical care delivery.
Results: The PIPES tool revealed severe deficiencies in personnel and infrastructure. Major barriers to quality were lacking infrastructure, inadequate skills and workforce, and large numbers of patients' attendants. Surgical inpatient volume was high, with wards booked beyond maximum bed capacity 83% and 60% of the time for males and females, respectively. Equipment, supplies, and procedures were generally available. Teamwork and dedication among providers were the main facilitators of quality care; challenges are tackled with teamwork, task sharing and innovative life-saving improvisations for lacking equipment (eg. underwater seal, chest tub) and processes. The median decision-to-intervention time (DIT) (n-31) was 2.5 hours [0.1 – 95]. However, 48.4% of subjects experienced delays. The median DIT delay was 14.8 hours [0.1 – 71.9].
Conclusion: The Regional Referral Hospital faces severe limitations in infrastructure, workforce, and skills required to adequately address the surgical needs of its population. We advocate for an increase in surgical workforce and training opportunities in conjunction with the expansion of the surgical wards and theater, in order to enhance the surgical capacity and cater for the huge surgical demand. There is a place for symbiotic partnerships with international development partners to improve surgical capacity and quality. The role of local policy and governance will be critical in creating an enabling environment for quality surgical care delivery and for sustainability.
