Assessment of Pediatric Surgery Capacity at Government Hospitals in Sierra Leone

ArticleinWorld Journal of Surgery 36(11):2554-8 · August 2012with56 Reads
Impact Factor: 2.64 · DOI: 10.1007/s00268-012-1737-3 · Source: PubMed
Abstract

Traditionally, efforts to reduce child mortality in low- and middle-income countries (LMICs) have focused on infectious diseases. However, surgical care is increasingly seen as an important component of primary health care. To understand the baseline surgical capacity in LMICs, a number of studies have recently been published, but none has focused on pediatric surgery. The Surgeons OverSeas (SOS) Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey was used to collect surgical capacity data from government hospitals in Sierra Leone. The data were analyzed specifically to identify baseline needs for pediatric surgery. Nine hospitals were assessed, and all had a functioning laboratory to test blood and urine and were capable of undertaking resuscitation, suturing, wound débridement, incision and drainage of an abscess, appendectomy, and male circumcision. However, in only 67 % could a pediatric hernia repair be performed, and in none were more complex procedures such as cleft lip and clubfoot repairs performed. Fewer than 50 % of facilities had sufficient gloves, nasogastric tubes, intravenous cannulas, syringes, needles, sutures, urinary catheters, infusion sets, anesthesia machines, or compressed oxygen. Using the standard PIPES tool, we found severe deficiencies in the pediatric surgical capacity at government hospitals in Sierra Leone. However, a pediatric-specific tool is required to understand more accurately the pediatric surgical situation.

Full-text

Available from: Adam L Kushner, Mar 18, 2016
Assessment of Pediatric Surgery Capacity at Government
Hospitals in Sierra Leone
Adam L. Kushner
Reinou S. Groen
Thaim B. Kamara
Richmond Dixon-Cole
Kisito S. Daoh
T. Peter Kingham
Benedict C. Nwomeh
Published online: 1 August 2012
Ó Socie
´
te
´
Internationale de Chirurgie 2012
Abstract
Background Traditionally, efforts to reduce child mor-
tality in low- and middle-income countries (LMICs) have
focused on infectious diseases. However, surgical care is
increasingly seen as an important component of primary
health care. To understand the baseline surgical capacity in
LMICs, a number of studies have recently been published,
but none has focused on pediatric surgery.
Methods The Surgeons OverSeas (SOS) Personnel,
Infrastructure, Procedures, Equipment and Supplies
(PIPES) survey was used to collect surgical capacity data
from government hospitals in Sierra Leone. The data were
analyzed specifically to identify baseline needs for pedi-
atric surgery.
Results Nine hospitals were assessed, and all had a
functioning laboratory to test blood and urine and were
capable of undertaking resuscitation, suturing, wound
de
´
bridement, incision and drainage of an abscess, appen-
dectomy, and male circumcision. However, in only 67 %
could a pediatric hernia repair be performed, and in none
were more complex procedures such as cleft lip and
clubfoot repairs performed. Fewer than 50 % of facilities
had sufficient gloves, nasogastric tubes, intravenous cann-
ulas, syringes, needles, sutures, urinary catheters, infusion
sets, anesthesia machines, or compressed oxygen.
Conclusions Using the standard PIPES tool, we found
severe deficiencies in the pediatric surgical capacity at
government hospitals in Sierra Leone. However, a pediat-
ric-specific tool is required to understand more accurately
the pediatric surgical situation.
Introduction
Traditionally, health care for pediatric populations in low-
and middle-income countries (LMICs) has concentrated on
infectious diseases. However, surgical care is increasingly
recognized as an important component of public health [1].
In an effort to highlight the deficiencies in surgical care in
LMICs, a number of studies documenting conditions have
been published [211]. These studies examined factors
such as personnel, infrastructure, procedures performed,
and equipment and supplies in general, but they did not
focus specifically on pediatric surgery.
In April 2010, Sierra Leone’s Ministry of Health and
Sanitation (MoHS) initiated a program to provide free
health care to all children under 5 years old and to pregnant
A. L. Kushner (&) R. S. Groen T. P. Kingham
B. C. Nwomeh
Surgeons OverSeas (SOS), 225 E. 6th St., Suite 7F, New York,
NY 10003, USA
e-mail: adamkushner@yahoo.com
A. L. Kushner
Department of Surgery, Columbia University, New York,
NY, USA
R. S. Groen
Department of International Health, Royal Tropical Institute,
Amsterdam, The Netherlands
T. B. Kamara R. Dixon-Cole
Department of Surgery, Connaught Hospital, Freetown, Sierra
Leone
K. S. Daoh
Ministry of Health and Sanitation, Freetown, Sierra Leone
T. P. Kingham
Memorial Sloan Kettering Cancer Center, New York, NY, USA
B. C. Nwomeh
Nationwide Children’s Hospital, Columbus, OH, USA
123
World J Surg (2012) 36:2554–2558
DOI 10.1007/s00268-012-1737-3
Page 1
and lactating women in an effort to reduce the high
childhood and maternal mortality rates in the country. The
program successfully increased access to health care for
many children [12]. It has also, however, led to an increase
in the number of pediatric surgery cases at Connaught
Hospital, the main tertiary care referral center in the capital
city, Freetown [13].
The goal of this study was to document pediatric surgery
capacity in Sierra Leone. It was aimed at helping Con-
naught Hospital and the MoHS identify needs and plan for
the increase in pediatric surgery cases.
Methods
Setting
Sierra Leone is a small West African country (area: 72,000
sq km) with an estimated population of 5.8 million. It is
one of the poorest countries in the world and ranks 180 of
187 on the 2012 United Nations Development Index [14].
It is estimated that in 2012 the infant mortality rate was
76.64 per 1000 live births—ranking it among the bottom 12
countries [15]. Sierra Leone has one of the lowest physi-
cian densities, with a total of only 95 physicians in 2008—
0.16 physicians per 10,000 population [16]. It is one of the
few countries without a trained pediatric subspecialist
surgeon. With the exception of the handful of cases per-
formed by visiting humanitarian surgeons, all procedures in
children are performed by local surgeons whose patients
are usually adults.
Design
The Surgeons OverSeas (SOS) Personnel, Infrastructure,
Procedures, Equipment, and Supplies (PIPES) tool was
developed as an easy to administer surgical capacity survey.
PIPES consist of 105 items and was designed to be admin-
istered rapidly to provide a quick snapshot of surgical
capacity at LMIC health facilities. In addition to docu-
menting individual items, an index can be calculated to show
changes in capacity over time and differences among facil-
ities. The PIPES tool was first used in Sierra Leone in August
2011 to reevaluate 10 MoHS hospitals initially assessed in
2008. A description of the PIPES tool and results of the
changes in PIPES indices was recently published [17].
For this study, unpublished data previously collected
during site visits and from interviews of key administrative
hospital staff using the PIPES tool were analyzed regarding
personnel specifically trained in pediatric procedures,
infrastructure, pediatric surgery-specific procedures per-
formed, and supplies and equipment relating to pediatric
surgery capacity.
As previously described by Kingham et al., there are
only 17 MoHS hospitals in Sierra Leone [2]. Of these
government hospitals, one is a pediatric hospital with no
surgical services, and six are in rural locations and provide
minimal surgical care (limited to minor procedures).
Therefore, only 10 hospitals were included in the 2008
assessment and it was data from these 10 hospitals that
were reassessed in 2011. As one of these hospitals is a
maternity hospital (Princess Christian Maternity Hospital)
where no pediatric or general surgery is performed, data
collected from this facility were excluded for this study.
Statistics
The data were analyzed using descriptive statistics.
Results
The nine MoHS hospitals assessed include four in Free-
town (Connaught, Kingharman, and Rokupa Hospitals and
Lumley Health Center) and five in the districts (Bo
Regional, Makeni Regional, Port Loko District, Magburka
District, and Moyamba District Hospitals). Connaught
Hospital is the country’s largest health care facility, with
327 beds. It is also the only MoHS tertiary care referral
center for medical and surgical conditions.
Personnel
None of the facilities surveyed had a pediatric surgeon or
other personnel specifically trained to perform pediatric
surgical procedures. General surgeons or other adult-spe-
cialty surgeons performed all the procedures in children.
Nurse anesthetists administered most of the anesthesia.
Infrastructure
The assessed facilities had between 30 and 327 beds. Six
facilities had only one functioning operating room. Con-
naught and Bo Hospitals each had three functioning oper-
ating rooms, and Moyamba District Hospital had two. All
facilities had a laboratory to test blood and urine, and seven
(78 %) had a generator to provide power. Only five (56 %)
had a recovery room, ultrasonography machine, and blood
bank. Plain radiography was available in three (33 %)
hospitals. Only one hospital (Connaught) offered computed
tomography and had an intensive care unit (Table 1).
Procedures
From the 2011 assessment, it was noted that all facilities
could perform resuscitation, suturing, incision and drainage
World J Surg (2012) 36:2554–2558 2555
123
Page 2
of abscesses, de
´
bridement, appendectomy, and male cir-
cumcision. Splinting of a fracture was done in eight
facilities (89 %), burn management and casting of fractures
in seven (78 %), bowel resection and anastomosis and
pediatric hernia repair in six (67 %), traction for fractures
in four (44 %), contracture release and open fracture
management in three (33 %), and management of osteo-
myelitis in two (22 %). Only Connaught Hospital attemp-
ted repair of pediatric abdominal wall defects. No facility
performed cleft lip, clubfoot, or imperforate anus repairs
(Table 2).
Equipment and supplies
Equipment and supplies related to pediatric surgery that
were sufficiently available at the hospitals included pedi-
atric bag valve masks in eight (89 %) hospitals; oxygen
concentrators, pulse oximeters, pediatric oropharyngeal
airways, and pediatric endotracheal tubes in seven (78 %);
scalpel blades and sterile gauze in six (67 %); sterile
bandages in five (56 %); examination gloves, nasogastric
tubes, intravenous cannulas, syringes, disposable needles,
sterile gloves, absorbable and nonabsorbable sutures, and
urinary catheters in four (44 %); intravenous infusion sets
in three (33 %); and compressed oxygen in only two
(22 %) hospitals (Table 3).
Discussion
Although surgical care is increasingly recognized as an
important component of public health [1] and a number of
studies have documented the overall lack of surgical
capacity in LMICs [211], little is known about the
capacity of these countries to provide surgical care to
children, who constitute nearly half of the population. In
fact, data extrapolated from a study in The Gambia by
Bickler and Sanno-Duanda estimated that 85 % of children
Table 1 Percentage of selected Sierra Leone government hospitals
with available infrastructure (n = 9)
Infrastructure items %
Laboratory (blood and urine) 100
Generator 78
Recovery room 56
Ultrasonography 56
Blood bank 56
Running water 44
Plain radiography 33
Electricity 22
Computed tomography 11
Intensive care unit 11
Table 2 Percentage of selected Sierra Leone government hospitals
that had performed procedures at least once (n = 9)
Procedure %
Resuscitation 100
Suturing 100
Wound de
´
bridement 100
Incision and drainage of abscess 100
Appendectomy 100
Male circumcision 100
Splinting fracture 89
Burn management 78
Casting a fracture 78
Bowel resection and anastomosis 67
Pediatric hernia repair 67
Traction fracture 44
Contracture release 33
Open treatment of fracture 33
Management of osteomyelitis 22
Pediatric abdominal wall defects 11
Clubfoot repair 0
Cleft lip repair 0
Imperforate anus repair 0
Table 3 Percentage of selected Sierra Leone government hospitals
with equipment and supplies always available (n = 9)
Equipment and supplies %
Bag-valve mask (pediatric) 89
Oxygen concentrator 78
Pulse oximeter 78
Oropharyngeal airway (pediatric) 78
Endotrachael tubes (pediatric) 78
Scalpel blades 67
Gauze (sterile) 67
Bandages (sterile) 56
Gloves (examination) 44
Nasogastric tubes 44
Intravenous cannulas 44
Syringes 44
Disposable needles 44
Gloves (sterile) 44
Suture
Absorbable 44
Nonabsorbable 44
Urinary catheters 44
Anesthesia machine 33
Intravenous infusion sets 33
Compressed oxygen in cylinder 22
2556 World J Surg (2012) 36:2554–2558
123
Page 3
in LIMCs need some form of surgical care before their 15th
birthday [18]. There are no comprehensive surveys of
pediatric surgical disease burden, although needed. How-
ever, several reports provide an insight into the number of
children undergoing surgery and the types of cases treated.
A cross-sectional survey in 29 hospitals in south-western
Uganda estimated an annual rate of surgery for children
\15 years of age to be 180 operations per 100,000 popu-
lation [10]. In Rwanda, a representative survey of district
and regional hospitals across the country found that pedi-
atric surgical cases constituted only 1 % of the 45,759
cases performed each year [19].
Other reports in the literature documenting pediatric
surgery from sub-Saharan Africa are mostly from single
institutions, and they report only procedures, providing
little information on facility and personnel [18, 20, 21]
More information on overall personnel has been provided
by Chirdan et al. in a survey of eight African countries
representing 402 million people, approximately one-third
of the population of the continent. In these countries, there
were a total of 231 pediatric surgeons—only a fraction of
the estimated 1006 needed for their populations. Compared
to Europe and North America, which have two to three
pediatric surgeons per million people, Nigeria, the most
populous country in Africa, has 0.43 per million and
Malawi only 0.06 per million. Some countries, such as
Sierra Leone, do not have a single pediatric surgeon [22].
Thus, an increase in resources is needed to address the
shortfalls in personnel, infrastructure, procedures, equip-
ment, and supplies pediatric surgical care in LMICs is to
provided. However, before policymakers and donors will
fund and support such programs, the baseline conditions
must be sufficiently documented and an assessment of the
community’s needs undertaken. Only by understanding the
magnitude of the problem will it be possible to begin to
develop programs and measure the effects of interventions.
A high proportion of the population in LMICs are
infants and children, with nearly 50 % of the population in
Sierra Leone \15 years of age [23]. With increasing rec-
ognition of the importance of noncommunicable dis-
eases—congenital malformations, malignant diseases,
injuries—surgery plays an increasingly important role.
Common conditions for which surgical interventions can
offer a cure, palliate, or reduce disability include traumatic
injuries, cancer, and congenital malformations such as cleft
lip and clubfoot [24]. Despite the increasing evidence,
improving surgical care in general and especially for
children is rarely a priority for policymakers.
In Sierra Leone, where there are no trained pediatric
surgeons, local general surgeons perform the operations
done in children, and nurse anesthetists give most of the
anesthesia. The surgery performed is mostly limited to
hernia repairs, orchiopexies, burns, and fracture repair,
although these surgeons also perform more complex
operations (e.g., Wilms tumor resection, major abdominal
operations for conditions such as typhoid perforation).
These cases are not specifically documented in the current
version of the PIPES tool [17]. PIPES was developed as a
modification of the World Health Organization (WHO)
Tool for the Situational Analysis of Emergency and
Essential Surgical Care that was originally introduced in
2008 [2]. PIPES is more concise (105 items vs. 256 for the
WHO tool), has a binary system of measurement for ease
of data collection, and permits easier calculation of an
index to compare facilities or follow longitudinal trends.
The differences between PIPES and the WHO tool have
been discussed in detail elsewhere [17]. Although neither
tool was specifically designed for pediatric use, we found it
easier to select items from PIPES that could provide a
snapshot of pediatric surgical capacity. However, once we
had removed the ‘adult-specific’ items, it was not possible
to determine a true PIPES index. We suggest that a pedi-
atric version of PIPES be created and include more pro-
cedures commonly found in pediatric populations.
Congenital anomalies contribute to childhood death and
disability in LMICs. In this study, however, we docu-
mented only the congenital conditions that require spe-
cialized surgical expertise, such as cleft lip, clubfoot, and
imperforate anus. Currently, these conditions cannot be
treated at the government hospitals. More complex anom-
alies, such as tracheoesophageal fistula repairs, congenital
diaphragmatic hernia, and congenital cardiac abnormali-
ties, are even less likely to be treated in LMICs such as
Sierra Leone. These conditions, although treatable in
competent hands and with sufficient resources, are beyond
the scope of most surgeons and anesthetists in LMICs and
are therefore not included as data points in the current
version of the PIPES tool.
On a positive note, all of the government hospitals
assessed in this study were capable of providing resusci-
tation, suturing, wound de
´
bridement, incision and drainage
of abscesses, appendectomy, and male circumcision; and
six facilities undertook pediatric hernia repair.
There are a number of limitations in this study. First, it
is only a snapshot of the MoHS hospitals where surgery is
performed. It does not take into account that at different
times supplies are available or not or that infrastructure
improves or deteriorates. It is therefore important that such
assessments be repeated over time and that trends be
documented. Second, this study did not document the
capacity of the limited number of nongovernmental orga-
nization, mission, or private hospitals or the short-term
medical missions that periodically provide care for children
with congenital anomalies. Third, the PIPES survey is not
specifically designed to assess pediatric surgery needs, so
it likely overestimates the availability of items such as
World J Surg (2012) 36:2554–2558 2557
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Page 4
intravenous and urinary catheters if adult sizes are in suf-
ficient supply but pediatric sizes are not. As such, even
though the results of this survey were useful to Connaught
Hospital and to the MoHS in identifying deficiencies, it
would be preferable to have a tool that could specifically
measure pediatric surgery capacity. In light of the findings
of this study, such a survey is being developed that will
include documenting the number of pediatric surgeons if
there are any, recording if a greater array of pediatric
surgical procedures are performed, and documenting more
pediatric surgery-specific equipment and supplies such as
nasogastric tubes (B14F), intravenous cannulas (C22 gauge),
and sutures (4/0 and higher). Ideally, such a pediatric PIPES
survey would also be undertaken in conjunction with a review
of the operating room logbook and physical inspection of the
stock.
Conclusions
Surgical care is increasingly recognized as an important
part of public health. This study documents the great
deficiencies in the infrastructure, procedures, equipment,
and supplies for pediatric surgery identified during an
assessment of government hospitals in Sierra Leone. It is
hoped that the results of this survey will help direct poli-
cymakers and donors to provide additional resources for
improving the surgical care of the pediatric population in
LMICs and help plan interventions. We recommend that
such surveys be undertaken in other countries and be
repeated over time. We also recommend that a survey be
developed that specifically documents pediatric surgery
capacity.
Conflict of interest None.
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  • [Show abstract] [Hide abstract] ABSTRACT: Background: Nigeria, with a population of >150 million people in which half of the population are children encounters challenges in paediatric surgery practice in rural areas. There are paediatric surgeons in Nigeria, but majority practice in tertiary health facilities in cities. The poor rural dwellers have little or no access to such highly trained specialists. Hence, children with congenital and acquired paediatric surgical pathologies including anterior abdominal wall defects not only grow up with these diseases to adulthood, they are also exposed to various health hazards posed by unqualified personnel. Therefore, we are evaluating the burden of congenital inguinal hernia/hydrocele in northern and southern Nigeria for awareness creation and the way forward. Materials and methods: Data obtained from organised free hernia missions to the rural populace from northern and southern Nigeria by the West African Collage of Surgeons in 2010 and Kano State Government in 2013 was analysed. Results: A total of 811 patients aged from 3 months (0.25 years) to 35 years was screened and found to have congenital hernia and/or hydrocele from the two centres. 171 (21.1%) were successfully operated, while the remaining 640 (78.9%) could not benefit from a surgical procedure during the missions. There were n = 46 (26.9%) patients with various forms of genital mutilations/and or surgical mismanagements among the operated patients. Conclusion: The burden of congenital anterior abdominal wall defects among Nigerian children is high. A little effort could bring succor and create awareness among this group of people.
    Full-text · Article · Oct 2014 · African Journal of Paediatric Surgery
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