Reallocation of Hospital Resources During COVID-19 Pandemic and Effect on Trauma Outcomes in a Resource-Limited Setting.
Journal
World journal of surgery
ISSN: 1432-2323
Titre abrégé: World J Surg
Pays: United States
ID NLM: 7704052
Informations de publication
Date de publication:
09 2022
09 2022
Historique:
accepted:
05
06
2022
pubmed:
27
6
2022
medline:
2
8
2022
entrez:
26
6
2022
Statut:
ppublish
Résumé
The COVID-19 pandemic has caused unprecedented disruptions to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre-and intra-pandemic trauma clinical outcomes at a busy tertiary hospital in Malawi. We analyzed trauma patients that presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic (defined as starting March 11, 2020, the date of the official WHO designation). We used logistic regression modeling to estimate the adjusted odds ratio of death based on presentation. A total of 137,867 patients presented during the study period, with 13,526 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs. 25 years, p < 0.001), male (79 vs. 74%, p < 0.001), and suffer a traumatic brain injury (TBI) as their primary injury (9.7 vs. 4.9%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs. 2.1% (p < 0.001). The odds ratio of mortality during the pandemic compared to pre-pandemic presentation was 1.28 (95% CI 1.06, 1.53) adjusted for age, sex, initial AVPU score, transfer status, injury type, and mechanism. During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting despite decreasing patient volume. Further research is urgently needed to prepare for future pandemics. Potential targets for improvement include improving pre-hospital care and transportation, planning for intensive care utilization, and addressing nursing shortages.
Sections du résumé
BACKGROUND
The COVID-19 pandemic has caused unprecedented disruptions to surgical care worldwide, particularly in low-resource countries. We sought to characterize the association between pre-and intra-pandemic trauma clinical outcomes at a busy tertiary hospital in Malawi.
METHODS
We analyzed trauma patients that presented to Kamuzu Central Hospital in Lilongwe, Malawi, from 2011 through July 2021. Burn patients were excluded. We compared patients based on whether they presented before or during the pandemic (defined as starting March 11, 2020, the date of the official WHO designation). We used logistic regression modeling to estimate the adjusted odds ratio of death based on presentation.
RESULTS
A total of 137,867 patients presented during the study period, with 13,526 patients during the pandemic. During the pandemic, patients were more likely to be older (mean 28 vs. 25 years, p < 0.001), male (79 vs. 74%, p < 0.001), and suffer a traumatic brain injury (TBI) as their primary injury (9.7 vs. 4.9%, p < 0.001). Crude trauma-associated mortality was higher during the pandemic at 3.7% vs. 2.1% (p < 0.001). The odds ratio of mortality during the pandemic compared to pre-pandemic presentation was 1.28 (95% CI 1.06, 1.53) adjusted for age, sex, initial AVPU score, transfer status, injury type, and mechanism.
CONCLUSIONS
During the pandemic, adjusted trauma-associated mortality significantly increased at a tertiary trauma center in a low-resource setting despite decreasing patient volume. Further research is urgently needed to prepare for future pandemics. Potential targets for improvement include improving pre-hospital care and transportation, planning for intensive care utilization, and addressing nursing shortages.
Identifiants
pubmed: 35754058
doi: 10.1007/s00268-022-06636-4
pii: 10.1007/s00268-022-06636-4
pmc: PMC9244557
doi:
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
2036-2044Informations de copyright
© 2022. The Author(s) under exclusive licence to Société Internationale de Chirurgie.
Références
Abubakar I, Tillmann T, Banerjee A (2015) Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 385:117–171
doi: 10.1016/S0140-6736(14)61638-X
Haagsma JA, Graetz N, Bolliger I et al (2016) The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013. Inj Prev 22:3–18
doi: 10.1136/injuryprev-2015-041616
French G, Hulse M, Nguyen D et al (2021) Impact of hospital strain on excess deaths during the COVID-19 pandemic—United States, July 2020–July 2021. Morb Mortal Wkly Rep 70:1613
doi: 10.15585/mmwr.mm7046a5
Iuliano AD, Brunkard JM, Boehmer TK et al (2022) Trends in disease severity and health care utilization during the early omicron variant period compared with previous SARS-CoV-2 high transmission periods—United States, December 2020-January 2022. MMWR Morb Mortal Wkly Rep 71:146–152
doi: 10.15585/mmwr.mm7104e4
Lange SJ, Ritchey MD, Goodman AB et al (2020) Potential indirect effects of the COVID-19 pandemic on use of emergency departments for acute life-threatening conditions—United States, January-May 2020. MMWR Morb Mortal Wkly Rep 69:795–800
doi: 10.15585/mmwr.mm6925e2
Szarfer JL, Puente L, Bono L et al (2021) Impact of a prolonged COVID-19 lockdown on patterns of admission, mortality and performance indicators in a cardiovascular intensive care unit. Int J Qual Health Care 33:mzab029
doi: 10.1093/intqhc/mzab029
Waseem S, Nayar S, Hull P et al (2021) The global burden of trauma during the COVID-19 pandemic: a scoping review. J Clin Orthop Trauma 12:200–207
doi: 10.1016/j.jcot.2020.11.005
Horan J, Duddy JC, Gilmartin B et al (2021) The impact of COVID-19 on trauma referrals to a National Neurosurgical Centre (1971-). Ir J Med Sci 190:1281–1293
doi: 10.1007/s11845-021-02504-7
Sobti A, Memon K, Bhaskar RRP et al (2020) Outcome of trauma and orthopaedic surgery at a UK district general hospital during the Covid-19 pandemic. J Clin Orthop Trauma 11:S442–S445
doi: 10.1016/j.jcot.2020.06.042
Rault F, Terrier L, Leclerc A et al (2021) Decreased number of deaths related to severe traumatic brain injury in intensive care unit during the first lockdown in Normandy: at least one positive side effect of the COVID-19 pandemic. Acta Neurochir 163:1829–1836
doi: 10.1007/s00701-021-04831-1
Trier F, Fjølner J, Raaber N et al (2022) Effect of the COVID-19 pandemic at a major Danish trauma center in 2020 compared with 2018–2019: a retrospective cohort study. Acta Anaesthesiol Scand 66:265–272
doi: 10.1111/aas.13997
Haut ER, Leeds IL, Livingston DH (2020) The effect on trauma care secondary to the COVID-19 pandemic: collateral damage from diversion of resources. Ann Surg 272:e204–e207
doi: 10.1097/SLA.0000000000004105
Quaglio G, Cavallin F, Nsubuga J et al (2022) The impact of the COVID-19 pandemic on health service use in sub-Saharan Africa. Public Health Action 12:34–39
doi: 10.5588/pha.21.0073
Lemoine M, Kim JU, Ndow G et al (2020) Effect of the COVID-19 pandemic on viral hepatitis services in sub-Saharan Africa. Lancet Gastroenterol Hepatol 5:966–967
doi: 10.1016/S2468-1253(20)30305-8
Sevalie S, Youkee D, van Duinen AJ et al (2021) The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone. BMJ Glob Health 6:e005988
doi: 10.1136/bmjgh-2021-005988
Chu K, Reddy CL, Makasa E (2020) The collateral damage of the COVID-19 pandemic on surgical health care in sub-Saharan Africa. J Glob Health 10:020347
doi: 10.7189/jogh.10.020347
Navsaria P, Nicol A, Parry C et al (2021) The effect of lockdown on intentional and non-intentional injury during the COVID-19 pandemic in Cape Town, South Africa: a preliminary report. S Afr Med J 111:110–113
doi: 10.7196/SAMJ.2021.v111i2.15318
Waters R, Dey R, Laubscher M et al (2021) Drastic reduction of orthopaedic services at an urban tertiary hospital in South Africa during COVID-19: lessons for the future response to the pandemic. S Afr Med J 111:240–244
doi: 10.7196/SAMJ.2021.v111i3.15263
Morris D, Rogers M, Kissmer N et al (2020) Impact of lockdown measures implemented during the COVID-19 pandemic on the burden of trauma presentations to a regional emergency department in Kwa-Zulu Natal, South Africa. Afr J Emerge Med 10:193–196
doi: 10.1016/j.afjem.2020.06.005
Samuel JC, Akinkuotu A, Villaveces A et al (2009) Epidemiology of injuries at a tertiary care center in Malawi. World J Surg 33:1836–1841. https://doi.org/10.1007/s00268-009-0113-4
doi: 10.1007/s00268-009-0113-4
pubmed: 19597877
pmcid: 3290404
Kelly CA, Upex A, Bateman DN (2004) Comparison of consciousness level assessment in the poisoned patient using the alert/verbal/painful/unresponsive scale and the Glasgow Coma Scale. Ann Emerg Med 44:108–113
doi: 10.1016/j.annemergmed.2004.03.028
Cucinotta D, Vanelli M (2020) WHO Declares COVID-19 a pandemic. Acta Biomed 91:157–160
pubmed: 32191675
pmcid: 7569573
Williams BM, Kayange L, Purcell L et al (2021) Elderly trauma mortality in a resource-limited setting: a benchmark for process improvement. Injury 52:2651–2656
doi: 10.1016/j.injury.2021.07.001
Mahmud MR, Cheserem B, Esene IN et al (2021) The impact of COVID-19 on neurosurgical services in Africa. World Neurosurg 146:e747–e754
doi: 10.1016/j.wneu.2020.11.004
Ogundele IO, Alakaloko FM, Nwokoro CC et al (2020) Early impact of COVID-19 pandemic on paediatric surgical practice in Nigeria: a national survey of paediatric surgeons. BMJ Paediatr Open 4:e000732
doi: 10.1136/bmjpo-2020-000732
Karthigeyan M, Dhandapani S, Salunke P et al (2021) The collateral fallout of COVID19 lockdown on patients with head injury from north-west India. Acta Neurochir 163:1053–1060
doi: 10.1007/s00701-021-04723-4
Hoyler M, Finlayson SR, McClain CD et al (2014) Shortage of doctors, shortage of data: a review of the global surgery, obstetrics, and anesthesia workforce literature. World J Surg 38:269–280. https://doi.org/10.1007/s00268-013-2324-y
doi: 10.1007/s00268-013-2324-y
pubmed: 24218153
Meara JG, Leather AJ, Hagander L et al (2015) Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 386:569–624
doi: 10.1016/S0140-6736(15)60160-X
Purcell LN, Mulima G, Reiss R et al (2020) Epidemiological comparisons and risk factors for pre-hospital and in-hospital mortality following traumatic injury in Malawi. World J Surg 44:2116–2122. https://doi.org/10.1007/s00268-020-05470-w
doi: 10.1007/s00268-020-05470-w
pubmed: 32157403
pmcid: 7272292
Ma X, Vervoort D (2020) Critical care capacity during the COVID-19 pandemic: global availability of intensive care beds. J Crit Care 58:96–97
doi: 10.1016/j.jcrc.2020.04.012
Gallaher JR, Yohann A, Purcell LN et al (2021) Trends in head injury associated mortality in Malawi. Injury 52:1170–1175
doi: 10.1016/j.injury.2020.12.031
Collaborative C (2020) Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg 107:1440–1449
Ademuyiwa AO, Bekele A, Berhea AB et al (2020) COVID-19 preparedness within the surgical, obstetric, and anesthetic ecosystem in sub-Saharan Africa. Ann Surg 272:e9–e13
doi: 10.1097/SLA.0000000000003964
Mazingi D, Ihediwa G, Ford K et al (2020) Mitigating the impact of COVID-19 on children’s surgery in Africa. BMJ Glob Health 5:e003016
doi: 10.1136/bmjgh-2020-003016
Grudziak J, Gallaher J, Banza L et al (2017) The effect of a surgery residency program and enhanced educational activities on trauma mortality in sub-Saharan Africa. World J Surg 41:3031–3037. https://doi.org/10.1007/s00268-017-4272-4
doi: 10.1007/s00268-017-4272-4
pubmed: 29018914
Drennan VM, Ross F (2019) Global nurse shortages: the facts, the impact and action for change. Br Med Bull 130:25–37
doi: 10.1093/bmb/ldz014
Scheffler RM, Mahoney CB, Fulton BD et al (2009) Estimates of health care professional shortages in sub-Saharan Africa By 2015: critical shortages of health workers are projected in 2015 throughout sub-Saharan Africa, and the projected cost to eliminate them approaches $20 billion. Health Aff 28:w849–w862
doi: 10.1377/hlthaff.28.5.w849