Delays in hospital admissions in patients with fractures across 18 low-income and middle-income countries (INORMUS): a prospective observational study

© 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: The Lancet Commission on Global Surgery established the Three Delays framework, categorising delays in accessing timely surgical care into delays in seeking care (First Delay), reaching care (Second Delay), and receiving care (Third Delay). Globally, knowledge gaps regarding delays for fracture care, and the lack of large prospective studies informed the rationale for our international observational study. We investigated delays in hospital admission as a surrogate for accessing timely fracture care and explored factors associated with delayed hospital admission. Methods: In this prospective observational substudy of the ongoing International Orthopaedic Multicenter Study in Fracture Care (INORMUS), we enrolled patients with fracture across 49 hospitals in 18 low-income and middle-income countries, categorised into the regions of China, Africa, India, south and east Asia, and Latin America. Eligible patients were aged 18 years or older and had been admitted to a hospital within 3 months of sustaining an orthopaedic trauma. We collected demographic injury data and time to hospital admission. Our primary outcome was the number of patients with open and closed fractures who were delayed in their admission to a treating hospital. Delays for patients with open fractures were defined as being more than 2 h from the time of injury (in accordance with the Lancet Commission on Global Surgery) and for those with closed fractures as being a delay of more than 24 h. Secondary outcomes were reasons for delay for all patients with either open or closed fractures who were delayed for more than 24 h. We did logistic regression analyses to identify risk factors of delays of more than 2 h in patients with open fractures and delays of more than 24 h in patients with closed fractures. Logistic regressions were adjusted for region, age, employment, urban living, health insurance, interfacility referral, method of transportation, number of fractures, mechanism of injury, and fracture location. We further calculated adjusted relative risk (RR) from adjusted odds ratios, adjusted for the same variables. This study was registered with ClinicalTrials.gov, NCT02150980, and is ongoing. Findings: Between April 3, 2014, and May 10, 2019, we enrolled 31 255 patients with fractures, with a median age of 45 years (IQR 31–62), of whom 19 937 (63·8%) were men, and 14 524 (46·5%) had lower limb fractures, making them the most common fractures. Of 5256 patients with open fractures, 3778 (71·9%) were not admitted to hospital within 2 h. Of 25 999 patients with closed fractures, 7141 (27·5%) were delayed by more than 24 h. Of all regions, Latin America had the greatest proportions of patients with delays (173 [88·7%] of 195 patients with open fractures; 426 [44·7%] of 952 with closed fractures). Among patients delayed by more than 24 h, the most common reason for delays were interfacility referrals (3755 [47·7%] of 7875) and Third Delays (cumulatively interfacility referral and delay in emergency department: 3974 [50·5%]), while Second Delays (delays in reaching care) were the least common (423 [5·4%]). Compared with other methods of transportation (eg, walking, rickshaw), ambulances led to delay in transporting patients with open fractures to a treating hospital (adjusted RR 0·66, 99% CI 0·46–0·93). Compared with patients with closed lower limb fractures, patients with closed spine (adjusted RR 2·47, 99% CI 2·17–2·81) and pelvic (1·35, 1·10–1·66) fractures were most likely to have delays of more than 24 h before admission to hospital. Interpretation: In low-income and middle-income countries, timely hospital admission remains largely inaccessible, especially among patients with open fractures. Reducing hospital-based delays in receiving care, and, in particular, improving interfacility referral systems are the most substantial tools for reducing delays in admissions to hospital. Funding: National Health and Medical Research Council of Australia, Canadian Institutes of Health Research, McMaster Surgical Associates, and Hamilton Health Sciences

The United Nations world water development report 2019: leaving no one behind - Chapter 2: Physical and environmental dimensions

The 2030 Agenda for Sustainable Development sets a series of ambitious challenges for the global community. These Sustainable Development Goals (SDGs) include targets for access to safe drinking water and sanitation and better water management, as well as goals for addressing inequality and discrimination, including the overarching aims of \u2018leaving no one behind\u2019 and \u2018reaching the furthest behind first\u2019. These are challenges that, to date, have proven difficult to meet, partly because they are complex, but also due to political inertia. The global context for this agenda may be characterized as \u2018crisis is the new normal\u2019, with political insecurity, social, economic and environmental challenges on a daunting scale. This calls for redoubled efforts and carefully selected approaches towards achieving transformative change.The issues underlying both water-related goals and leaving no one behind intersect in several ways. Both water supply and sanitation, and issues of equality for all people and for specific disadvantaged groups in particular, are recognized through international human rights instruments and agreements. However, these have not been enough to bring about the necessary changes. To some extent, the issues share both root causes and similar challenges. The same people who are being left behind are those who could benefit most from improved access to water and sanitation. Improved access to water and sanitation, water management and governance, and the multiple benefits they bring, can contribute significantly to positive transformation for marginalized people. Benefits include better health, savings in time and money, dignity, improved access to food and energy, and greater opportunities in terms of education, employment and livelihoods. These benefits, directly and indirectly, separately and in combination, contribute to improving the lives of all, but can be particularly transformative for people in vulnerable situations. At the same time, engaging with marginalized groups can enhance the achievement and sustainability of water-related goals. This process of engagement can also be transformative in giving a voice to those rarely heard, in turn creating space for vital water-related knowledge and experience that might otherwise be lost.As the sixth in a series of annual, thematic reports, the 2019 edition of the United Nations World Water Development Report (WWDR) examines how improved water resource management and access to water supply and sanitation services can help address the causes and alleviate the impacts of poverty and social inequity. It provides insights and guidance in helping identify \u2018who\u2019 is being left behind, and describes how existing frameworks and mandates, such as the 2030 Agenda and the SDGs and human rights-based approaches, can help \u2018reach the furthest first\u2019, through improved water management.The report assesses the issues and offers potential responses from technical, social, institutional and financial perspectives, while taking account of the many different challenges faced in rural and urban settings. With the world witnessing the highest levels of human displacement on record, an entire chapter has been dedicated to the exceptional challenges faced by refugees and forcibly displaced people with respect to water and sanitation. We have endeavoured to produce a balanced, fact-based and neutral account of the current state of knowledge, covering the most recent developments, and highlighting the challenges and opportunities provided by improved water management in the context of human development. Although primarily targeted at national-level decision-makers and water resources managers, as well as academics and the broader development community, we hope this report will also be well received by those interested in poverty alleviation, humanitarian crises, human rights and the 2030 Agenda.This latest edition of the WWDR is the result of a concerted effort between the Chapter Lead Agencies, FAO, OHCHR, UNDP, UNESCO-IHP, UN-Habitat, UNHCR, UNU-INWEH, UNU-FLORES, WWAP and the World Bank, with regional perspectives provided by UNECE, UNECLAC, UNESCAP and UNESCWA. The Report also benefited to a great extent from the inputs and contributions of several other UN-Water members and partners, as well as of dozens of scientists, professionals and NGOs, who provided a wide range of relevant material.On behalf of the WWAP Secretariat, we would like to extend our deepest appreciation to the afore-mentioned agencies, members and partners of UN-Water, and to the writers and other contributors for collectively producing this unique and authoritative report that will, hopefully, have multiple impacts worldwide. L\ue9o Heller, Special Rapporteur on the human rights to safe drinking water and sanitation, deserves specific recognition for having generously shared his knowledge and wisdom in the early critical phases of the report\u2019s production process.We are profoundly grateful to the Italian Government for funding the Programme and to the Regione Umbria for generously hosting the WWAP Secretariat in Villa La Colombella in Perugia. Their contributions have been instrumental to the production of the WWDR.Our special thanks go to Audrey Azoulay, Director-General of UNESCO, for her vital support to WWAP and the production of the WWDR. The guidance of Gilbert F. Houngbo, President of IFAD, as Chair of UN-Water has made this publication possible. Last but not least, we extend our most sincere gratitude to all our colleagues at the WWAP Secretariat for their professionalism and dedication, without whom the report would not have been completed