Wounds of war : surgical care for conflict-related injuries among civilians in resource-limited settings

Background: Armed conflicts significantly contribute to the global burden of injury and death. Armed conflicts shocks health systems, deprive its resources and reduce its function, as well as limits access to civilian hospital care. In such resource-limited settings, the evidence on how to optimally manage the injuries sustained by civilians remains scarce. Objectives: To generate knowledge on how wound infection affects outcomes for civilian patients treated for conflict-related injuries, to explore the challenges associated with the treatment of such patients, and to evaluate the safety, effectiveness, and cost-effectiveness of negative pressure wound therapy (NPWT) for conflict-related extremity wounds. Methods: All patients were wounded in armed conflicts in Syria and Iraq. The studies were performed at two civilian hospitals in Jordan and Iraqi Kurdistan. In a cohort study (Paper I), utilising routinely collected clinical data from consecutive patients surgically treated for conflict-related injuries, we compared patients with wound infection to those without, in terms of clinical outcome and resource consumption. Paper II was a qualitative study where treating physicians in Jordan were interviewed to explore the perceived main challenges in conflict wound management. Paper III was a randomised controlled trial on the safety and effectiveness of NPWT compared to standard treatment for conflict-related extremity wounds. In Paper IV we used clinical outcome data from Paper III to perform a health economic evaluation of NPWT in resource-limited settings. Main Findings: Wound infection was associated with poor clinical outcomes and excess resource consumption. In addition, three out of four infected wounds contained multidrug-resistant bacteria. The main challenges in conflict wound management related to protocol adherence. Reasons for protocol deviations included resource scarcity, high patient loads, and limited compliance among patients and caregivers. Neither time to wound closure nor net clinical benefit was improved by NPWT compared to standard treatment for conflict-related extremity wounds. Treatment-related healthcare costs were higher for NPWT compared to standard treatment Conclusions: Wound infection was associated with poor clinical outcomes and an excess resource consumption among patients receiving surgery for conflict-related injuries. Physicians found protocol adherence to be the main challenge in the management of conflict-related wounds. NPWT did not result in superior clinical outcomes compared to standard treatment. In addition, costs were higher, indicating that NPWT is not a cost-effective treatment option

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Research Protocol - A prospective, randomized, controlled trial of negative-pressure wound therapy use in conflict-related extremity wounds

Research ProtocolWe aim to evaluate the efficacy and safety of NPWT in the treatment of traumatic extremity wounds in a context associated with a high level of contamination and infection

Vietnam_flood_questionnaire_answers.xlsx

Primary health care flood preparedness questionnaire answers from central Vietna

Vietnam flood questionnaire results

Flood preparedness at primary health care facilitie

Perceptions of Healthcare-Associated Infection and Antibiotic Resistance among Physicians Treating Syrian Patients with War-Related Injuries

Healthcare-associated infections (HAIs) constitute a major contributor to morbidity and mortality worldwide, with a greater burden on low- and middle-income countries. War-related injuries generally lead to large tissue defects, with a high risk of infection. The aim of this study was to explore how physicians in a middle-income country in an emergency setting perceive HAI and antibiotic resistance (ABR). Ten physicians at a Jordanian hospital supported by Médecins Sans Frontières were interviewed face-to-face. The recorded interviews were transcribed verbatim and analyzed by qualitative content analysis with an inductive and deductive approach. The participants acknowledged risk factors of HAI and ABR development, such as patient behavior, high numbers of injured patients, limited space, and non-compliance with hygiene protocols, but did not express a sense of urgency or any course of action. Overuse and misuse of antibiotics were reported as main contributors to ABR development, but participants expressed no direct interrelationship between ABR and HAI. We conclude that due to high patient load and limited resources, physicians do not see HAI as a problem they can prioritize. The knowledge gained by this study could provide insights for the allocation of resources and development of hygiene and wound treatment protocols in resource-limited settings

“Reality rarely looks like the guidelines”: a qualitative study of the challenges hospital-based physicians encounter in war wound management

Abstract Background Globally, armed conflict is a major contributor to mortality and morbidity. The treatment of war-associated injuries is largely experience-based. Evidence is weak due to difficulty in conducting medical research in war settings. A qualitative method could provide insight into the specific challenges associated with providing health care to injured civilians. The aim of this study was to explore the challenges hospital-based physicians encounter in war wound management, focusing on surgical intervention and antibiotic use. Methods Semi-structured, face-to-face interviews were conducted with physicians at a Jordanian hospital supported by Médecins Sans Frontières. The interviews were recorded, transcribed verbatim and analysed using content analysis with an inductive and deductive approach. Results We found that challenges in war wound management primarily relate to protocol adherence. Protocols for the management of acute war wounds were adhered to on areas that could be considered commonly agreed principles of war wound surgery, such as the use of wound debridement and the evaluation of the systemic condition of the patient before initiating antibiotic treatment. We identified limitations imposed on the physicians that complicate or even hinder protocol adherence. Additionally, we identified factors associated with conscious deviations from the protocols. Conclusions We conclude that adherence to established protocols around the management of acute war wounds is difficult. We present aspects that may be considered when establishing clinical projects in similar contexts. The knowledge gained by this study could provide insights for the development of protocols or guidelines for wound management and antibiotic use in an unstable setting, such as a hospital in close proximity to armed conflict. We suggest the use of a grounded theory approach to further study the discrepancy between guideline recommendations and actual practice

Infection with high proportion of multidrug-resistant bacteria in conflict-related injuries is associated with poor outcomes and excess resource consumption: a cohort study of Syrian patients treated in Jordan

Abstract Background Armed conflicts are a major contributor to injury and death globally. Conflict-related injuries are associated with a high risk of wound infection, but it is unknown to what extent infection directly relates to sustainment of life and restoration of function. The aim of this study was to investigate the outcome and resource consumption among civilians receiving acute surgical treatment due to conflict-related injuries. Patients with and without wound infections were compared. Methods We performed a cohort study using routinely collected data from 457 consecutive Syrian civilians that received surgical treatment for acute conflict-related injuries during 2014–2016 at a Jordanian hospital supported by Médecins Sans Frontières. We defined wound infection as clinical signs of infection verified by a positive culture. We used logistic regression models to evaluate infection-related differences in outcome and resource consumption. Results Wound infection was verified in 49/457 (11%) patients. Multidrug-resistance (MDR) was detected in 36/49 (73%) of patients with infection. Among patients with infection, 11/49 (22%) were amputated, compared to 37/408 (9%) without infection, crude relative risk = 2.62 (95% confidence interval 1.42–4.81). Infected patients needed 12 surgeries on average, compared to five in non-infected patients (p < .00001). Mean length of stay was 77 days for patients with infection, and 35 days for patients without infection (p = .000001). Conclusions Among Syrian civilians, infected conflict-related wounds had a high prevalence of MDR bacteria. Wound infection was associated with poor outcomes and high resource consumption. These results could guide the development of antibiotic protocols and adaptations of surgical management to improve care for wound infections in conflict-related injuries. Trial registration ClinicalTrials.gov (NCT02744144). Registered April 13, 2016. Retrospectively registered

Additional file 1 of Exploratory laparotomy during the battle of Mosul, 2016–2017: results from a tertiary civilian hospital in Erbil, Iraqi Kurdistan

Additional file 1