Elective surgery system strengthening: development, measurement, and validation of the surgical preparedness index across 1632 hospitals in 119 countries.

BACKGROUND The 2015 Lancet Commission on global surgery identified surgery and anaesthesia as indispensable parts of holistic health-care systems. However, COVID-19 exposed the fragility of planned surgical services around the world, which have also been neglected in pandemic recovery planning. This study aimed to develop and validate a novel index to support local elective surgical system strengthening and address growing backlogs. METHODS First, we performed an international consultation through a four-stage consensus process to develop a multidomain index for hospital-level assessment (surgical preparedness index; SPI). Second, we measured surgical preparedness across a global network of hospitals in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) to explore the distribution of the SPI at national, subnational, and hospital levels. Finally, using COVID-19 as an example of an external system shock, we compared hospitals' SPI to their planned surgical volume ratio (SVR; ie, operations for which the decision for surgery was made before hospital admission), calculated as the ratio of the observed surgical volume over a 1-month assessment period between June 6 and Aug 5, 2021, against the expected surgical volume based on hospital administrative data from the same period in 2019 (ie, a pre-pandemic baseline). A linear mixed-effects regression model was used to determine the effect of increasing SPI score. FINDINGS In the first phase, from a longlist of 103 candidate indicators, 23 were prioritised as core indicators of elective surgical system preparedness by 69 clinicians (23 [33%] women; 46 [67%] men; 41 from HICs, 22 from MICs, and six from LICs) from 32 countries. The multidomain SPI included 11 indicators on facilities and consumables, two on staffing, two on prioritisation, and eight on systems. Hospitals were scored from 23 (least prepared) to 115 points (most prepared). In the second phase, surgical preparedness was measured in 1632 hospitals by 4714 clinicians from 119 countries. 745 (45·6%) of 1632 hospitals were in MICs or LICs. The mean SPI score was 84·5 (95% CI 84·1-84·9), which varied between HIC (88·5 [89·0-88·0]), MIC (81·8 [82·5-81·1]), and LIC (66·8 [64·9-68·7]) settings. In the third phase, 1217 (74·6%) hospitals did not maintain their expected SVR during the COVID-19 pandemic, of which 625 (51·4%) were from HIC, 538 (44·2%) from MIC, and 54 (4·4%) from LIC settings. In the mixed-effects model, a 10-point increase in SPI corresponded to a 3·6% (95% CI 3·0-4·1; p<0·0001) increase in SVR. This was consistent in HIC (4·8% [4·1-5·5]; p<0·0001), MIC (2·8 [2·0-3·7]; p<0·0001), and LIC (3·8 [1·3-6·7%]; p<0·0001) settings. INTERPRETATION The SPI contains 23 indicators that are globally applicable, relevant across different system stressors, vary at a subnational level, and are collectable by front-line teams. In the case study of COVID-19, a higher SPI was associated with an increased planned surgical volume ratio independent of country income status, COVID-19 burden, and hospital type. Hospitals should perform annual self-assessment of their surgical preparedness to identify areas that can be improved, create resilience in local surgical systems, and upscale capacity to address elective surgery backlogs. FUNDING National Institute for Health Research (NIHR) Global Health Research Unit on Global Surgery, NIHR Academy, Association of Coloproctology of Great Britain and Ireland, Bowel Research UK, British Association of Surgical Oncology, British Gynaecological Cancer Society, and Medtronic

Reducing the Environmental Impact of Surgery on a Global Scale: Systematic Review and Co-Prioritization With Healthcare Workers in 132 Countries

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 \u27single-use\u27 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

Use of Telemedicine for Postdischarge Assessment of the Surgical Wound: International Cohort Study, and Systematic Review With Meta-analysis.

OBJECTIVE: This study aimed to determine whether remote wound reviews using telemedicine can be safely upscaled, and if standardized assessment tools are needed. BACKGROUND: Surgical site infection (SSI) is the most common complication of surgery worldwide, and frequently occurs after hospital discharge. Evidence to support implementation of telemedicine during postoperative recovery will be an essential component of pandemic recovery. METHODS: The primary outcome of this study was SSI reported up to 30 days after surgery (SSI), comparing rates reported using telemedicine (telephone and/or video assessment) to those with in-person review. The first part of this study analyzed primary data from an international cohort study of adult patients undergoing abdominal surgery who were discharged from hospital before 30 days after surgery. The second part combined this data with the results of a systematic review to perform a meta-analysis of all available data conducted in accordance with PRIMSA guidelines (PROSPERO:192596). RESULTS: The cohort study included 15,358 patients from 66 countries (8069 high, 4448 middle, 1744 low income). Of these, 6907 (45.0%) were followed up using telemedicine. The SSI rate reported using telemedicine was slightly lower than with in-person follow-up (13.4% vs 11.1%, P CONCLUSIONS: Use of telemedicine to assess the surgical wound postdischarge is feasible, but risks underreporting of SSI. Standardized tools for remote assessment of SSI must be evaluated and adopted as telemedicine is upscaled globally

Emerging Global Health Crisis of Our Times- Climate Change

The progress of the human race over the last 200 years is unprecedented in recent history. Rapid industrialization, urbanization, and consumerism have made lives easier for humankind. Still, these changes come at a very high price. We never anticipated that we will have to pay the price in the form of climate change and global warming. Our planet, the earth is getting warmer by 0.85 ̊centigrde annually for the last one hundred and seventy years. Hence, glaciers are melting faster than ever, water levels are rising, and cities are sinking, while greenhouse gas emission numbers are at their highest points in human history. Unfortunately we humans are living in anthropogenic epoch and are also speeding up the destruction of the earth's ecosystem by being the dominant cause of the warming observed since the 20th century. Deforestation coupled with increased greenhouse gas emissions has led to a surge of heat-waves globally. These environmental disasters not only affect the environment, plants, and land but also have a profound direct and indirect impact on the health of people. In-fact the health impact has already debuted in the form of worsening key health indicators. In Pakistan alone, the 2015 heat-wave claimed the lives of twelve hundred people in Sindh province. Due to variable rainfall patterns that affect the availability of fresh water, it also affects food production &amp; delivery and brings on the drought. Quality of air, clean drinking water, and availability of food are the top three indicators most influenced by these disasters. Coupled with these, the more than the frequent occurrence of natural calamities; tsunamis, wildfires, snowstorms, and extremes of temperatures has put an extra financial burden on already, stretched to limits budgets of health

Global Public Goods and Global Health

The repair rate on electron beam welded diaphragm hasn’t been at the desired level at Siemens SIT for several years. An improvement program the past five years has reduce the repair rate from 60% to 12-15% but the goal of 5% repair rate hasn’t been met. Collection of diaphragm weld and repair data started in the fall 2011 and in this thesis the material composition of the materials used for the production will be analysed from a statistical perspective. The thesis includes a comprehensive research of the nonparametric statistical methods suitable for non normally distributed, highly kurtotic and skewed data. Unfortunately a lot of statistical tests loose their power to correctly reject a false hypothesis with this kind of data. All of the elements in the material composition and the mechanical properties were analysed individually. In some of the cases it was possible to use statistical methods but in other it was not possible to conclude anything with statistics. Every case of outliers was evaluated individually. The main conclusions are that in all of the four materials there are some elements and mechanical properties outside of the material specifications. A number of cases also had outliers inside of the material specification and in most cases those were causing the variability in the data and had higher repair rates than the overall repair rate. Some trends were found, for example the weld quality was better for lower yield strength in all materials and higher chromium content in material A produced better quality. The first steps to improvement for Siemens are to find out why materials outside of the material specifications are getting all the way to the production without anyone noticing. A simple material process control chart could visually notify if a material is outside of the specification limits or even just outside of the usual. Knowing exactly how the material is before starting the production will give time and space for preventive measures if they are necessary and could improve lead times and decrease costs.För några år har Siemens hatt kvalitetsproblem med Electron Beam svetsing av mellanväggar. Förbättringsprojekt har reducerat reparationer intensivt men fortfarande finns det problemer med svetsningen. Inga mellanväggar lämnar produktionen utan att ha bra kvalitet så att förbättringarna ska fokusera på att reducera produktionskostnader och ledtider. Hösten 2011 började Siemens att samla reparation data för mellanväggarna och i det examens arbetet blir materialsamansättningen analyserad med statistiska metoder. Arbetet innehåller övergripande analysis på non-parametriska statistiska metoder och hur dom funkerar på skevat data med hög kurtosis. Tyvärr finns det inte många metoder som har hög chans att förkasta falska hypoteser när man jobbar med sånt data. Alla elementer och mekaniska egenskaper av materialet blev analyserade, men tyvärr inte alltid med statistiska metoder. Alla extremvärden blev analyserade individuellt. I alla fyra materialer finns det elementer och mekaniska egenskaper utan förmaterialets specifikationer. I vissa fall finns det outliers inom materialets specifikationer men som har högre reparation procent än det vanliga och orsakar variationen i datat. Vissa tendenser kunne hittas, till exempel att det går bättre att svetsa materialer med lägre sträckgräns och högre kromhalt går bättre för material A. Simpelt processstyrningdiagram skulle kunna visa om material är utanför material specifikationen men också om materialet är utanför det ”vanliga”. Att veta exact hur materialet är innan produktion kan sjunka ledtider och produktionskostnader