RESUMO
BACKGROUND: Trauma is the leading cause of mortality in the pediatric population >1 year. Analyzing relationships between pediatric trauma-related mortality and geographic access to trauma centers (among other social covariates) elucidates the importance of cost and care effective regionalization of designated trauma facilities. METHODS: Pediatric crude injury mortality in 49 United States served as a dependent variable and state population within 45 minutes of trauma centers acted as the independent variable in four linear regression models. Multivariate analyses were performed using previously identified demographics as covariates. RESULTS: There is a favorable inverse relation between pediatric access to trauma centers and pediatric trauma-related mortality. Though research shows care is best at pediatric trauma centers, access to Adult Level 1 or 2 trauma centers held the most predictive power over mortality. A 4-year college degree attainment proved to be the most influential covariate, with predictive powers greater than the proximity variable. CONCLUSIONS: Increased access to adult or pediatric trauma facilities yields improved outcomes in pediatric trauma mortality. Implementation of qualified, designated trauma centers, with respect to regionalization, has the potential to further lower pediatric mortality. Additionally, the percentage of state populations holding 4-year degrees is a stronger predictor of mortality than proximity and warrants further investigation.
Assuntos
Centros de Traumatologia , Ferimentos e Lesões , Adulto , Criança , Mortalidade Hospitalar , Humanos , Modelos Lineares , Estados Unidos/epidemiologia , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Trauma is a leading cause of mortality in low- and middle-income countries. The Pediatric Resuscitation and Trauma Outcomes (PRESTO) model uses six low-tech variables available at point of care in resource-limited environments to predict in-hospital mortality of injured children. This model was never calibrated and validated in a low-income country. We aimed to calibrate the model's coefficients and compare its performance against the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) using data from a low-income country. STUDY DESIGN: Data from 2011 to 2015 in the prospectively-maintained Rwanda Injury Registry were reviewed after ethical approval was obtained. Patients were included for analysis if they were referred or admitted for traumatic injury, were younger than 15â¯years and if hospital outcomes were recorded. The variables in the PRESTO model include age, hypotension, heart rate, neurological status, oxygen saturation and airway intervention. The outcome of interest was in-hospital death. After calibration, Receiver-Operating-Characteristic curves were constructed to compare the area-under-curve (AUC) of PRESTO, RTS, and KTS with imputation of missing data. Comparisons of the relative AUC's were performed using Delong's test after bootstrapping in the full cohort and in a subset of patients <5â¯years-old. RESULTS: There were 113 in-hospital deaths out of 1695 included patients (6.7%). The AUC for the PRESTO model was 0.90 (95% CI [0.82-0.91]), higher than for RTS (0.77, 95% CI [0.80-0.97], pâ¯<â¯0.01) but not statistically different from KTS (0.89, 95% CI [0.72-0.82], pâ¯=â¯0.856). In the under-five cohort, the PRESTO model AUC was 0.84 (95% CI [0.75-0.92]), significantly higher than RTS (0.73 95% CI [0.64-0.81], pâ¯<â¯0.01) and KTS (0.58, 95% CI [0.50-0.66], pâ¯<â¯0.01). CONCLUSION: PRESTO appears to be the superior benchmarking tool for pediatric patients in a low- and middle-income country context. The PRESTO score outperforms the KTS in children <5â¯years of age. Further validation of the PRESTO model is needed from other low- and middle-income settings. LEVEL OF EVIDENCE: Level III: case-control (prognostic) study.
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Ferimentos e Lesões , Calibragem , Criança , Pré-Escolar , Mortalidade Hospitalar , Humanos , Ruanda/epidemiologia , Índices de Gravidade do Trauma , Uganda , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Child survival initiatives historically prioritized efforts to reduce child morbidity and mortality from infectious diseases and maternal conditions. Little attention has been devoted to paediatric injuries in resource-limited settings. This study aimed to evaluate the demographics and outcomes of paediatric injury in a sub-Saharan African country in an effort to improve prevention and treatment. METHODS: A prospective trauma registry was established at the two university teaching campuses of the University of Rwanda to record systematically patient demographics, prehospital care, initial physiology and patient outcomes from May 2011 to July 2015. Univariable analysis was performed for demographic characteristics, injury mechanisms, geographical location and outcomes. Multivariable analysis was performed for mortality estimates. RESULTS: Of 11 036 patients in the registry, 3010 (27·3 per cent) were under 18 years of age. Paediatric patients were predominantly boys (69·9 per cent) and the median age was 8 years. The mortality rate was 4·8 per cent. Falls were the most common injury (45·3 per cent), followed by road traffic accidents (30·9 per cent), burns (10·7 per cent) and blunt force/assault (7·5 per cent). Patients treated in the capital city, Kigali, had a higher incidence of head injury (7·6 per cent versus 2·0 per cent in a rural town, P < 0·001; odds ratio (OR) 4·08, 95 per cent c.i. 2·61 to 6·38) and a higher overall injury-related mortality rate (adjusted OR 3·00, 1·50 to 6·01; P = 0·019). Pedestrians had higher overall injury-related mortality compared with other road users (adjusted OR 3·26, 1·37 to 7·73; P = 0·007). CONCLUSION: Paediatric injury is a significant contributor to morbidity and mortality. Delineating trauma demographics is important when planning resource utilization and capacity-building efforts to address paediatric injury in low-resource settings and identify vulnerable populations.
ANTECEDENTES: Históricamente, las iniciativas relativas a la supervivencia pediátrica han priorizado los esfuerzos para reducir la morbilidad y la mortalidad debida a enfermedades infecciosas y patología materna. Se ha prestado escasa atención a los traumatismos en pediatría en entornos de recursos limitados. El objetivo de este estudio ha sido evaluar la demografía y los resultados de los traumatismos pediátricos en un país del África subsahariana en un intento para mejorar la prevención y el tratamiento. MÉTODOS: Se estableció un registro prospectivo de traumatismos en dos campus universitarios de Ruanda para recoger sistemáticamente las características demográficas, atención pre-hospitalaria, fisiología inicial y resultados, de mayo de 2011 a julio de 2015. Se efectuó un análisis univariado para los datos demográficos, mecanismos del traumatismo, localización geográfica y resultados. Para las estimaciones de mortalidad se llevó a cabo un análisis multivariable. RESULTADOS: De un total de 11.036 pacientes incluidos en el registro, 3.010 (27,3%) tenían menos de 18 años. Los pacientes pediátricos eran predominantemente varones (69,9%) con una edad media de 8,3 años. Las caídas fueron la causa más frecuente del traumatismo (45,3%) seguidas de los accidentes de tráfico (30,9%), quemaduras (10,7%) y traumatismo cerrado/asalto (7,5%). Los pacientes tratados en la capital presentaban una incidencia más elevada de traumatismos craneales (7,5% versus 2,0%, P < 0,0001, razón de oportunidades, odds ratio, OR 4,08, i.c. del 95% 2,6-6,4) y una mayor mortalidad global relacionada con el traumatismo (P = 0,019, OR ajustado 3,00, i.c. del 95% 1,5-6,0). Los peatones presentaron una mortalidad global relacionada con el traumatismo más alta en comparación con otros usuarios de la carretera (P = 0,0074, OR ajustado 3,26, i.c. del 95% 1,37-7,73). CONCLUSIÓN: Los traumatismos pediátricos contribuyen significativamente a la morbilidad y mortalidad. Delinear la demografía de los traumatismos es importante a la hora de planificar el uso de recursos y el desarrollo de capacidades dirigidas al esfuerzo para abordar los traumatismos pediátricos en entornos de bajos recursos e identificar poblaciones vulnerables.
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Serviços Médicos de Emergência/estatística & dados numéricos , Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/epidemiologia , Adolescente , Criança , Pré-Escolar , Serviços Médicos de Emergência/métodos , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Estudos Prospectivos , Sistema de Registros/estatística & dados numéricos , Ruanda/epidemiologia , Ferimentos e Lesões/mortalidadeRESUMO
OBJECTIVE: Emergency medical service (EMS) providers are systematically subjected to intense stimuli in their work that may result in distress and emotional suffering. While it is known that mindfulness-based stress reduction (MBSR) helps to foster well-being in healthcare workers, the effectiveness of MBSR among EMS providers is less understood. We explored the impact of a modified version of MBSR for healthcare workers called Mindfulness for Healthcare Providers (MHP) on reducing distress and promoting wellbeing in EMS providers. METHODS: A one-arm pilot study was conducted. We implemented eight two-and-a-half hour sessions of Mindfulness for Healthcare Providers with an additional day-long retreat at the end. Feasibility, perceived stress, professional quality of life, and trait mindfulness were assessed prior to and after the intervention. The professional quality of life scale includes measures of compassion satisfaction, burnout, and secondary trauma. RESULTS: Fifteen veteran EMS providers enrolled in the course; four participants dropped out. Prior to initiation of the study, no significant differences were revealed between those who did not participate (n = 48) and those who did (nâ¯=â¯11). After the intervention EMS providers endorsed statistically significant increases in compassion satisfaction, trait mindfulness, and decreases in burnout compared to the beginning of the program. These changes were sustained at six months post-completion. No significant changes over time were found for secondary trauma or perceived stress. CONCLUSIONS: To our knowledge, this study is the first to employ Mindfulness for Healthcare Providers in an EMS population and to demonstrate a positive impact on self-reported compassion, trait mindfulness, and burnout in this population. Additional research regarding mindfulness training within EMS populations should be conducted to further understand the relationship between mindfulness and perceived stress over time.
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Auxiliares de Emergência/psicologia , Atenção Plena , Estresse Ocupacional/psicologia , Adulto , Esgotamento Profissional/psicologia , Empatia , Estudos de Viabilidade , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Qualidade de Vida , Voluntários/psicologiaRESUMO
Predictive analytics monitoring, the use of patient data to provide continuous risk estimation of deterioration, is a promising new application of big data analytical techniques to the care of individual patients. We tested the hypothesis that continuous display of novel electronic risk visualization of respiratory and cardiovascular events would impact intensive care unit (ICU) patient outcomes. In an adult tertiary care surgical trauma ICU, we displayed risk estimation visualizations on a large monitor, but in the medical ICU in the same institution we did not. The risk estimates were based solely on analysis of continuous cardiorespiratory monitoring. We examined 4275 individual patient records within a 7 month time period preceding and following data display. We determined cases of septic shock, emergency intubation, hemorrhage, and death to compare rates per patient care pre-and post-implementation. Following implementation, the incidence of septic shock fell by half (p < 0.01 in a multivariate model that included age and APACHE) in the surgical trauma ICU, where the data were continuously on display, but by only 10% (p = NS) in the control Medical ICU. There were no significant changes in the other outcomes. Display of a predictive analytics monitor based on continuous cardiorespiratory monitoring was followed by a reduction in the rate of septic shock, even when controlling for age and APACHE score.
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Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Monitorização Fisiológica/instrumentação , Processamento de Sinais Assistido por Computador , APACHE , Idoso , Feminino , Hemorragia , Humanos , Estudos Longitudinais , Masculino , Informática Médica , Pessoa de Meia-Idade , Monitorização Fisiológica/métodos , Análise Multivariada , Avaliação de Resultados em Cuidados de Saúde , Estudos Retrospectivos , Risco , Choque Séptico/patologiaRESUMO
OBJECTIVE: Predictive analytics monitoring that informs clinicians of the risk for failed extubation would help minimize both the duration of mechanical ventilation and the risk of emergency re-intubation in ICU patients. We hypothesized that dynamic monitoring of cardiorespiratory data, vital signs, and lab test results would add information to standard clinical risk factors. METHODS: We report model development in a retrospective observational cohort admitted to either the medical or surgical/trauma ICU that were intubated during their ICU stay and had available physiologic monitoring data (n = 1202). The primary outcome was removal of endotracheal intubation (i.e. extubation) followed within 48 h by reintubation or death (i.e. failed extubation). We developed a standard risk marker model based on demographic and clinical data. We also developed a novel risk marker model using dynamic data elements-continuous cardiorespiratory monitoring, vital signs, and lab values. RESULTS: Risk estimates from multivariate predictive models in the 24 h preceding extubation were significantly higher for patients that failed. Combined standard and novel risk markers demonstrated good predictive performance in leave-one-out validation: AUC of 0.64 (95% CI: 0.57-0.69) and 1.6 alerts per week to identify 32% of extubations that will fail. Novel risk factors added significantly to the standard model. CONCLUSION: Predictive analytics monitoring models can detect changes in vital signs, continuous cardiorespiratory monitoring, and laboratory measurements in both the hours preceding and following extubation for those patients destined for extubation failure.
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Extubação/estatística & dados numéricos , Unidades de Terapia Intensiva/estatística & dados numéricos , Idoso , Fenômenos Fisiológicos Cardiovasculares , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Respiração , Respiração Artificial , Estudos RetrospectivosRESUMO
BACKGROUND: Continuous predictive monitoring has been employed successfully to predict subclinical adverse events. Should low values on these models, however, reassure us that a patient will not have an adverse outcome? Negative predictive values of such models could help predict safe patient discharge. The goal of this study was to validate the negative predictive value of an ensemble model for critical illness (using previously developed models for respiratory instability, hemorrhage, and sepsis) based on bedside monitoring data in the intensive care units and intermediate care unit. METHODS: We calculated the relative risk of 3 critical illnesses for all patients every 15 minutes (n= 124,588) for 2,924 patients downgraded from the surgical intensive care units and intermediate care unit between May 2014 to May 2016. We constructed an ensemble model to estimate at the time of intensive care units or intermediate care unit discharge the probability of favorable outcome after downgrade. RESULTS: Outputs form the ensemble model stratified patients by risk of favorable and bad outcomes in both intensive care units/intermediate care unit; area under the receiver operating characteristic curve = .639/.629 respectively for favorable outcomes and .645/.641 for adverse events. These performance characteristics are commensurate with published models for predicting readmission. The ensemble model remained a statistically significant predictor after adjusting for hospital duration of stay and admitting service. The rate of favorable outcome in the highest and lowest deciles in the intensive care units were 76.2% and 27.3% (2.8-fold decrease) and 88.3% and 33.2% in the intermediate care unit (2.7-fold decrease), respectively. CONCLUSION: An ensemble model for critical illness predicts favorable outcome after downgrade and safe patient discharge (hospital stay <7 days, no readmission, upgrade, or death).
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Cuidados Críticos/métodos , Estado Terminal/terapia , Técnicas de Apoio para a Decisão , Unidades de Terapia Intensiva , Monitorização Fisiológica/métodos , Alta do Paciente , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Sistemas Automatizados de Assistência Junto ao Leito , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Adulto JovemRESUMO
Background: Ongoing development and expansion of trauma centers in the United States necessitates empirical analysis of the effect of investment in such resources on population-level health outcomes. Methods: Multiple linear regressions were performed to predict state-level trauma-related mortality among adults and the elderly across 50 US states in 2010. The number of trauma centers per capita in each state and the percentage of each state's population living within 45-min of a trauma center served as the key independent variables and injury-related mortality served as the dependent variable. All analyses were stratified by age (adult versus elderly; elderly ≥ 65 years old) and were performed in SPSS. Results: The proportion of a population with geographic proximity to a trauma center demonstrates a consistent inverse linear relationship to injury-related mortality. The relationship reliably retains its significance in models including demographic covariates. Interestingly, access to Levels I and II trauma centers demonstrates a stronger correlation with mortality than was observed with Level III centers. Conclusion: Trauma center access is associated with reduced trauma-related mortality among both adults and the elderly as measured by state reported mortality rates. Ongoing efforts to designate and verify new trauma centers, particularly in poorly-served 'trauma deserts', could lead to lower mortality for large populations.
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Centros de Traumatologia/provisão & distribuição , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Humanos , Modelos Lineares , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise Espacial , Resultado do Tratamento , Estados Unidos/epidemiologia , Adulto JovemRESUMO
BACKGROUND: Preventing urgent intubation and upgrade in level of care in patients with subclinical deterioration could be of great utility in hospitalized patients. Early detection should result in decreased mortality, duration of stay, and/or resource use. The goal of this study was to externally validate a previously developed, vital sign-based, intensive care unit, respiratory instability model on a separate population, intermediate care patients. METHODS: From May 2014 to May 2016, the model calculated relative risk of adverse events every 15 minutes (n = 373,271 observations) for 2,050 patients in a surgical intermediate care unit. RESULTS: We identified 167 upgrades and 57 intubations. The performance of the model for predicting upgrades within 12 hours was highly significant with an area under the curve of 0.693 (95% confidence interval, 0.658-0.724). The model was well calibrated with relative risks in the highest and lowest deciles of 2.99 and 0.45, respectively (a 6.6-fold increase). The model was effective at predicting intubation, with a demonstrated area under the curve within 12 hours of the event of 0.748 (95% confidence interval, 0.685-0.800). The highest and lowest deciles of observed relative risk were 3.91 and 0.39, respectively (a 10.1-fold increase). Univariate analysis of vital signs showed that transfer upgrades were associated, in order of importance, with rising respiration rate, rising heart rate, and falling pulse-oxygen saturation level. CONCLUSION: The respiratory instability model developed previously is valid in intermediate care patients to predict both urgent intubations and requirements for upgrade in level of care to an intensive care unit.
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Cuidados Críticos , Insuficiência Respiratória/diagnóstico , Insuficiência Respiratória/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Curva ROC , Reprodutibilidade dos Testes , Insuficiência Respiratória/terapia , Estudos Retrospectivos , Medição de Risco , Sinais VitaisRESUMO
OBJECTIVES: Patients in ICUs are susceptible to subacute potentially catastrophic illnesses such as respiratory failure, sepsis, and hemorrhage that present as severe derangements of vital signs. More subtle physiologic signatures may be present before clinical deterioration, when treatment might be more effective. We performed multivariate statistical analyses of bedside physiologic monitoring data to identify such early subclinical signatures of incipient life-threatening illness. DESIGN: We report a study of model development and validation of a retrospective observational cohort using resampling (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis type 1b internal validation) and a study of model validation using separate data (type 2b internal/external validation). SETTING: University of Virginia Health System (Charlottesville), a tertiary-care, academic medical center. PATIENTS: Critically ill patients consecutively admitted between January 2009 and June 2015 to either the neonatal, surgical/trauma/burn, or medical ICUs with available physiologic monitoring data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 146 patient-years of vital sign and electrocardiography waveform time series from the bedside monitors of 9,232 ICU admissions. Calculations from 30-minute windows of the physiologic monitoring data were made every 15 minutes. Clinicians identified 1,206 episodes of respiratory failure leading to urgent unplanned intubation, sepsis, or hemorrhage leading to multi-unit transfusions from systematic individual chart reviews. Multivariate models to predict events up to 24 hours prior had internally validated C-statistics of 0.61-0.88. In adults, physiologic signatures of respiratory failure and hemorrhage were distinct from each other but externally consistent across ICUs. Sepsis, on the other hand, demonstrated less distinct and inconsistent signatures. Physiologic signatures of all neonatal illnesses were similar. CONCLUSIONS: Subacute potentially catastrophic illnesses in three diverse ICU populations have physiologic signatures that are detectable in the hours preceding clinical detection and intervention. Detection of such signatures can draw attention to patients at highest risk, potentially enabling earlier intervention and better outcomes.
Assuntos
Doença Catastrófica , Cuidados Críticos , Hemorragia/fisiopatologia , Insuficiência Respiratória/fisiopatologia , Sepse/fisiopatologia , Adulto , Hemorragia/complicações , Hemorragia/mortalidade , Mortalidade Hospitalar , Humanos , Recém-Nascido , Tempo de Internação , Pessoa de Meia-Idade , Modelos Estatísticos , Monitorização Fisiológica , Prognóstico , Reprodutibilidade dos Testes , Insuficiência Respiratória/complicações , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Sensibilidade e Especificidade , Sepse/complicações , Sepse/mortalidade , Sinais VitaisRESUMO
BACKGROUND: Several studies have examined the relationship between injury volumes and trauma centre outcomes, with varying results attributable to differences in the measurement of volume's effect on mortality and differences in how characteristics are addressed as potential confounders. METHODS: This analysis includes all trauma cases reported to the NTDB 2012. The effect of trauma centre volume on patient mortality risk was measured in three different contexts: as a linear function of trauma centre volume, as a dichotomous function comparing patients in trauma centres with and without 1200 or more cases, and as a non-linear function of trauma centre volume. Multivariable weighted Hierarchical Generalized Linear Models were used to account for the combined effects of facility level and patient level covariates. Patient level mortality risk was assessed using the ACS Trauma Quality Improvement Programme methodology. RESULTS: Trauma centre volume was not a statistically significant predictor (at the α=0.01 level) of patient mortality risk, in any of the three models. Comprehensive adjustments for patient level risk were obtained, with excellent discrimination between survivor and decedent cases. The addition of trauma volume to baseline patient mortality risk yielded no improvement in the accuracy of any model. These results were not sensitive to the inclusion of Level II trauma centres. Equivalent results were obtained by repeating the analysis for the Level I subpopulation only. CONCLUSIONS: Case volume may be a reasonable standard for determining whether adequate numbers of injured patients are available to support training needs and experience requirements of a Level I trauma centre. However, case volume is not a useful predictor of patient mortality in individual facilities. Trauma centre volume has no independent effect, after accounting for the patient level characteristics that predominantly influence mortality.
Assuntos
Atenção à Saúde/organização & administração , Hospitais com Alto Volume de Atendimentos , Tempo de Internação/estatística & dados numéricos , Melhoria de Qualidade/organização & administração , Centros de Traumatologia , Ferimentos e Lesões/terapia , Adolescente , Adulto , Idoso , Atenção à Saúde/normas , Mortalidade Hospitalar , Hospitais com Alto Volume de Atendimentos/normas , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Humanos , Escala de Gravidade do Ferimento , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Garantia da Qualidade dos Cuidados de Saúde , Medição de Risco , Tempo para o Tratamento , Centros de Traumatologia/organização & administração , Centros de Traumatologia/normas , Estados Unidos/epidemiologia , Ferimentos e Lesões/mortalidade , Adulto JovemRESUMO
Occult hemorrhage in surgical/trauma intensive care unit (STICU) patients is common and may lead to circulatory collapse. Continuous electrocardiography (ECG) monitoring may allow for early identification and treatment, and could improve outcomes. We studied 4,259 consecutive admissions to the STICU at the University of Virginia Health System. We collected ECG waveform data captured by bedside monitors and calculated linear and non-linear measures of the RR interbeat intervals. We tested the hypothesis that a transfusion requirement of 3 or more PRBC transfusions in a 24 hour period is preceded by dynamical changes in these heart rate measures and performed logistic regression modeling. We identified 308 hemorrhage events. A multivariate model including heart rate, standard deviation of the RR intervals, detrended fluctuation analysis, and local dynamics density had a C-statistic of 0.62. Earlier detection of hemorrhage might improve outcomes by allowing earlier resuscitation in STICU patients.
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Cuidados Críticos/estatística & dados numéricos , Diagnóstico por Computador/métodos , Eletrocardiografia/métodos , Hemorragia/diagnóstico , Hemorragia/mortalidade , Unidades de Terapia Intensiva/estatística & dados numéricos , Transfusão de Sangue/mortalidade , Feminino , Frequência Cardíaca , Hemorragia/terapia , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prognóstico , Modelos de Riscos Proporcionais , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Virginia/epidemiologiaRESUMO
BACKGROUND: Over 90% of injury deaths occur in low-income countries. Evaluating the impact of focused trauma courses in these settings is challenging. We hypothesized that implementation of a focused trauma education initiative in a low-income country would result in measurable differences in injury-related outcomes and resource utilization. METHODS: Two 3-day trauma education courses were conducted in the Rwandan capital over a one-month period (October-November, 2011). An ATLS provider demonstration course was delivered to 24 faculty surgeons and 15 Rwandan trauma nurse auditors, and a Canadian Network for International Surgery Trauma Team Training (TTT) course was delivered to 25 faculty, residents, and nurses. Trauma registry data over the 6 months prior to the courses were compared to the 6 months afterward with emergency department (ED) mortality as the primary endpoint. Secondary endpoints included radiology utilization and early procedural interventions. Univariate analyses were conducted using χ(2) and Fisher's exact test. RESULTS: A total of 798 and 575 patients were prospectively studied during the pre-intervention and post-intervention periods, respectively. Overall mortality of injured patients decreased after education implementation from 8.8 to 6.3%, but was not statistically significant (p = 0.09). Patients with an initial Glasgow Coma Score (GCS) of 3-8 had the highest injury-related mortality, which significantly decreased from 58.5% (n = 55) to 37.1% (n = 23), (p = 0.009, OR 0.42, 95% CI 0.22-0.81). There was no statistical difference in the rates of early intubation, cervical collar use, imaging studies, or transfusion in the overall cohort or the head injury subset. When further stratified by GCS, patients with an initial GCS of 3-5 in the post-intervention period had higher utilization of head CT scans and chest X-rays. CONCLUSIONS: The mortality of severely injured patients decreased after initiation of focused trauma education courses, but no significant increase in resource utilization was observed. The explanation may be complex and multi-factorial. Long-term multidisciplinary efforts that pair training with changes in resources and mentorship may be needed to produce broad and lasting changes in the overall care system.
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Traumatismos Craniocerebrais/mortalidade , Traumatismos Craniocerebrais/terapia , Países em Desenvolvimento , Educação Médica Continuada , Educação Continuada em Enfermagem , Recursos em Saúde/estatística & dados numéricos , Adolescente , Adulto , Cuidados de Suporte Avançado de Vida no Trauma , Criança , Traumatismos Craniocerebrais/diagnóstico por imagem , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Escala de Coma de Glasgow , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Radiografia Torácica/estatística & dados numéricos , Sistema de Registros , Ressuscitação/educação , Ruanda , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: Disparities in access to quality injury care are a growing concern worldwide, with over 90 % of global injury-related morbidity and mortality occurring in low-income countries. We describe the use of a survey tool that evaluates the prevalence of surgical conditions at the population level, with a focus on the burden of traumatic injuries, subsequent disabilities, and barriers to injury care in Rwanda. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate surgical consultation or intervention. Questions are structured anatomically and designed around a representative spectrum of surgical conditions. Households in Rwanda were sampled using two-stage cluster sampling, and interviews were conducted over a one-month period in 52 villages nationwide, with representation of all 30 administrative districts. Injury-related results were descriptively analyzed and population-weighted by age and gender. RESULTS: A total of 1,627 households (3,175 individuals) were sampled; 1,185 lifetime injury-related surgical conditions were reported, with 38 % resulting in some form of perceived disability. Of the population, 27.4 % had ever had a serious injury-related condition, with 2.8 % having an injury-related condition at the time of interview. Over 30 % of household deaths in the previous year may have been surgically treatable, but only 4 % were injury-related. CONCLUSIONS: Determining accurate injury and disability burden is crucial to health system planning in low-income countries. SOSAS is a useful survey for determining injury epidemiology at the community level, which can in turn help to plan prevention efforts and optimize provision of care.
Assuntos
Pessoas com Deficiência/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Ferimentos e Lesões/epidemiologia , Adolescente , Adulto , Estudos Transversais , Avaliação da Deficiência , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Pobreza , Prevalência , Encaminhamento e Consulta , Ruanda/epidemiologia , Ferimentos e Lesões/cirurgia , Adulto JovemRESUMO
BACKGROUND AND OBJECTIVES: Breast cancer incidence may be increasing in low- and middle-income countries (LMIC). This study estimates the prevalence of breast masses in Rwanda (RW) and Sierra Leone (SL) and identifies barriers to care for women with breast masses. only. METHODS: Data were collected from households in RW and SL using Surgeons Overseas Assessment of Surgical Need (SOSAS), a cross-sectional, randomized, cluster-based population survey designed to identify surgical conditions. Data regarding breast masses and barriers to care in women with breast masses were analyzed. RESULTS: 3,469 households (1,626 RW; 1,843 SL) were surveyed and 6,820 persons (3,175 RW; 3,645 SL) interviewed. Breast mass prevalence was 3.3% (SL) and 4.6% (RW). Overall, 93.8% of masses were in women, with 49.1% (SL) and 86.1% (RW) in women >30 years. 73.7% (SL) and 92.4% (RW) of women reported no disability; this was their primary reason for not seeking medical attention. Overall, 36.8% of women who reported masses consulted traditional healers only. CONCLUSIONS: For women in RW and SL, minimal education, poverty, and reliance on traditional healers are barriers to medical care for breast masses. Public health programs to increase awareness and decrease barriers are necessary to lower breast cancer mortality rates in low- and middle-income countries (LMIC).
Assuntos
Neoplasias da Mama/epidemiologia , Acessibilidade aos Serviços de Saúde , Adulto , Idoso , Neoplasias da Mama/cirurgia , Estudos Transversais , Feminino , Humanos , Masculino , Mastectomia , Pessoa de Meia-Idade , Prevalência , Ruanda/epidemiologia , Serra Leoa/epidemiologiaRESUMO
PURPOSE: Surgical services for children are often absent in resource-limited settings. Identifying the prevalence of surgical disease at the community level is important for developing evidence-based pediatric surgical services and training. We hypothesize that the untreated surgical conditions in the pediatric population are largely uncharacterized and that such burden is significant and poorly understood. Furthermore, no such data exist at the population level to describe this population. METHODS: We conducted a nationwide cross-sectional cluster-based population survey to estimate the magnitude of surgical disease in Rwanda. Conducted as a verbal questionnaire, questions included representative congenital, acquired, malignant and injury-related conditions. Pediatric responses were analyzed using descriptive statistics and univariate analysis. RESULTS: A total of 1626 households (3175 individuals) were sampled with a 99% response rate; 51.1% of all individuals surveyed were younger than age 18. An estimated 50.5% of the total current surgical need occurs in children. Of all Rwandan children, 6.3% (95% CI 5.4%-7.4%), an estimated 341,164 individuals, were identified to have a potentially treatable surgical condition at the time of the interview. The geographic distribution of surgical conditions significantly differed between adults and children (p<0.001). CONCLUSIONS: The results emphasize the magnitude of the pediatric surgery need as well as the need for improved education and resources. This may be useful in developing a collaborative local training program.
Assuntos
Países em Desenvolvimento/estatística & dados numéricos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Estudos Transversais , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Pediatria/educação , Gravidez , Ruanda , Procedimentos Cirúrgicos Operatórios/educação , Inquéritos e QuestionáriosRESUMO
BACKGROUND: More than 90% of injury deaths occur in low-income countries where a shortage of personnel, infrastructure, and materials challenge health system strengthening efforts. Trauma registries developed regionally have been used previously for injury surveillance in resource-limited settings, but scant outcomes data exist. METHODS: A 31-item, two-page registry form was developed for use in Rwanda, East Africa. Data were collected over a one-year period from April 2011 to April 2012 at two university referral hospitals. Inpatient 30-d follow up data were abstracted from patient charts, ward reports, and operating room logs. Complications tracked included surgical site infection (SSI), pneumonia, urinary tract infection (UTI), decubitus ulcers, transfusion, cardiac arrest, respiratory failure, and blood thromboses. Univariate analysis with chi-square and the Fisher exact test was performed to determine the association between complications and hospital stay and complications and mortality. Multivariable logistic regression was used to control for age, gender, hospital, mechanism of injury (penetrating versus blunt), and Glasgow Coma scale score (GCS). RESULTS: A total of 2,227 patients were recorded prospectively. One thousand five hundred nineteen patients were admitted for inpatient care (69%) with a 4% (n=67) 30-d mortality. One hundred thirteen patients developed a hospital-acquired infection (88 SSI, 15 UTI, 12 pneumonia). For admitted patients, 25% (n=387) were still in-hospital at 30-d. Whereas the development of any complication was associated with an increased mortality (p<0.0001, unadjusted OR 3.2, 95% CI 1.8-5.7), there was no association between the development of an infection and mortality (p=0.6). Hospital-acquired infection was associated with an increased length of stay (p<0.0001, adjusted odds ratio (OR) 7.3, 95% confidence interval (CI) 4.7-11.2). Surgical site infection and UTI were individually associated with an increased length of stay. CONCLUSIONS: The development of hospital-acquired infections is associated with an increased hospital stay in the trauma population in Rwanda. This has important implications in improving a health system already strained by limited infrastructure, personnel, and finances.
Assuntos
Infecção Hospitalar/epidemiologia , Adolescente , Adulto , Infecção Hospitalar/mortalidade , Países em Desenvolvimento , Feminino , Hospitais Universitários , Humanos , Tempo de Internação , Masculino , Avaliação de Resultados em Cuidados de Saúde , Ruanda/epidemiologia , Análise de Sobrevida , Adulto JovemRESUMO
BACKGROUND: Increasing access to surgical care is among the prioritized healthcare initiatives in Rwanda and other low income countries, where only 3.5 % of surgical procedures worldwide are being performed. Partnerships among surgeons at academic medical centers, non-governmental organizations, and representatives of industry for building sustainable local surgical capacity in developing settings should be explored. METHODS: With the goal of improving collaboration and coordination among the many stakeholders in Rwandan surgery, the Rwanda Surgical Society (RSS) convened a participatory workshop of these groups in Kigali in March 2011. The meeting consisted of presentations from Rwandan surgical leaders and focused brainstorming sessions on collaborative methods for surgical capacity building. RESULTS: The outcome of the meeting was a set of recommendations to the Rwandan Ministry of Health (MOH) and the formation of an ad hoc team, the Strengthening Rwanda Surgery (SRS) Advising Group. The inaugural meeting of the advising group served to establish common goals, a framework for ongoing communication and collaboration, and commitment to a fully Rwandan agenda for surgical and anesthesia capacity development. The SRS Advising Group continues to meet and collaborate on training initiatives and has been integrated into the MOH plan to scale up human resources across disciplines. CONCLUSIONS: The SRS Initiative serves as an example of the concept of early communication and international collaboration in global surgical and anesthesia capacity building partnerships.
Assuntos
Fortalecimento Institucional/organização & administração , Comportamento Cooperativo , Países em Desenvolvimento , Cirurgia Geral/organização & administração , Planejamento em Saúde/organização & administração , Acessibilidade aos Serviços de Saúde/organização & administração , Relações Interprofissionais , Comitês Consultivos , Cirurgia Geral/educação , Humanos , Cooperação Internacional , Ruanda , Sociedades MédicasRESUMO
BACKGROUND: Operative disease is estimated to contribute to 11% of the global burden of disease, but no studies have correlated this figure to operative burden at the community level. We describe a survey tool that evaluates population-based prevalence of operative conditions and its first full-country implementation in Rwanda. METHODS: The Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool is a cross-sectional, cluster-based population survey designed to measure conditions that may necessitate an operative consultation or intervention. Household surveys in Rwanda were conducted in October 2011 in 52 clusters nationwide. Data were population-weighted and analyzed with the use of descriptive statistics. RESULTS: A total of 1626 households (3175 individuals) were sampled with a 99% response rate. 41.2% (95% confidence interval [95 CI%] 38.8-43.6%) of the population has had at least one operative condition during their lifetime, 14.8% (95% CI 13.3-16.5%) had an operative condition during the previous 12 months, and 6.4% (95% CI 5.6-7.3%) of the population were determined to have a current operative condition. A total of 55.3% of the current operative need was found in female respondents and 40.3% in children younger than 15 years of age. A total of 32.9% of household deaths in the previous year may have been related to operative conditions, and 55.0% of responding households lacked funds for transport to the nearest hospital providing general practitioner operative services. CONCLUSION: The SOSAS survey tool provides important insight into the burden of operative disease in the community. Our results show a high need for operative care, which has important implications for the global operative community as well as for local health system strengthening in Rwanda.