Experience with the WHO Surgical Safety Checklist

Despite years of efforts by organizations throughout the world “wrong site” surgery has proven to be a resilient opponent. The purpose of present review article is to revisit the various tools that have been designed specially the WHO Surgical Safety Checklist (SSCL), the purpose of which is to improve patient safety and prevent errors in the site of surgery. Three items were the corner stone of this review. Firstly effectiveness of the tools specially the WHO SSCL, secondly approach of those responsible for implementation and thirdly adherence by organizations to the provided guideline. A general review of the available data showed a clear improvement in patient safety. As a whole medical personnel considered SSCl and other tools as a good addition but these tools have yet to prove their worth in the prevention of “wrong site” surgery. There is a need to strive continuously for improving patient safety and to capitalize on the advances made in this regard to prevent this menace. At our Rawalpindi Medical University affiliated Holy Family Hospital efforts are in place for improving ways and developing protocols to curb the evil of wrong site surgery. We currently adopted a new way proposed by Ragusa et al in which we experimented with keeping the surgical instruments and trolley outside the OR away from the surgery team members. Thus preventing distraction of team members till the completion of SSCl. Additionally the Anesthetist took the responsibility of the implementation of the SSCL. This method also prevented the hierarchal style seen in the operation theatres. 1,2 These sentinel events policy was published in 1996.3 By the Joint Commission. This commission is an independent body which has 20,500 health care facilities accredited with it in the USA. The aim of this policy was to help individuals and organizations to learn from their mistakes and achieve the objective of patient safety and zero rate of wrong site surgery4. Wrong site surgery mean surgery done on the wrong patient, surgery on the wrong site or may be a wrong surgery on the wrong patient.4 After review of the record the American Academy of Orthopedics claimed that the orthopedic surgeons have a 25% likelihood of operating a wrong site during their careers. After this claim a campaign “Sign Your Site” was started which proposed that surgeons should sign the surgical site before surgery is done.5 A similar scheme known as the “SMaX” which stands for signing, marking and X-ray of the spine segment was launched by the North American Spine Society in 2001.6     In 2004 The Joint Commission proposed a Universal Protocol. The Commission made it compulsory for all medical facilities under its accreditation to adopt it.7 This document included confirmation of patient and surgical site, its marking and time out before any elective surgery. The World Health Organization (WHO) a subsidiary of the United Nations, which is charged with managing the global health affairs, developed the “surgical Safety Checklist” in the year 2008. This checklist was a product of the “Safe Surgery Saves Lives” campaign. According to this document three phases have been identified in any surgery,. i.e., “Sign In” prior to the anesthesia induction, “Time Out” before incision and “Sign Out” before the patient leaves the operating room. 8-10 Unfortunately in 2009 Stahel et al found an increased number of wrong site surgery.  11 This was preceded by the Joint Commission report  with similar findings.10 Following these disappointing results the Commission further augmented the importance given to the issue by declaring the Universal Protocol as the National patient Safety Goal.12,13 This review article goes through the studies and literature recently published as SSCL and similar tools that have been developed over time to prevent wrong site surgery and improve patient care. The aim was to identify how effective is the SSCL in achieving its goals. Hurdles in the achieving maximum results were also identified. The thinking and view point of those involved in the implementation were sought, emphasis was also placed on how thoroughly organizations comply with the provided guideline

Breast carcinoma grading, estimation of tumor size, axillary lymph node status, staging, and nottingham prognostic index scoring on mastectomy specimens.

Introduction: Breast carcinoma is the most common malignant tumor and the leading cause of cancer death in women. In western countries, a sharp increase in the detection of breast carcinoma, largely due to widespread use of mammography, has recently led to a fall in breast cancer mortality. This, however, is not true for less developed countries, in which mortality continues to rise.Objective:The aim of this study was to acquire information about the extent and spread of breast carcinoma in our Patients by grading the tumors, determining the tumor size, and axillary lymph node status, staging of the tumors and Nottingham Prognostic Index (NPI) scoring on the available material. Materials AndMethods:One hundred and twenty consecutive mastectomy specimens with axillary lymph node sampling removed for breast carcinoma and received in the section of histopathology, Aga Khan University, in the year 2005, were included in the study. Standard protocols were used for the processing of the specimens, and reporting was done using a standard format incorporating all relevant tumor parameters. NPI was applied to the cases.Results:Out of the 120 cases, 5 (4.17) were grade 1, 91 (75.83) were grade 2, and 24 (20%) were grade 3. Also, 9 cases (7.5%) were T1 (4 were T1b, and 5 were T1c), 53 (44.16%) were T2, 50 (41.66%) were T3, and 8 (6.66%) were T4. Axillary lymph nodes were available in 107 cases. In 13 cases, no lymph nodes were recovered. Out of 107 cases 27 (25.23%) lymph nodes were negative for metastases pN0, 29 (27.10%) cases were pN1, 26 (24.30) were pN2, and 25 cases (23.36%) were pN3. Extranodal spread was present in 56 (70%) out of the 80 cases in which lymph nodes were positive. The average microscopic size of nodal metastasis was 1.7 cms. Significant statistical association was found between the number of positive nodes and perinodal extension (P = 0.001). Tumor necrosis was present in 76 out of 120 cases (63.33%). Vascular invasion was present in 43 out of 120 cases (35.83%). NPI scores were greater than 5.4 in 60 out of 107 cases (56.1%) indicating poor prognosis.Conclusion:The large majority of the cases were grade 2 tumors. Most cases (all grades) were T2 or T3, and were axillary lymph node positive. Large majority of cases with nodel metastases showed extra nodal spread. The majority of Patients had NPI scores greater than 5.4 indicating poor prognosis. Significant statistical association was found between the number of positive nodes and perinodal extension (P = 0.001). The findings show extensive and advanced disease trends in our Patients

Use of Ondansetron for Prevention of Spinal Induced Hypotension

Objective: To compare the efficacy of prophylactic administration of Ondansetron before induction of spinal anesthesia with placebo, in preventing spinal induced hypotension. Patients and Methods: This Randomized Control trial was carried out at Holy Family Hospital, Rawalpindi from 29 April 2015 till 28 October 2015. A total of 106 patients were enrolled in the study. Patients in group A, received 6 mg Ondansetron. Patients in group B received normal saline. Mean arterial pressure (MAP) and heart rate (HR) were recorded every 5 minutes after performing spinal anesthesia. The study drug was considered efficacious if absence of hypotension for 20 minutes was recorded after inducing spinal anaesthesia. Data was analyzed using SPSS 17. Results: Hypotension occurred in 7.5% cases in Ondansetron group compared to 28.3% in normal saline group (p=0.005). Conclusion: Ondansetron is effective in preventing spinal induced hypotension.&nbsp

The Learning Curve for Robot-Assisted Radical Cystectomy

The authors found that the learning curve for robotassisted radical cystectomy is constantly evolving to improve oncologic outcomes

Alcohol use and burden for 195 countries and territories, 1990-2016 : a systematic analysis for the Global Burden of Disease Study 2016

Background Alcohol use is a leading risk factor for death and disability, but its overall association with health remains complex given the possible protective effects of moderate alcohol consumption on some conditions. With our comprehensive approach to health accounting within the Global Burden of Diseases, Injuries, and Risk Factors Study 2016, we generated improved estimates of alcohol use and alcohol-attributable deaths and disability-adjusted life-years (DALYs) for 195 locations from 1990 to 2016, for both sexes and for 5-year age groups between the ages of 15 years and 95 years and older. Methods Using 694 data sources of individual and population-level alcohol consumption, along with 592 prospective and retrospective studies on the risk of alcohol use, we produced estimates of the prevalence of current drinking, abstention, the distribution of alcohol consumption among current drinkers in standard drinks daily (defined as 10 g of pure ethyl alcohol), and alcohol-attributable deaths and DALYs. We made several methodological improvements compared with previous estimates: first, we adjusted alcohol sales estimates to take into account tourist and unrecorded consumption; second, we did a new meta-analysis of relative risks for 23 health outcomes associated with alcohol use; and third, we developed a new method to quantify the level of alcohol consumption that minimises the overall risk to individual health. Findings Globally, alcohol use was the seventh leading risk factor for both deaths and DALYs in 2016, accounting for 2.2% (95% uncertainty interval [UI] 1.5-3.0) of age-standardised female deaths and 6.8% (5.8-8.0) of age-standardised male deaths. Among the population aged 15-49 years, alcohol use was the leading risk factor globally in 2016, with 3.8% (95% UI 3.2-4-3) of female deaths and 12.2% (10.8-13-6) of male deaths attributable to alcohol use. For the population aged 15-49 years, female attributable DALYs were 2.3% (95% UI 2.0-2.6) and male attributable DALYs were 8.9% (7.8-9.9). The three leading causes of attributable deaths in this age group were tuberculosis (1.4% [95% UI 1. 0-1. 7] of total deaths), road injuries (1.2% [0.7-1.9]), and self-harm (1.1% [0.6-1.5]). For populations aged 50 years and older, cancers accounted for a large proportion of total alcohol-attributable deaths in 2016, constituting 27.1% (95% UI 21.2-33.3) of total alcohol-attributable female deaths and 18.9% (15.3-22.6) of male deaths. The level of alcohol consumption that minimised harm across health outcomes was zero (95% UI 0.0-0.8) standard drinks per week. Interpretation Alcohol use is a leading risk factor for global disease burden and causes substantial health loss. We found that the risk of all-cause mortality, and of cancers specifically, rises with increasing levels of consumption, and the level of consumption that minimises health loss is zero. These results suggest that alcohol control policies might need to be revised worldwide, refocusing on efforts to lower overall population-level consumption.Peer reviewe

Measuring progress and projecting attainment on the basis of past trends of the health-related Sustainable Development Goals in 188 countries: an analysis from the Global Burden of Disease Study 2016

The UN’s Sustainable Development Goals (SDGs) are grounded in the global ambition of “leaving no one behind”. Understanding today’s gains and gaps for the health-related SDGs is essential for decision makers as they aim to improve the health of populations. As part of the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016), we measured 37 of the 50 health-related SDG indicators over the period 1990–2016 for 188 countries, and then on the basis of these past trends, we projected indicators to 2030

Adolescent transport and unintentional injuries: a systematic analysis using the Global Burden of Disease Study 2019

Background: Globally, transport and unintentional injuries persist as leading preventable causes of mortality and morbidity for adolescents. We sought to report comprehensive trends in injury-related mortality and morbidity for adolescents aged 10–24 years during the past three decades. Methods: Using the Global Burden of Disease, Injuries, and Risk Factors 2019 Study, we analysed mortality and disability-adjusted life-years (DALYs) attributed to transport and unintentional injuries for adolescents in 204 countries. Burden is reported in absolute numbers and age-standardised rates per 100 000 population by sex, age group (10–14, 15–19, and 20–24 years), and sociodemographic index (SDI) with 95% uncertainty intervals (UIs). We report percentage changes in deaths and DALYs between 1990 and 2019. Findings: In 2019, 369 061 deaths (of which 214 337 [58%] were transport related) and 31·1 million DALYs (of which 16·2 million [52%] were transport related) among adolescents aged 10–24 years were caused by transport and unintentional injuries combined. If compared with other causes, transport and unintentional injuries combined accounted for 25% of deaths and 14% of DALYs in 2019, and showed little improvement from 1990 when such injuries accounted for 26% of adolescent deaths and 17% of adolescent DALYs. Throughout adolescence, transport and unintentional injury fatality rates increased by age group. The unintentional injury burden was higher among males than females for all injury types, except for injuries related to fire, heat, and hot substances, or to adverse effects of medical treatment. From 1990 to 2019, global mortality rates declined by 34·4% (from 17·5 to 11·5 per 100 000) for transport injuries, and by 47·7% (from 15·9 to 8·3 per 100 000) for unintentional injuries. However, in low-SDI nations the absolute number of deaths increased (by 80·5% to 42 774 for transport injuries and by 39·4% to 31 961 for unintentional injuries). In the high-SDI quintile in 2010–19, the rate per 100 000 of transport injury DALYs was reduced by 16·7%, from 838 in 2010 to 699 in 2019. This was a substantially slower pace of reduction compared with the 48·5% reduction between 1990 and 2010, from 1626 per 100 000 in 1990 to 838 per 100 000 in 2010. Between 2010 and 2019, the rate of unintentional injury DALYs per 100 000 also remained largely unchanged in high-SDI countries (555 in 2010 vs 554 in 2019; 0·2% reduction). The number and rate of adolescent deaths and DALYs owing to environmental heat and cold exposure increased for the high-SDI quintile during 2010–19. Interpretation: As other causes of mortality are addressed, inadequate progress in reducing transport and unintentional injury mortality as a proportion of adolescent deaths becomes apparent. The relative shift in the burden of injury from high-SDI countries to low and low–middle-SDI countries necessitates focused action, including global donor, government, and industry investment in injury prevention. The persisting burden of DALYs related to transport and unintentional injuries indicates a need to prioritise innovative measures for the primary prevention of adolescent injury. Funding: Bill & Melinda Gates Foundation

Measuring universal health coverage based on an index of effective coverage of health services in 204 countries and territories, 1990–2019 : A systematic analysis for the Global Burden of Disease Study 2019

Background Achieving universal health coverage (UHC) involves all people receiving the health services they need, of high quality, without experiencing financial hardship. Making progress towards UHC is a policy priority for both countries and global institutions, as highlighted by the agenda of the UN Sustainable Development Goals (SDGs) and WHO's Thirteenth General Programme of Work (GPW13). Measuring effective coverage at the health-system level is important for understanding whether health services are aligned with countries' health profiles and are of sufficient quality to produce health gains for populations of all ages. Methods Based on the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019, we assessed UHC effective coverage for 204 countries and territories from 1990 to 2019. Drawing from a measurement framework developed through WHO's GPW13 consultation, we mapped 23 effective coverage indicators to a matrix representing health service types (eg, promotion, prevention, and treatment) and five population-age groups spanning from reproductive and newborn to older adults (≥65 years). Effective coverage indicators were based on intervention coverage or outcome-based measures such as mortality-to-incidence ratios to approximate access to quality care; outcome-based measures were transformed to values on a scale of 0–100 based on the 2·5th and 97·5th percentile of location-year values. We constructed the UHC effective coverage index by weighting each effective coverage indicator relative to its associated potential health gains, as measured by disability-adjusted life-years for each location-year and population-age group. For three tests of validity (content, known-groups, and convergent), UHC effective coverage index performance was generally better than that of other UHC service coverage indices from WHO (ie, the current metric for SDG indicator 3.8.1 on UHC service coverage), the World Bank, and GBD 2017. We quantified frontiers of UHC effective coverage performance on the basis of pooled health spending per capita, representing UHC effective coverage index levels achieved in 2019 relative to country-level government health spending, prepaid private expenditures, and development assistance for health. To assess current trajectories towards the GPW13 UHC billion target—1 billion more people benefiting from UHC by 2023—we estimated additional population equivalents with UHC effective coverage from 2018 to 2023. Findings Globally, performance on the UHC effective coverage index improved from 45·8 (95% uncertainty interval 44·2–47·5) in 1990 to 60·3 (58·7–61·9) in 2019, yet country-level UHC effective coverage in 2019 still spanned from 95 or higher in Japan and Iceland to lower than 25 in Somalia and the Central African Republic. Since 2010, sub-Saharan Africa showed accelerated gains on the UHC effective coverage index (at an average increase of 2·6% [1·9–3·3] per year up to 2019); by contrast, most other GBD super-regions had slowed rates of progress in 2010–2019 relative to 1990–2010. Many countries showed lagging performance on effective coverage indicators for non-communicable diseases relative to those for communicable diseases and maternal and child health, despite non-communicable diseases accounting for a greater proportion of potential health gains in 2019, suggesting that many health systems are not keeping pace with the rising non-communicable disease burden and associated population health needs. In 2019, the UHC effective coverage index was associated with pooled health spending per capita (r=0·79), although countries across the development spectrum had much lower UHC effective coverage than is potentially achievable relative to their health spending. Under maximum efficiency of translating health spending into UHC effective coverage performance, countries would need to reach $1398 pooled health spending per capita (US$ adjusted for purchasing power parity) in order to achieve 80 on the UHC effective coverage index. From 2018 to 2023, an estimated 388·9 million (358·6–421·3) more population equivalents would have UHC effective coverage, falling well short of the GPW13 target of 1 billion more people benefiting from UHC during this time. Current projections point to an estimated 3·1 billion (3·0–3·2) population equivalents still lacking UHC effective coverage in 2023, with nearly a third (968·1 million [903·5–1040·3]) residing in south Asia. Interpretation The present study demonstrates the utility of measuring effective coverage and its role in supporting improved health outcomes for all people—the ultimate goal of UHC and its achievement. Global ambitions to accelerate progress on UHC service coverage are increasingly unlikely unless concerted action on non-communicable diseases occurs and countries can better translate health spending into improved performance. Focusing on effective coverage and accounting for the world's evolving health needs lays the groundwork for better understanding how close—or how far—all populations are in benefiting from UHC

Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016

As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016