Abstract
BackgroundIn sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD.MethodsUtilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD.ResultsOf 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment.ConclusionIHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.
Highlights
Timely and affordable surgical care is limited for over five billion people globally, most of whom live in low- and middle-income countries (LMICs)[1]
Sub-Saharan Africa bears a disproportionate burden compared with other regions, with approximately 35⋅7–99⋅4 per cent of the population unable to access surgical care[2]
It was hypothesized that patients with emergency surgical conditions whose operations were delayed beyond 24 h after arrival in the hospital would have higher postoperative mortality than patients receiving earlier surgery. This analysis involved a cohort of patients collected prospectively in the Emergency General Surgery database who presented with abdominal symptoms to Kamuzu Central Hospital (KCH) in Lilongwe, Malawi
Summary
Timely and affordable surgical care is limited for over five billion people globally, most of whom live in low- and middle-income countries (LMICs)[1]. The three primary sources of delay to surgical care for patients in limited-resource settings include: delay in seeking care (pre-hospital), delay in transferring to a facility equipped to perform the procedure (interfacility), and delay from presentation at a hospital able to provide definitive care to the start of the operative intervention (in-hospital delays; IHDs). Few studies have assessed the impact of IHDs on perioperative mortality, or examined factors associated with IHDs. In sub-Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care-seeking by patients. This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed
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