Estimating the surgical backlog from the COVID-19 lockdown in South Africa: A retrospective analysis of six government hospitals.

BACKGROUND: The COVID-19 pandemic reached South Africa (SA) in March 2020. A national lockdown began on 27 March 2020, and health facilities reduced non-essential activity, including many surgical services. PRIMARY OBJECTIVE: to estimate the COVID-19 surgical backlog in Western Cape Province, SA, by comparing 2019 and 2020 general surgery operative volume and proportion at six district and regional hospitals. SECONDARY OBJECTIVE: to compare the operative volume of appendicectomy, laparoscopic cholecystectomy, cancer and trauma between the 2 years. METHODS: This was a retrospective study of general surgery operations from six SA government hospitals in the Western Cape. Data were obtained from electronic operative databases or operative theatre logbooks from 1 April to 31 July 2019 and 1 April to 31 July 2020. RESULTS: Total general surgery operations decreased by 44% between 2019 (n=3 247) and 2020 (n=1 810) (p<0.001). Elective operations decreased by 74% (n=1 379 v. n=362; p<0.001), and one common elective procedure, laparoscopic cholecystectomy, decreased by 68% (p<0.001). Emergency operations decreased by 22% (n=1 868 v. n=1 448; p<0.001) and trauma operations by 42% (n=325 v. n=190; p<0.001). However, non-trauma emergency operations such as appendicectomy and cancer did not decrease. The surgical backlog for elective operations after 4 months from these six hospitals is 1 017 cases, which will take between 4 and 14 months to address if each hospital can do one additional operation per weekday. CONCLUSIONS: The COVID-19 pandemic has created large backlogs of elective operations that will need to be addressed urgently. Clear and structured guidelines need to be developed in order to streamline the reintroduction of full surgical healthcare services as SA slowly recovers from this unprecedented pandemic.

Thirty-day readmission rate: A predictor of initial surgical severity or quality of surgical care? A regional hospital analysis.

BACKGROUND: Unplanned readmission within 30 days is currently being used in high-income countries (HICs) for measuring the quality of surgical care. Surgical site infection (SSI), abdominal complaints and pain are the most common causes for such readmission. The correlation between readmission rates and mortality, increased patient volumes and complexity of surgery remains controversial. OBJECTIVES: To explore the risk factors for unplanned readmission in the surgical population in a low- and middle-income country setting. METHODS: This is a retrospective review of prospectively collected data of unplanned 30-day readmissions from January 2014 to December 2017 in the Department of General Surgery, Worcester Hospital, South Africa (SA). Basic patient demographics, reasons for readmission, operative urgency and severity, wound class, length of stay and final outcomes were used to compare the inpatient cohort and identify predictors for unplanned readmission. RESULTS: A total of 9 649 patients were admitted to the general surgery department at Worcester Hospital - 2.87% (n=270) were unplanned readmissions within 30 days. The mean age of this cohort was 42 (standard deviation (SD) 22) years, with 61% male patients. SSI (60.37%; n=163), gastrointestinal complications (24.44%; n=66) and blood transfusion (7.03%; n=19) were the most common causes for readmission. Median initial length of stay (LOS) was 4 days; after readmission it was 5 days. Readmissions were responsible for 1 914 additional patient days. Operative Portsmouth-POSSUM (P-POSSUM) (Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity) score (p<0.001), increase in operative wound classification (p=0.001) and emergency surgical procedures (p=0.001) were significant risk factors for readmission within 30 days. CONCLUSIONS: The Department of General Surgery, Worcester Hospital, had a readmission rate comparable with that in HICs. Readmission rate is an indicator of advanced surgical pathology requiring an operative intervention of greater magnitude, often presenting as an emergency. Our results can be used to improve postoperative surveillance and ultimately improve outcomes in high-risk surgical populations. This study provides a benchmark for other regional hospitals in SA and has implications for quality-improvement programmes.

The effect of the introduction of an electronic booking system to appropriately prioritise gastroscopies at a regional hospital in South Africa.

BACKGROUND: The National Institute for Health and Clinical Excellence (NICE) guidelines state that patients with dyspepsia as well as alarm symptoms, or those that are 55 years and older with new onset dyspepsia, urgently require an upper endoscopy within two weeks. The 'Be Clear on Cancer Campaign' launched by Public Health England estimated that 9% of deaths due to gastric and oesophageal cancers could have been avoided if the diagnosis was made at an earlier stage. Worcester Provincial Hospital (WPH) is a regional hospital in the Western Cape, South Africa, that due to resource constraints was unable to comply with these guidelines. An electronic endoscopy booking system was implemented in June 2014 to assist referring clinicians. OBJECTIVES: To evaluate the ability of the booking system to appropriately prioritise and accommodate clinically appropriate patients for an urgent gastroscopy within 2 weeks at WPH. METHODS: Retrospective analysis of patients booked for urgent gastroscopies using the online booking system at WPH from July 2014 to June 2017. RESULTS: A total of 1 589 gastroscopies were performed, with 1 085 (65%) categorised as urgent by the booking system algorithm, during the study period. The median (interquartile range) waiting time for urgent gastroscopies was 19 (8 - 31) days and 437 (40%) patients underwent a gastroscopy within the recommended 2-week period. Of the patients undergoing gastroscopy within 2 weeks, 87 (20%) were diagnosed with upper gastrointestinal malignancies and 73 (17%) had significant benign pathology (stricture or ulcer). A total of 150 malignancies were diagnosed in the urgent patients of whom 87 (58%) were scoped within 2 weeks. CONCLUSIONS: The volume of patients requiring urgent gastroscopy at WPH outstrips the available resources. The introduction of the online algorithm-based booking system was effective in prioritising patients. The use of this system facilitated a malignancy diagnosis rate which compares favourably with similar fast track endoscopy services in more developed countries.

Bilateral internal carotid artery occlusion with compensatory perfusion in a HIV-infected patient.

BACKGROUND: Worcester Hospital is a regional healthcare facility in the Western Cape, South Africa, without a dedicated burns unit. Currently there is limited data available of burns patient management outside of academic institutions in South Africa. To describe the incidence and demographics, and to determine the outcomes of burn patients admitted to Worcester Hospital. METHODOLOGY: A retrospective descriptive study of burn patients admitted to Worcester Hospital between 1 September 2016 and 31 August 2017. RESULTS: A total of 66 burn patients were included in this study which accounted for 1.6% of the total surgical admissions for this time period. The mean age of the patients was 39 (SD ± 19) years with a male predominance (59%). The mechanism of burn was mostly flame burns (71%); 16 patients (24%) were burned with hot fluids and 3 patients (5%) sustained electrical burns. The median TBSA was 9% (IQR: 5-28). Ten patients (15%) required critical care unit admission. The burn patients' median length of stay was 6 days (IQR: 2-11 days) versus 2 days (IQR: 1-5 days) for non-burn general surgery patients. Fifty burn patients (76%) required surgical intervention comprising of either debridement or skin grafting, or a combination of this. Forty-four patients (67%) underwent skin grafting procedures and the median TBSA grafted was 5% (IQR: 3.5-9.5). The median time from admission to first surgical procedure was 25 hours (IQR: 18.33-51.08). The in-hospital mortality rate was 23% and of the 15 mortalities, 9 patients (60%) had TBSA of 30% or more and therefore classified as a major burn. CONCLUSION: Burn injuries treated at Worcester Hospital are often severe and require significant resources. This study supplies critical information regarding the burden of burn related injuries managed at a regional level.

Four-year review of admissions to a South African regional hospital general surgery department.

BACKGROUND: There are limited published data describing surgical admissions at a regional hospital level in the South African (SA) context. OBJECTIVES: To retrospectively review data from an electronic discharge summary  database at a regional SA hospital from 2012 to 2016 to describe the burden of surgical disease by analysing characteristics of the patients admitted. METHODS: All discharge summary records for the 4-year period were reviewed after extraction from a database created for the surgery department. Admissions were classified into 5 types: (i) elective surgery or investigations (ESI); (ii) trauma; (iii) burns; (iv) non-traumatic surgical emergencies (NTSE); and (v) unplanned readmission within 30 days. Other variables reviewed were demographic data, the International Statistical Classification of Diseases and Related Health Problems - Version 10 (ICD-10) diagnosis; area of origin; and outcome (death, tertiary referral, discharge). Data were subgrouped into 12-month periods to facilitate trend analysis. RESULTS: Discharge summaries (N=9 805) over the 4-year study period were assessed and 9 799 were included in the analysis. All data were entered by the attending medical personnel. A total of 5 647 male patients (57.6%) and 4 152 female patients (42.4%) were admitted, with a mean age of 43.3 years (95% confidence interval (CI) 43.0 - 43.8) and a mean length of stay of 4.9 days (95% CI 4.7 - 5.1). Male patients comprised a larger proportion of trauma (83.7%) and burn (63.9%) admissions. The mean length of stay ranged from 3.5 days for elective patients to 9.1 days for burn patients. The most common diagnoses for emergency admissions were appendicitis, peripheral vascular disease and peptic ulcer disease. Common diagnoses for elective admissions were gallstone disease, inguinal hernia, anal fistulas/fissures, and ventral and incisional hernia. The most common cancer diagnoses were of the colorectum, oesophagus, breast and stomach. The overall mortality rate was 2.2%, and highest by subtype was burn patients (6.3%). Trend analysis showed a statistically significant increase in admission for NTSE (p=0.019), trauma (p<0.001) and 30-day readmission rates (p<0.001), with a decrease in admissions for ESI (p=0.001) over the 4 years. CONCLUSIONS: A precise understanding of the burden of disease profile is essential for national, provincial and district budgeting and resource allocation. Ongoing surveillance such as that performed in the study provides this critical information.

A review of primary and secondary burn services in the Western Cape, South Africa.

BACKGROUND: In 2011, the Department of Health of the Western Cape Province, South Africa, requested a review of current burn services in the province, with a view to formulating a more efficient and cost-effective service. This article considers the findings of the review and presents strategies to improve delivery of appropriate burn care at primary and secondary levels. METHODS: Surveys were conducted at eight rural and urban hospitals, two outreach workshops on burn care, four regional hospitals and at least 60 clinics in Cape Town and in the Western Cape as far as Ladismith. A survey on community management of paediatric burns was also included in the study. RESULTS: The incidence of burns was highest in the winter months, more than half of those affected were children, and the majority of burns were scalds from hot liquids. Most burn injuries managed at primary level were minor, with 75% of patients treated by nurse practitioners and discharged. The four regional secondary hospitals managed the majority of moderate to severe burns. There is room for improvement in terms of treatment facilities and consumables at all levels, regional hospitals being particularly restricted in terms of outdated equipment, a shortage of intensive care unit beds, and difficulties in transferring patients with major burns to a burns unit when indicated. CONCLUSION: The community management of paediatric burns was satisfactory, although considerable delays in transfer and insufficient pain control hampered appropriate care. A great need for ongoing education at all levels was identified. Ten strategies are presented that could, if implemented, lead to tangible improvements in the management of burn patients at primary and secondary levels in the Western Cape.