16.10 Benchmarking Statewide Trauma Mortality and Using AHRQ's Safety Indicators to Identify Intervention

Posted on December 22, 2014

D. Ang1, S. Kurek1, M. McKenney1, E. Barquist1, E. Barquist1, S. Norwood1, B. Kimbrell1, D. Villarreal1, H. Liu1, M. Ziglar2, J. Hurst1  1University Of South Florida College Of Medicine,Tampa, FL, USA 2Hospital Corporation Of America,Nashville, TENNESSEE, USA

Introduction:   Improving clinical outcomes of trauma patients is a challenging problem at a statewide level, particularly if data from the State’s registry is not publically available.  Promotion of optimal care throughout the State is not possible unless clinical benchmarks are available for comparison.  Using publically available administrative data from the State’s Department of Health and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSI), we sought to create a statewide method for benchmarking trauma mortality while also identifying a pattern of unique complications that have an independent influence on mortality. 

Methods: Data for this study was obtained from State’s Agency for Health Care Administration (AHCA). Adult trauma patients were identified as having ICD-9 codes defined by the State. Stepwise logistic regression was used in order to create a parsimonious and predictive inpatient expected mortality model. The expected value of PSIs was created in a similar method using a multivariate model provided by the AHRQ.  Case mix adjusted mortality results were reported as observed to expected ratios (O/E).

Results:There were 37,793 trauma patients evaluated during the study period.  The overall fit of the expected mortality model was very strong at a c-statistic of 0.891.  Eleven out of 25 trauma centers had O/E ratios less than one, or better than expected.  Six statewide PSIs had O/E ratios higher than expected.  The PSI which had the strongest influence on trauma mortality for the State was PSI# 4 or death among surgical Inpatients with serious treatable complications.  Mortality could be further sub-stratified by complications at the hospital level.

Conclusion:This method offers an adjusted benchmarking method which screens at risk trauma centers in the State for higher than expected mortality.  Stratifying mortality based on Patient Safety Indicators may identify areas of needed improvement at a statewide level. 

 

16.11 Massive Transfusion Protocol: From Zero To Hero

Posted on December 22, 2014

I. A. Struve1, E. S. Salcedo1, C. S. Marshall1, J. M. Galante1  1University Of California – Davis,School Of Medicine,Sacramento, CA, USA

Introduction:  The Massive Transfusion Protocol (MTP) facilitates rapid transfusion of blood components for patients in hemorrhagic shock.  MTP implementation is highly resource intensive.  Rapid deployment of all available transfusion service personnel is necessary to prepare and issue blood products promptly.  This study explores factors contributing to appropriate blood product use with MTP activation in a Level 1 Trauma Center.  We aim to establish a quality benchmark for the use of a limited resource.  

Methods:  Records of patients, for whom MTP was activated, from 3-month intervals over three consecutive years, were reviewed.  Data collected includes: ordering specialty, patient location at the time of activation, and units transfused at 6 hours and at 24 hours.  The primary outcome assessed was zero-use rates, which were compared by ordering specialty and patient location at the time of MTP activation.  Zero-use was defined as zero PRBC units transfused at 24 hours following MTP activation. Secondary outcomes assessed were median PRBC units transfused and Crossed-To-Transfused (C:T) ratios, both compared by specialty and location. Categorical variables were compared with the chi-square test and continuous variables with confidence intervals using alpha=0.05.

Results:  MTP was activated for 183 patients. The predominant specialties that activated MTP were emergency medicine (43%), surgery (24%), and anesthesia (22%), The predominant patient locations at the time of MTP activation were the ER (50%) and the OR (43%). Zero-use rates compared between predominant ordering specialties were not significant (p=0.75). Zero-use rates compared between the ER and the OR were significant (p=0.008) (Table 1). When MTP did not result in zero use, only activations made with the patient in the OR results in massive transfusion (MT) (6 units) (Table 1). 

Conclusion:  Patient location at the time of MTP activation is a significant predictor of appropriate MTP use. The OR is superior likely because the source and extent of hemorrhage is directly visualized. In the OR, zero-use rates are lowest and the median number of transfused units are 6 within 6 hours, an accepted definition of massive transfusion.  Using the OR as a model for appropriate MTP activation, we propose a zero-use rate benchmark of 15%. 

 

16.12 Reduced Mortality in Females After Traumatic Hemorrhage: Does It Extend to Non-Traumatic Hemorrhage?

Posted on December 22, 2014

H. Alshaikh1, S. Selvarajah1, N. Nagarajan1, F. Gani1, C. K. Zogg1, H. Alturki1, A. Najafian1, D. T. Efron2, C. G. Velopulos2, E. B. Schneider1, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Johns Hopkins University School Of Medicine,Department Of Surgery,Baltimore, MD, USA

Introduction:  Multiple studies have demonstrated gender dimorphism in survival after trauma-induced hemorrhage. These findings have led to gender based therapeutics such as the administration of progesterone to males after injury. However, the potential survival benefit females may enjoy has not been well studied in non-traumatic emergency situations such as gastrointestinal (GI) hemorrhage. The objective of this study was to examine the association between gender and survival in patients presenting with acute non-traumatic GI hemorrhage using a nationally representative database. 

Methods:  Using Nationwide Inpatient Sample (NIS) data from 2007-2011, adults admitted through the emergency department with GI hemorrhage were identified using ICD-9 diagnosis code (578.*). Patients <18 years of age were excluded as were patients with missing demographic information and elective admissions. Weighted univariate and multivariable logistic regression was done to assess the relationship between gender and in-hospital mortality. The adjusted analysis controlled for demographic factors, hospital characteristics, patient transfer status and patient clinical severity. Severity was assessed using All-Patient Refined Diagnosis-Related Group (APR-DRG) severity scores. 

Results: A total of 809,798 weighted inpatient visits met the inclusion criteria, 51% of patient were female. Mean age was higher for women compared with men (72.1 vs. 65.8, p<0.001). Non-operative intervention was common among therapeutic options, including esophagogastroduodenoscopy (27.5%), small intestine endoscopy (26.5%) and colonoscopy (16.9%). About 43.9% of patients received blood transfusion, with higher proportion of women receiving them (51.7% vs. 48.3%, p<0.001). The proportion of patients with APR-DRG severity scores 1 and 2 (non-severe) was 52.9% for females (95%CI=52.3-53.6) and 52.4% for males (95%CI=51.7-53.1). Women demonstrated 14% lower unadjusted odds of death compared with men (OR 0.86, 95% CI 0.82-0.91). Moreover after adjustment, women demonstrated 22% lower odds of in-hospital mortality compared with men (OR 0.78, 95% CI 0.74-0.82). Alternative regression models were consistent with these results.

Conclusion: Females demonstrated significantly lower mortality after emergent GI hemorrhage despite controlling for severity and age. This evidence, in conjunction with other studies that demonstrate lower female mortality in traumatic hemorrhage, should prompt researchers to further investigate potential gender-related physiological pathways that could be altered by novel therapeutic options to improve patient outcomes.

16.13 Evaluation Of A Clinical Management Guideline For Tube Thoracostomy Removal In Trauma Patients

Posted on December 22, 2014

J. A. Marks1, G. Telford1, J. McMaster1, N. D. Martin1, P. Kim1  1University Of Pennsylvania,Division Of Traumatology, Surgical Critical Care And Emergency Surgery,Philadelphia, PA, USA

Introduction:
Recurrent pneumothorax after chest tube removal is a potential complication in trauma patients.  One potential mitigating maneuver is placement of a U-stitch at the skin incision during initial tube placement that is tied down during tube removal.  In this study, we evaluate this performance improvement initiative and its efficacy.

Methods:
At our urban, level one trauma center, we implemented a  Clinical Management Guideline (CMG) mandating U-stitch placement with all chest tubes in January 2012. The CMG further dictates that the procedure is performed by two providers. One provider secures the skin suture, and the second provider maintains an occlusive dressing with Vaseline and dry gauze. The tube is removed at end inspiration, or while patient performs Valsalva maneuver. A chest x ray is performed 4-6 hours after tube thoracostomy is removed.  Data was collected from our prospectively entered performance improvement database comparing pre and post CMG implementation.  

Results:
During the year preceding CMG implementation there were 9 recurrent pneumothoraces requiring reinsertion of a chest tube out of a total of 172 chest tube placements (5.2% recurrence rate).  In the two years after the CMG was instituted, recurrences were reduced to 1 out of 177 (0.6%) and 1 out of 139 (0.7%), respectively (p<0.002) (FIGURE).

Conclusion:
Recurrent pneumothorax after chest tube removal is a significant complication.  Placement of a U-stitch as part of a CMG can significantly reduce this complication.  This CMG should be considered broadly for all traumatic chest tube removals. 
 

16.14 Airway Management of Trauma Patients as an Indicator of Quality in a Pre-Hospital Flight Program

Posted on December 22, 2014

R. Weston1, D. Chesire1, D. Meysenburg1, J. Fortner1, R. Houghton1, K. Solomon1, B. Burns1  1University Of Florida,College Of Medicine,Jacksonville, FL, USA

Introduction:  Airway compromise has been identified as a preventable cause of poor outcomes and death in trauma patients. Given its importance, pre-hospital airway management is vital and can be used as a valuable indicator of critical care quality.  The purpose of this study was to analyze successful pre-hospital airway management performed by helicopter flight staff.    

Methods:  This retrospective chart review evaluated all flight crew airway interventions involving trauma patients between January 1, 2008 through December 31, 2013. Descriptive statistics were used on the number of successful intubations as well as alternative airways.

Results: Of a total of 191 trauma patients requiring airway intervention,  167 were endotracheal intubations (87.4%), 24 were alternative airway intervention such as laryngeal mask airway, combitube or bag valve mask (12.5%). Of the endotracheal intubations, 80.1% were successfully placed by flight crew on their first attempt and the overall success rate was 94.2%. Of the intubations attempted by the flight crew, 43 patients had unsuccessful attempted endotracheal intubation by ground crew.  Of these, the flight crew was ultimately successful at placing an endotracheal tube in  41/43 (95.3%) trauma patients.

Conclusion: High endotracheal success rate by flight personnel suggests that medical air transport is more than just an expedited transport mode to the hospital; it can be considered a mobile critical care unit. The fact that 95.3% of previously attempted airways were “rescued” by the flight crew further demonstrates a higher level of care administered in the field
 

16.15 Missed Tetanus Prophylaxis in Severe Trauma Patients at a Level One Academic Trauma Center

Posted on December 22, 2014

E. O. Pierce1, J. B. Brock1, A. V. Dukes1, C. Stevens1, T. E. Robertson1  1University Of Mississippi,Surgery,Jackson, MS, USA

Introduction:
Tetanus has become an uncommon disease in developed countries due to vaccinations. Appropriate tetanus prophylaxis continues to be a problem, allowing for tetanus cases to still occur in the United States. The Advisory Committee on Immunization Practices (ACIP) recommends that tetanus-prone wounds be given prophylaxis.  Tetanus-prone wounds are contaminated wounds, including abrasions, as well as puncture wounds, avulsions, missiles, crushes, burns or frostbite. The purpose of this study was to determine if there are missed tetanus vaccination opportunities at a level one academic trauma center.

Methods:
A retrospective chart review was performed on severe trauma patients between July 2012 and June 2014. All leveled trauma patients ages 18 and older who met the Trauma Quality Improvement Program (TQIP) inclusion criteria were reviewed. These patients were compared to patients given tetanus prophylaxis in our institution. The results were further evaluated by age of patient, type of trauma (blunt, penetrating, burns), and type of presentation (transfer from outside hospital, direct presentation from the scene).

Results:
4,319 patients ages 18 and over presented as leveled traumas during the given time period. Of these, 30.2% received the recommended tetanus prophylaxis. 571 of these leveled trauma patients (13%) were greater than 65 years of age and 19.6% of these patients received tetanus prophylaxis. There were 3,314 blunt traumas and 27.8% of these received prophylaxes. There were 945 penetrating traumas and 37.7% of these received prophylaxes. There were 36 burns and 58.3% of these received prophylaxes. 1,586 patients were transferred from outside hospitals and 2,667 were brought in directly from the trauma scene. 13.4% of transfers received prophylaxis and 39.9% of direct responses received prophylaxis

Conclusion:
A large number of trauma patients are not receiving tetanus prophylaxis despite presenting with tetanus-prone wounds. Immunization status could not be gleaned from this retrospective chart review, but most adults after major trauma are unable to recall their immunization status. Patients who were transferred from another center may have received immunization there, but even primary response teams from the scene had only a 40% immunization rate. All penetrating wounds meet vaccination criteria and blunt may or may not include a tetanus prone wound, but considering the risks and benefits of vaccination, it would be reasonable to have all traumas receive tetanus prophylaxis. Major blunt trauma rarely presents without an abrasion. Further research will include provider education and systems improvements to determine the best mechanism to increase vaccination rates. There are missed tetanus vaccination opportunities at this level one academic trauma center.
 

16.16 Structured Interdisciplinary Rounds (SIR) on a Trauma Ward

Posted on December 22, 2014

A. E. Liepert1, D. Segersten1, H. Jung1, A. O’Rourke1, S. Agarwal1  1University Of Wisconsin,Department Of Surgery,Madison, WI, USA

Introduction: Patient satisfaction is becoming an important factor in healthcare reimbursement. Structured interdisciplinary rounding (SIR) has been shown to be effective in improving patient care and satisfaction, but trauma has often been excluded as this population is associated with uncertainty in presentation, hospital course, and outcome. We examined the impact of non-ICU interdisciplinary rounding upon trauma patient satisfaction.

Methods: Over a nine-month period, patient satisfaction scores were reported in the trauma inpatient population before and after intervention of SIR at our ACS verified Level One trauma center. Pre-intervention rounding consisted of separate physician (resident and attending) examination and discussion with patients, whereas the intervention group consisted of bedside rounds with physicians (resident and attending), nursing, pharmacy, nutrition, physical therapy, occupational therapy, and social work. Scripted and practiced communication between team members, patients and families was instituted. Patient satisfaction surveys were mailed to patients at time of discharge, collected, and reported in rolling three month reports. As this was a quality improvement initiative, with aggregate data devoid of patient identifiers, the study is exempt from Institutional Review Board review.

Results: 2339 trauma patients were admitted to the hospital, of which 829 patients were admitted to the trauma care ward, making up 67% of the floor’s total population. From patient satisfaction surveys, patient perception of satisfaction in nursing communication revealed an overall downward trend (83.3% to 76.9%); however, patient perception of physician communication improved (nadir 69.6% to 76.9%).

Conclusion: The implementation of SIR can have an impact upon patient satisfaction in the trauma population. Future studies examining team communication and patient outcome need to be performed to fully evaluate the impact of this intervention.

 

14.07 Rectal bleeding and hidden colorectal diseases in Nepal: A cross sectional countrywide survey

Posted on December 22, 2014

P. Ghimire7, S. Gupta1,2, J. Pathak6, T. P. Kingham2,3, A. L. Kushner2,5, B. C. Nwomeh2,4  1University Of California – San Francisco , East Bay,Surgery,Oakland, CA, USA 2Surgeons OverSeas,New York, NY, USA 3Memorial Sloan-Kettering Cancer Center,Surgery,New York, NY, USA 4Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 5Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 6Kathmandu Medical College,Kathmandu, , Nepal 7B.P.Koirala Institute Of Health Science,Dharan, , Nepal

Introduction:  Because rectal bleeding is a cardinal symptom of many colorectal diseases including colorectal cancers, its presence alone could give insight into the prevalence of these conditions where direct population screening is lacking. In South Asia, which is home to over one fifth of the world’s population, there is paucity of epidemiologic data on colorectal diseases, particularly in the lower-income countries (LIC) such as Nepal.  The aim of this study is to enumerate the prevalence of rectal bleeding in Nepal and increase understanding of colorectal diseases as a health problem in the South Asian region.

Methods:  A countrywide survey utilizing the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool was administered from May 25th to June 12th 2014 in 15 of the 75 districts of Nepal, randomly selected proportional to population.  In each district, three Village Development Committees were selected randomly, two rural and one urban based on the Demographic Health Survey methodology.  Individuals were interviewed to determine the period and point prevalence of rectal bleeding, and patterns of health-seeking behavior related to surgical care for this problem.  Individuals aged over 18 were included in this analysis.

Results:  A total of 1350 households and 2,695 individuals were surveyed with a 97% response rate.   Thirty-eight individuals (55% male) of the 1,941 individuals 18 years and older stated they had experienced rectal bleeding (2.0%, 95% CI 1.4% to 2.7%), with a mean age of 45.5 (SD 2.2).  Of these 38 individuals, 30 stated they currently experience rectal bleeding.  Healthcare was sought in 18 participants with current rectal bleeding, with 2 major procedures performed, one an operation for an anal fistula.  For those who sought healthcare but did not receive surgical care, reasons included no need (4), not available (6), fear/no trust (5) and no money for healthcare (1).  For those with current rectal bleeding who did not seek healthcare, reasons included no need (1), not available (2), fear/no trust (6) and no money for healthcare (4).  Twenty-four individuals had an unmet surgical need secondary to rectal bleeding (1.2%, 95% CI 0.8% to 1.8%).

Conclusion:  The Nepal healthcare system at present does not emphasize the importance of surveillance colonoscopies or initial diagnostics by a primary care physician for rectal bleeding.  Our data demonstrate limited access for patients to undergo evaluation of rectal bleeding by a healthcare professional, and that potentially there are people in Nepal with rectal bleeding that may have undiagnosed colorectal cancer.  Further advocacy for preventative medicine and easier access to surgical care in LIC is crucial to avoid emergency surgeries, advanced stage malignancies or fatalities from treatable conditions.

 

14.08 Designing an International Partnership to Improve Surgical Training in a Low-Income Country

Posted on December 22, 2014

E. Snyder1, V. Amado3, M. Jacobe3, M. Bruzoni1, D. Mapasse3, D. DeUgarte2  1Stanford University,School Of Medicine,Palo Alto, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Los Angeles, CA, USA 3Eduardo Mondlane University,School Of Medicine,Maputo, MAPUTO, Mozambique

Introduction:  Sub-Saharan Africa has the lowest number of surgeons per population in the world. Mozambique has 0.2 general surgeons per 100,000 people whereas the United States has 7 per 100,000. Mozambique’s few attending general surgeons are not only involved in the training of surgical residents but also in the education of “tecnicos de cirurgia,” non-physician surgical specialists that address Mozambique’s surgeon shortage by performing operations in provincial and district hospitals where surgical care would otherwise be unavailable. The expense and expertise required to improve surgical training are major barriers to increasing surgical capacity in low-income countries. In this study, we reviewed general surgery admissions and operative logs to guide international academic partnership efforts to improve surgical training in Mozambique.

Methods:

A retrospective review was performed of all general surgery logbooks and ward discharge records from August 2012 to August 2013 at a large tertiary care hospital in Mozambique. Local and international partners reviewed the data to identify strategies for improving surgical training and delivery of surgical care.

Results:

2,617 inpatient records and 1,598 major surgical procedures were reviewed. Of patients undergoing surgery, 58% were male and mean age was 39 years. The mortality rate of patients treated in the department was 5.6%, and the mean age of deceased patients was 49 years. Most common conditions contributing to death were sepsis (23%) and HIV (14%). Of 688 elective procedures, the most commonly performed were hernia repair (29%), breast surgery (12%), hemorrhoidectomy (9%), and amputations (9%). Of 910 emergency procedures, the most frequently performed were appendectomy (15%), hernia repair (13%), amputation (12%), and incision and drainage (12%). Overall, 153 (17%) of emergency operations performed were for traumatic injuries. Of the 30 cases involving spleen trauma, 87% resulted in splenectomy. No standardized trauma resuscitation protocol was identified; CT-scan and ultrasound are not routinely available. 36% of hernias were repaired as emergencies. No laparoscopic procedures were performed.

Conclusion:

International partners can support surgical programs in low-income countries by providing funding and expertise to improve surgical skills and research. We recommend a needs-assessment approach in order for collaborative efforts to be contextually appropriate. For Mozambique, these training projects could address the development of a trauma and critical care system, the improvement of the availability of imaging, earlier referral and treatment of hemorrhoids and hernias, and the introduction of minimally invasive treatment strategies to address limited bed space and operative capacity. Our experience could serve as a model for international collaborations focused on increasing surgical capacity and supporting surgical training in other low-income countries.

 

14.09 Sustainable Surgical Care Through Collaboration with Rural Guatemalan Health Promoters

Posted on December 22, 2014

L. S. Foley1, J. Schoen1  1University Of Colorado Denver,Surgery,Aurora, CO, USA

Introduction:  Rural Guatemalans face obstacles limiting healthcare access that are common to impoverished, remote communities: lack of financial resources, limited transportation, discrimination, language barriers, and fear of unfamiliar health centers.  Delivering surgical care within these remote communities is challenging.  We hypothesized that delivery of sustainable surgical treatment is possible through coordination between existing Guatemalan health promoters and visiting surgical teams.  

Methods:  A general surgical team and translators from International Surgical Missions (ISM; Pueblo, CO) have joined with Asociación Compañero Para Cirugía (ACPC, local health promoters) in San Juan Sacatepéquez, Guatemala, through Partners for Surgery (PFS) in October 2012 and 2013.  PFS is a volunteer organization that provides sustainable access to surgery and medical care by connecting indigenous Guatemalan communities and international volunteer teams.  In advance, health promoters screened remote villages for individuals with surgical complaints.   Those identified were transported, along with their family members, to a converted surgical center with communal living quarters.  A Guatemalan family physician performed basic screenings and tests.  ISM provided instruments, medications and surgical care. 

Results: Data from the October 2012 mission were reviewed.  Two general surgeons and two surgical residents performed pre-operative histories and examinations on seventy-seven potential surgical candidates identified by ACPC.  Sixty-six patients (85.7%) were deemed appropriate candidates and underwent surgery over six operative days.  Forty-eight cases (72.3%) were performed under general anesthesia.  Fourteen laparoscopic cholecystectomies were performed without open conversion.   Patients recovered in adjacent living quarters and were transported back to villages.  Health promoters continue visiting villages to identify new surgical patients and anyone with post-operative issues.  Patients in need of surgical attention are transported back to converted surgical center and evaluated by incoming surgical teams.

Conclusion: Sustainable delivery of surgical care in remote Guatemalan regions is possible through coordinated local and international efforts. 

 

14.10 Humanitarian Skill Set Acquisition Trends Among Graduating U.S. Surgical Residents, 2003-2013

Posted on December 22, 2014

D. H. Rothstein4, A. L. Halverson3, M. Swaroop2  2Northwestern University,Trauma And Critical Care Surgery,Chicago, IL, USA 3Northwestern University,Colon And Rectal Surgery,Chicago, IL, USA 4Women And Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA

Introduction:  While interest in practicing surgery in resource-constrained settings is on the rise among graduating U.S. surgical residents, there is ongoing debate about an optimal humanitarian skill set for surgeons who chose to work in such settings. In addition, increased emphasis on general surgery case exposure at the cost of specialty surgery case exposure has been documented, and may have a negative impact on the breadth of resident training. Review of general surgery resident case logs to gauge experience in specialty surgery may provide insight into residents’ readiness for work in resource-limited settings.  

Methods:  We compared Accreditation Council for Graduate Medical Education general surgery resident case logs from 2003 and 2013 for operations thought to be essential for working in resource-constrained settings. Case numbers for specialty operations were compared by unpaired t-test analysis between the two time periods.

Results: Case averages in hand, pediatric, genitourinary, and gynecologic surgery decreased significantly from 2003 to 2013 (range 22-51%; p<0.0001). Orthopedic surgery case averages were unchanged, and plastic and general abdominal surgery case averages increased (range 30-44%; p<0.0001). 

Conclusion: Case mix among graduating U.S. surgical residents has narrowed over the past 10 years. Resident experience in a variety of specialty fields, thought to be essential in resource-constrained settings, decreased markedly over the study period. Residents who intend to work in resource-constrained settings may need to craft individualized residency experiences or pursue post-graduate training in specialty surgery courses to best prepare for such work.

 

14.11 Massive Pleural Fluid Collection in Adult Nigerians: Aetio-epidemiologic Profile and Outcome

Posted on December 22, 2014

K. E. Okonta1, .. O. Ocheli1  1University Of Port Harcourt Teaching Hospital,Cardiothoracic Unit, /Department Of Surgery,Port Harcourt, RIVERS, Nigeria

Introduction: To determine the aetiology and incidence and, comparing the mortality of malignant with non-malignant massive pleural effusion (MPE] in our setting

Methods: Prospective study of all the patients diagnosed of massive pleural effusion for one year in two tertiary federal  Hospitals in southern part of the country, Nigeria. Forty-eight of 101 consecutive  patients with MPE and required Chest Tube Drainage and chemical pleurodesis for malignant MPE. The patients were followed-up two weekly at clinic and phone calls

Results:Forty-eight patients(47.5%) had MPE with a mean age of 43 years + 14.04; 35were females and 13 were males with a ratio of 2.7:1.The cardinal symptoms were dyspnoea in 97.7%, cough in 79.1%,chest pain in 48.8% and weight loss in 39.5%. Eighteen patients(37.5%) had malignancy(11 from metastatic breast cancer and 7 in others).Thirty patients(62.5%) were diagnosed of non-malignant conditions-21(44.9%) from pulmonary tuberculosis. Haemorrhagic effusions were from Malignancy in 12(30.8%), pulmonary tuberculosis in 6(15.4%) and trauma in 3(7.7%); straw-coloured effusion were from malignancy in 9(23.1%), pulmonary tuberculosis in 8(20.1%).Eight of 14 patients diagnosed of malignant MPE died within 6 months. Compared with non malignant MPE, patients with malignant MPE had higher mortality (8/14 versus 0/23 with a p value of 0.000).

Conclusion:Pulmonary tuberculosis and Malignancy are the major contributors to the high incidence of MPE.The presentation of an adult patient with non traumatic haemorrhagic or straw-coloured MPE in this sub-region narrows the diagnosis to pulmonary tuberculosis and malignancy with malignant MPE being marker for short survival rate of 6 months

 

14.12 The Epidemiology of Gastroschisis in Zimbabwe in 2013

Posted on December 22, 2014

J. C. Apfeld2, Z. J. Kastenberg2, N. Macheka1, B. A. Mbuwayesango1, M. Bruzoni2, K. G. Sylvester2, S. M. Wren2  1Harare Children’s Hospital,Department Of Surgery,Harare, HA, Zimbabwe 2Stanford University School Of Medicine,Department Of Surgery,Stanford, CA, USA

Introduction:
Survival for infants with gastroschisis in developed countries has improved dramatically in recent years with mortality rates of 4-7%. Conversely, mortality rates for gastroschisis in Sub-Saharan Africa remain dismal at 40-60%. This study aimed to describe the burden of gastroschisis for the major pediatric hospital in Zimbabwe and to identify pre- and post-admission factors associated with in-hospital survival.

Methods:
We sorted the electronic records at Harare Children’s Hospital for abdominal wall defects (ICD-9 756.7) and cross-referenced the subsequent list with the local neonatal unit register. Paper records for these cases were retrieved from the 5,585 admissions to the neonatal unit in 2013, and clinical data was transcribed into a RedCAP database. Univariate analysis of gastroschisis patients was performed using SAS, and odds ratios were calculated to compare patients who survived versus died.  

Results:
95 infants with gastroschisis were admitted to Harare Children’s Hospital in 2013. The minority(42%) were male, the mean birth-weight was 2208g, and the mean gestational age was 36 weeks. Mean maternal age was 19 years. Ninety-one newborns were outborn (outside of Harare Children’s Hospital), 78 born outside Harare Province, and 25 at home. The time from birth to admission was 11 hours (median 6.5). Eighty of 95 patients died (84.2%). The odds of survival were significantly decreased for infants weighing less than 2,500 grams (OR 0.15, 95%CI: 0.05-0.51), for those born at less than 36 weeks gestation (0.06, CI: 0.01-0.50), and for those born to teenage mothers (0.05, CI: 0.01-0.46). The odds of survival trended towards being decreased for those born before arrival to a hospital (0.16, CI: 0.02-1.34) and for those born outside Harare Province (0.35, CI: 0.10-1.22).

Conclusion:
Gastroschisis mortality at Harare Children’s Hospital (84%) is associated with a number of factors that are well known to increase the risk of infant mortality such as low birth weight and prematurity. The high mortality rate observed in this population, however, is also likely due to a number of potentially modifiable factors. These data highlight an important opportunity for the development of innovative approaches to prenatal diagnosis, transportation, nutritional support, surgical management, and augmentation of the existing neonatal and surgical workforce.
 

14.13 Can Economic Performance Predict Pediatric Surgical Capacity in Sub-Saharan Africa?

Posted on December 22, 2014

M. T. Okoye1, E. T. Nguyen1, A. L. Kushner1,2,3, E. A. Ameh4, B. C. Nwomeh3,5  1Johns Hopkins Bloomberg School Of Public Health,Baltimore, MD, USA 2Columbia University College Of Physicians And Surgeons,Surgery,New York, NY, USA 3Surgeons OverSeas (SOS),New York, NY, USA 4National Hospital,Pediatric Surgery,Abuja, FCT, Nigeria 5Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:

The relationship between economic status and pediatric surgical capacity in low and middle income countries (LMICs) is poorly understood. In sub-Saharan Africa (SSA), Nigeria accounts for 20% of the population, and has the highest Gross Domestic Product (GDP), but whether this economic advantage has translated to increased pediatric surgical capacity is unknown. This study compares the pediatric surgical capacity between Nigeria and other countries within the region.

Methods:

The Pediatric Personnel, Infrastructure, Procedures, Equipment and Supplies (PediPIPES) survey, a recent tool that is useful in assessing and comparing the capacity of health facilities to deliver essential and emergency surgical care (EESC) to children, was conveniently distributed to surgeons throughout sub-Saharan Africa.  Descriptive statistics were computed.

Results:

In this report, data from hospitals in Nigeria (n=24) and hospitals in 18 other sub-Saharan African countries (n=26) were compared, as in Table 1:

 

Conclusion:
Despite better economic indicators in Nigeria, there were no distinct advantages over the other countries in the ability to deliver EESC to children. Attention to developing pediatric surgical capacity in SSA remains poor, highlighting the urgent need for more resources for pediatric surgical capacity building efforts across the entire region.
 

14.14 A Collaborative Experience in Caring for Infants Born with Esophageal Atresia in Belize

Posted on December 22, 2014

S. F. Rosati1, D. Parrish1, J. Haynes2, R. Maarouf1, C. Oiticica2, P. Lange2, D. Lanning2  1Virginia Commonwealth University,Department Of General Surgery,Richmond, VA, USA 2Virginia Commonwealth University,Division Of Pediatric Surgery,Richmond, VA, USA

Introduction:
 

Children born with congenital anomalies in low-income countries often face a multitude of challenges.  Access to pediatric surgical services is limited due to a lack of medical facilities, an adequate transportation system, and a lack of trained surgeons, anesthesiologists, and nurses, all of which leads to a high mortality rate. This is a report of a 5-year collaborative effort between the World Pediatric Project (WPP), the Children’s Hospital of Richmond (CHoR) at Virginia Commonwealth University, and multiple organizations within the country of Belize to provide care for infants born with esophageal atresia (EA).

Methods:
 

After IRB approval, we reviewed medical records of children with EA treated in conjunction with the World Pediatric Project, which is a nonprofit organization that provides tertiary surgical care to children in Central America and the Caribbean. From 2009-2014, neonatologists and pediatric surgeons at our institution have collaborated with the WPP to care for infants born in Belize with EA. Six infants with EA (five also with an associated tracheoesophageal fistula) were transferred to our institution for surgical repair.

Results:
 

A total of six infants, two boys and four girls, have been transferred to our institution for operative correction of their EA.  After the first patient was transferred to our institution, multiple opportunities for improving the process were identified.  A protocol was created to help diagnose infants with EA, outline initial management, and facilitate obtaining travel documents.  At the time of transfer, their ages ranged from 2 weeks to 2 months old. All six of the patients had gastrostomy tubes placed in Belize prior to transfer for decompression of their stomach and placement of a venous catheter for TPN after arrival.  Of the five infants with TEF, two underwent open repair and three had a thoracoscopic repair. The infant with a pure atresia underwent thoracoscopic converted to open repair. There were no peri- or post-operative complications.  All six infants were orally fed post–operatively and were transferred back to Belize where they are thriving.  Pediatric surgeons from CHoR see them annually.

Conclusion:
 

Caring for infants born with congenital anomalies, specifically EA, can be  challenging requiring the cooperation of a variety of specialties, including pediatric surgeons, neonatologists, pediatricians, and nutritionists. These challenges become even more complex with infants born in low-income countries. This report demonstrates how newborns with EA±TEF in a developing country can be successfully transferred to the US, receive medical and surgical care, and return to their country.  While this endeavor is challenging, the process can be facilitated by having a protocol in place, a well-organized local nonprofit organization, and a hospital that is committed to providing international care to children. 
 

14.15 Prevalence of injuries due to falls in Nepal: A countrywide population based survey

Posted on December 22, 2014

S. Devkota1, S. Gupta2,3, S. Ghimire1, A. Ranjit4, M. Swaroop5, A. L. Kushner3,6, B. C. Nwomeh3,7  1Chitwan Alpine Polyclinic And Diagnostic Center,Chitwan, , Nepal 2University Of California – San Francisco , East Bay,Surgery,Oakland, CA, USA 3Surgeons OverSeas,New York, NY, USA 4Johns Hopkins – Center For Surgical Trials And Outcomes Research,Baltimore, MD, USA 5Northwestern University Feinberg School Of Medicine,Surgery – Trauma/Critical Care And Center For Global Health,Chicago, IL, USA 6Johns Hopkins Bloomberg School Of Public Health,International Health,Baltimore, MD, USA 7Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:  An estimated 424 000 fatal falls occur globally each year, making it the second leading cause of unintentional injury-related deaths after road traffic injuries. Over 80% of fall-related fatalities occur in low- and middle-income countries, with regions of the Western Pacific and South East Asia accounting for more than two thirds of deaths.  Data from low-income South Asian countries like Nepal are lacking, particularly at the population level. 

Methods:  A nationally representative cross-sectional study was performed in 15 of the 75 districts in Nepal, randomly selected proportional to population, using the Surgeons OverSeas Assessment of Surgical Needs (SOSAS) survey tool. Three villages were randomly selected within each district, one urban and two rural. The SOSAS survey is divided into two portions: (1) demographic data including the household’s access to healthcare and recent deaths in the household and (2) assessment of a representative spectrum of surgical conditions, including injuries.  Data was collected regarding an individuals’ experience of injury including road traffic injuries, falls, penetrating trauma and burns.  Data included anatomic location, timing of injury and whether or not healthcare was sought, and if not, the reason for barrier to care.  Descriptive statistics was used to analyse the data.

Results:  Of the 2695 individuals from 1,350 households interviewed, 141 individuals reported injuries secondary to falls (5.2%, 95% CI 4.4% to 6.1%), with a mean age of 30.7 (SD 20.0); 58% were male.  Falls represented 44.3% of total injuries (n=320) reported (95%CI 38.8% to 50.0%).    The most common locations of injuries due to falls were in the extremity, 73.2% (SD 3.7%, 95% CI 65.7% to 80.8%, Table 1); the upper extremities were the most common site in the extremities that were involved (52.1%). Twelve individuals had an unmet surgical need (8.5%, 95% CI 4.5% to 14.4%).  Reasons for barrier to care included:  no money for healthcare (n=3), facility/personnel not available (n=7) and fear/no trust (n=2).  Of the 80 recent deaths, 7 were due to injuries from falls (8.8%, 95% CI 3.6% to 17.2%), with a mean age of 46 years (SD 22.8).  Surgical care was not delivered to those who died; reasons included no time (n=4), facility/personnel not available (n=1), fear/no trust (n=1) and no need (n=1). 

Conclusion:  This study provides population-based data on injury prevalence in Nepal, identifying injuries due to falls as a major public health problem.  While health education to reduce the risk of falls remains essential, these data highlight persistent barriers to access to care for the injured and the need to improve trauma care systems in Nepal.

 

14.16 Knowledge of Colorectal Carcinoma screening Among General Population in Western Region of Nepal

Posted on December 22, 2014

S. Nepal1, A. Shrestha2, J. Parajuli2, S. Sharma1, M. Acharya3, S. Baral2  1Manipal Teaching Hopital,Department Of Surgery,Pokhara, KASKI, Nepal 2Manipal Teaching Hopital,Medicine,Pokhara, KASKI, Nepal 3Manipal Teaching Hopital,Emergency,Pokhara, KASKI, Nepal

Introduction: Colorectal Carcinoma has emerged as third most common malignant tumor, second leading cause of death among cancer patients in the world and has been increasing in developing countries. In this study our objective was to determine the knowledge and attitude of CRC and to understand the factors that contribute to low screening rates in our region.

Methods: We interviewed 800 participants aged 40 years and above with 200 participants each from Kaski, Baglung, Parbat and Syangja district which are in Western region of Nepal. We used questionnaires to determine the socio-demographic characteristic, knowledge about CRC, screening, as well as screening test.

Results:The majority participants were illiterate with monthly income less than Nrs 10,000 ($100).Regarding lifestyle practices most of them were smokers (68%) and consumed alcohol (48%).Among the participants, 20% of them said there exists no cancer as Colorectal Carcinoma. The rest of them who knew CRC exists the knowledge about it and is screening were very poor. Only 25% and 10% of them knew about FOBT and Colonoscopy but none of them had idea about barium enema and flexible sigmoidoscopy .Majority of them (55%) agreed to do screening tests even if they did not have any symptom and 40% of the participants said the disease had good prognosis if diagnosed early.

Conclusion:The result of the current study provide information about the need for education campaigns about CRC and its screening to reduce the incidence of deaths due to CRC.

 

14.17 Impacting the Global Trauma Burden — Training First Responders in Mozambique

Posted on December 22, 2014

A. Merchant1, K. Mcqueen1, O. Gunter1  1Vanderbilt University Medical Center,Trauma And Critical Care,Nashville, TN, USA

Introduction: Over half of prehospital deaths in low-income countries are the result of airway compromise, respiratory failure or uncontrolled hemorrhage; all three of these conditions can be addressed using basic first aid measures. For both hospital personnel and laypersons, a  basic trauma resuscitation training in modified ABC techniques can be easily learned and applied to increase the number of first responders in Mozambique, a resource-challenged country. This approach supports WHO guidelines to reduce the impact of an injury once it occurs and optimize its outcome.

Methods: In March 2014, a trauma training session was administered to 100 people in Mozambique: half were hospital personnel from 7 district medical centers and the other half were selected laypersons. Five of the hospitals advertised surgical capability; two other medical centers were chosen based on long transport times to main hospitals and need for patient stabilization. This training session included a pre-test, intervention, and post-test to evaluate and demonstrate first response skills of airway management, hemorrhage control, and cervical spine precautions using resources available in hospital and street settings. Paired t-tests and linear regression curves were used to analyze the data.

Results: Laypersons answered 26.9% of the pre-test questions correctly and showed 86.9% improvement in their scores after the intervention; hospital personnel initially answered 41.7% correctly and improved their scores by 44%. All participants were able to open an airway, externally control hemorrhage, and transport a patient with appropriate precautions. In addition, hospital personnel were able to verbalize intravenous fluid resuscitation and oxygen application during assessment.

Conclusion: The trauma training session served as new information that improved knowledge and skills for both groups, as well as increased the number of first responders in Mozambique. This knowledge can minimize secondary and tertiary injuries by providing effective prehospital care in developing nations with limited trauma resources. Thus, this study supports WHO recommendations to utilize the strengths of a developing nation – population – as the first step in establishing an organized trauma triage system.

 

14.18 Geriatric Emergency General Surgery – Survival and Outcomes in a Low-Middle Income Country

Posted on December 22, 2014

A. A. Shah1,2, H. Zafar2, R. Riviello1, C. K. Zogg1, S. Zafar4, A. Latif5, Z. Rehman2, A. H. Haider1  1Johns Hopkins University School Of Medicine,Center For Surgical Trials And Outcomes Research, Department Of Surgery,Baltimore, MD, USA 2Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 3Harvard School Of Medicine,Center For Surgery And Public Health, Brigham And Women’s Hospital,Brookline, MA, USA 4Howard University College Of Medicine,Department Of Surgery,Washington, DC, USA 5Johns Hopkins University School Of Medicine,Department Of Anesthesia,Baltimore, MD, USA

Introduction:  Geriatric surgical outcomes remain grossly understudied in low-middle income healthcare settings. The purpose of this study was to compare epidemiology and outcomes between old and young adults presenting to a tertiary care facility in South Asia for emergency general surgical (EGS) conditions.

Methods:  Discharge data from a university hospital were obtained for all adult patients (≥16 years) presenting between March 2009 and April 2014 with ICD-9-CM diagnosis codes consistent with an EGS condition, as described by the American Association for the Surgery of Trauma (AAST). The patient population was dichotomized into old (>65 years) and young (≤65 years) adults. Multivariate analyses, accounting for age, gender, year of admission, type of admission, admitting specialty, length of stay (LOS), major complications and Charlson Comorbidity Index, were used to compare the two populations. Outcomes of interest included all-cause mortality, major complications and LOS.

Results: A total of 13,893 patients were included. Patients >65 years constituted 15.3% (n=2,123) of the patient population. Old adults were more likely to be male (OR[95%CI]:1.14 [1.02-1.27]) and present through the ED (OR[95%CI]: 1.22[1.09-1.38]). They more commonly presented with gastrointestinal bleeding (OR[95%CI]: 2.63[1.99-3.46]) and for resuscitation (OR[95%CI]: 2.17 [1.67-2.80]). After multivariate adjustment, age >65 years independently accounted for a 60% increase in mortality (OR[95%CI]: 1.60[1.18-2.16]). Elderly patients also had a higher likelihood of developing major complications (OR[95%CI]: 2.09[1.67-2.61]). There were no significant differences in lengths of hospital stay between elderly and young-adult patients (4.3 vs. 4.5 days, respectively).

Conclusion: Older adults seem to suffer from a different set of EGS conditions compared to their younger counterparts. The results of this study will assist in formulating specialized management guidelines and help prioritize care for geriatric patients with EGS conditions in low-middle income healthcare settings.

14.19 An Estimation of Cost Arising From Motorcycles Injuries in Kigali, Rwanda

Posted on December 22, 2014

J. Allen Ingabire1, J. Byiringiro1, F. J. Calland2, J. Okiria1  1National University Of Rwanda,College Of Health Sciences And Medicine,School Of Medicine,Department Of Surgery,Butare, SOUTH, Rwanda 2University Of Virginia,Surgery Depatment,Charlottesville, VA, Virgin Islands, U.S.

Introduction: Motorcycles has become a popular mean of transport in Kigali, Rwanda and their injuries are associated with a high number of admissions in the main referral hospital of Kigali. These accidents are associated with a high financial burden to the country. This study aimed at evaluates the total cost arising from motorcycles injuries of patients admitted at University Teaching Hospital of Kigali.

Methods: Retrospective cross-sectional cost study of motorcycles injured patients admitted in University Teaching Hospital of Kigali from January-December, 2011. Data were collected from patient medical, police, insurance and financial records as well as patient interviews. Cost analysis was based upon the standard road accident cost conceptual framework.

Results:A total of 1232 road traffic injuries were reported during the study period and Motorcycle injuries accounted for 73.05% (900 cases) of all injuries. Youths were more involved in motorcycle accident (53.2%) than other age group (16-30 years) .The majority of Motorcycles victims were motorcyclists, (30.86%) and Motorcycle-vehicle (41.61%) was the first cause of motorcycle injuries then motorcycle-pedestrian (30.86%). Head injuries and fractures were the predominant diagnoses (82.15%).The mean hospital stay was 15.43 days, permanent disability was confirmed in 11.5% (n=104), and mortality rate was 10.4% (n=94). The total economic cost of motorcycle injuries was US$ 4,141,300. This is made up of about 28.28% accident-related costs and 71.72% casualty-related costs. The accident-related costs totaling US$892,775 was made up of property damaged costs of 21.56% and administration costs of 6.72%. Whilst the casualty-related cost of US$886.665.50 was made up of labor output costs estimated at US$ 1,631550 (39.4%) was  the highest cost, followed by medical cost estimated atUS$901,150(21.76%),out-of-pocket expenditure (5.9%), intangible costs (4.35%) and the lowest cost was funeral costs totaling US$24,007 (0.58%). The average cost per patient was estimated at US$4,601. There was significant association between category of injured patients and total cost/patient (p>0.05).

 

 

Conclusion:Motorcycle injuries create a substantial disability and cost burden in Kigali, Rwanda. Prevention and early treatment should be promoted to decrease the morbidity and financial burden.
 

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