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International Journal of Surgery xxx (2014) 1e4
Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries Q5 Q1
Shailvi Gupta a, b, c, *, Evan Wong b, c, d, Umbareen Mahmood e, Anthony G. Charles f, Benedict C. Nwomeh c, g, Adam L. Kushner b, c, h a
Department of Surgery, University of California, San Francisco East Bay, Oakland, CA, USA Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Surgeons OverSeas (SOS), New York, NY, USA d Centre for Global Surgery, McGill University Health Centre, Montreal, QC, Canada e Department of Plastic Surgery, University of South Florida, Tampa, FL, USA f Department of Surgery, UNC School of Medicine, Chapel Hill, NC, USA g Department of Pediatric Surgery, Nationwide's Children Hospital, Columbus, OH, USA h Department of Surgery, Columbia University, New York, NY, USA b c
h i g h l i g h t s Disproportionately burns are greater in low and middle-income countries (LMICs). Given lack of data on burns, our review assesses burn management capacity in LMICs. Fourteen studies were reviewed, data from 458 hospitals in fourteen countries. Our review suggests that LMICs do not appear to be equipped for burn management. Efforts are needed to document resources to inform policy & guide burn management.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2014 Received in revised form 23 June 2014 Accepted 13 August 2014 Available online xxx
Importance: More than 90% of thermal injury-related deaths occur in low-resource settings. While baseline assessment of burn management capabilities is necessary to guide capacity building strategies, limited data exists from low and middle-income countries (LMICs). Objective: The objective of our review is to assess burn management capacity in LMICs. Evidence review: A PubMed literature review was performed based on studies assessing baseline surgical capacity in individual LMICs. Seven criteria were used to assess burn management capabilities: presence of surgeon, presence of anesthesiologist, basic resuscitation capabilities, acute burn management, management of burn complications, endotracheal intubation and skin grafts. Findings: Fourteen studies were reviewed using data from 458 hospitals in fourteen countries. Of these, 82.3% (284/345) of hospitals had the capacity to provide basic resuscitation and 84.9% (275/324) were capable of providing acute burn management. Endotracheal intubation was only available at 38.3% (51/133) of hospitals. Moreover, only 35.6% (111/312) and 37.9% (120/317) of hospitals were able to provide skin grafts and treat burn complications, respectively. Conclusion: Many hospitals in LMICs are capable of initial burn management and basic resuscitation. However, deficiencies still exist in the capacity to systematically provide advanced burn care. Efforts should be made to better document resources in order to guide burn management resource allocation. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Burns Global surgery Surgical capacity Low and middle income Countries
1. Background
Q2
* Corresponding author. Johns Hopkins Bloomberg School of Public Health, 850 Aliceanna Street, Baltimore, MD 21202, USA. E-mail addresses: [email protected], [email protected] (S. Gupta), [email protected] (E. Wong), [email protected] (U. Mahmood), anthchar@ med.unc.edu (A.G. Charles), [email protected] (B.C. Nwomeh), [email protected] (A.L. Kushner).
There is a disproportionate increased burden and prevalence of burn injury and its associated morbidity and mortality in low and middle-income countries (LMICs), particularly in Sub Saharan Africa. The incidence of burns in LMICs is 1.3 per 100,000 population compared with an incidence of 0.14 per 100,000 population in
http://dx.doi.org/10.1016/j.ijsu.2014.08.353 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Gupta, et al., Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.353
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high-income countries, ranking itself in the top 15 leading causes of burden of disease globally [1,2]. Furthermore, the incidence of burn injuries requiring medical care is approximately 20 times higher in the Western Pacific as compared to the Americas [3]. Despite this, there is a paucity of literature dedicated to burn injury in LMICs. Existing studies focus largely on epidemiology with an emphasis on prevention, with limited investigation on surgical capacity and available burn care resources. Assuming timely and appropriate recognition of burn injury, the initial barrier to treatment is often the long distance and poor transport system for patients to reach a burn or advanced treatment center, as most are situated in large cities [4]. Inadequate access to health care facilities often leads to dependence on traditional medicine and a delay in presentation to the hospital, lending patients to a higher risk of infection and greater complications [5]. Within burn centers of LMICs, the lack of resources, inadequate operating rooms, and shortage of intravenous fluid, medications, and blood has been well documented [4e7]. Hodges et al. demonstrated in their study of Ugandan anesthetists that only 23% had the facilities to deliver safe anesthesia to an adult, and 13% to deliver safe anesthesia to a child. Items most frequently unavailable included a pulse oximeter (74% of anesthetists), a tilting operating table (23%), an oxygen source (22%) and appropriately sized tracheal tubes (21%). Furthermore, fundamental items noted to be inconsistently available included running water for 44% of respondents, electricity for 80%, and intravenous fluids for 30% [8]. Additionally, the dearth of qualified health care workers, particularly general surgeons and indeed dedicated burn or plastic surgeons within LMICs, inevitably results in burn care management being delivered by personnel without formal burn training [8]. In order to allocate burn management resources for advanced care centers in LMICs, an evaluation of their existing capabilities, surgical capacity and resources (both equipment and personnel), must be specifically identified. We therefore sought to review and summarize available data on burn management capacity in LMICs. 2. Methods Available literature assessing baseline surgical capacity in individual LMICs utilizing the World Health Organization's (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (TSAAEESC) and the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey, was accessed using MEDLINE [9,10]. The classification of LMICs in this review is defined according to the World Bank for the World Development Report; this classification is based on the level of socio-economic development, epidemiological homogeneity and geographic location [11]. Combined controlled vocabulary and related key words such as “survey tool” and “surgical capacity” were used (see Fig. 1). Additional resources were identified through expert sources and the bibliographies of included articles. If there were multiple studies from a single country, the study with the most facilities was used. A study was excluded if it did not have at least two of the seven criteria for burn management capacity enumerated below. Two reviewers (SG, EGW) screened all the studies; a third party reviewer (ALK) evaluated the study if any discrepancies existed. Two reviewers (SG, EGW) independently extracted the data. Seven criteria for burn management capacity were used: presence of surgeon (consultant), presence of anesthesiologist (consultant), basic resuscitation, endotracheal intubation, acute burn management, skin graft and burn complications (contracture release). Endotracheal intubation was used in the criteria as a proxy for access to critical care treatment. Availability of each item was scored using a binary system for each hospital. An item was given a
Fig. 1. Study selection methodology.
point if cited as always available; other responses received no points. Efforts were made to record items at all facilities, however, when data were not reported, the denominator only included the facilities for which data were available. When only percentages of facilities were available, the absolute number of facilities was calculated. For the studies in which the data were reported as a range, the mean was calculated and used. All data were then analyzed into a single file and analyzed with descriptive statistics.
3. Results Fourteen individual country studies with relevant data were identified documenting our burn management capacity criteria from 458 hospitals (Table 1). Overall, of the 458 hospitals identified, most hospitals had the capability to perform basic resuscitation at 82.3% (284/345), but only 35.6% (111/312) of the hospitals had the capability to perform a skin graft. Endotracheal tubes and treatment of burn complications (contracture release) were both deficient, present in only 38.3% (51/133) and 37.9% (120/317) of hospitals identified, respectively. The proportion of hospitals able to perform skin grafts ranged widely from 0% (noted in Sri Lanka, 0/47) to as much as 70% in Sierra Leone (7/10). The ability to treat burn complications varied by country from 23% in Bolivia (7/31) to 59% in Afghanistan (10/17). Not one country identified was able to provide 100% of any of the criteria of burn management capacity. The only countries documenting each criterion were Nigeria and Mongolia. The number of surgeons and anesthesiologists was calculated as number of respective consultants per hospital. The Afghan study reported number of facilities with surgeons and number of facilities with anesthesiologists, thus this study not included in the total calculation. Data available revealed that 0.71 surgeons per hospital were present over 379 hospitals and only 0.18 anesthesiologists
Please cite this article in press as: S. Gupta, et al., Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.353
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3
Table 1 Surgical burn management capacity per country [19e32]. Country
Number of hospitals
Number of surgeons
Number of anesthesiologists
Basic Endotracheal resuscitation intubation
Acute burn management
Skin graft
Burn complications
Afghanistan (Contini) Bolivia (Markin) Gambia (Iddriss) Ghana (Choo) Liberia (Sherman) Mongolia (Spiegel) Nigeria (Henry) Rwanda (Petroze) Sierra Leone (Kingham) Solomon Islands (Natuzzi) Sri Lanka (Taira)
17
11a
4.6b
17
X
13
10
10
31 18 17 16 44
X 14 7 3 0
X 4 0 0 0
X 12 17 15 25
X X X X 11
X 15 17 15 35
6 7 6 X 11
9 X 6 5 11
41 44 10
26 50 14
6 13 2
36 X 8
14 X X
36 X X
17 X 3
12 X X
9
4
3
7
X
X
X
X
31
X
1
X
X
64
11
26
8 (of 20 hospitals) 43
0
48
12 (of 22 hospitals) 42
X
16
29 103
43 44
9 25
X 93
X X
X 93
X 51
X 51
458 facilities
0.71 surgeons per hospital (269/379)
0.18 anesthesiologists per hospital (74/410)
82.3% (284/ 345)
38.3% (51/133)
84.9% (275/324) 35.6% (111/312)
Tanzania (Penoyar) Uganda (Walker) Zambia (Bowman) Total a b
Number denotes number of facilities with surgeons, not number of surgeons, not counted in total. Number denotes number of facilities with anesthesiologists, not number of anesthesiologists, not counted in total.
were present over 410 hospitals; thus with the data collected, not even one surgeon or anesthesiologist per hospital was present to provide care. For comparison, the number of physicians per 1000 people is noted in Table 2 [12]; these statistics are not specific to surgeons or anesthesiologists, but provides a context about the availability of health care personnel in the specific LMICs. 4. Discussion It is estimated that almost 11 million people have burns severe enough to require medical attention annually and this number is greater in LMICs. Our review elucidates that overall, hospitals in LMICs do not appear to be equipped for burn management [13]. While prevention of burn injury cannot be underemphasized, beyond this, it is clear that deficiencies still exist in the capacity to systematically deliver burn care. Stevenson et al. outlined key objectives in establishing a burn unit based on their experience in Malawi. These include: developing treatment protocols with local medical and nursing staff, training a core group of nursing staff in burn dressing techniques, training medical staff in burn
Table 2 Number of physicians per country. Country
Number of physicians per 1000 people [12],a
Afghanistan Bolivia Gambia Ghana Liberia Mongolia Nigeria Rwanda Sierra Leone Solomon Islands Sri Lanka Tanzania Uganda Zambia
0.2 X 0.0 0.1 1.9 2.8 0.4 0.1 0.0 0.2 0.5 0.0 0.1 0.1 (2009)
a
37.9% (120/ 317)
2010 data unless otherwise indicated.
management, skin grafting techniques and management of contractures, establishing physiotherapy as an integral part of the unit, and auditing the work of the unit to continuously address deficiencies and ensure ongoing quality improvement [14]. Irrefutably, practitioners in LMICs are burdened by limitations in infrastructure and are therefore unable to provide the same technical support and resources as in HICs [15]. Resources needed for burn care in developing countries are not necessarily centered on the need for costly equipment; they are knowledge, fundamental surgical skills and dedicated health care providers [16]. Local health care providers must continue to be innovative in adapting existing resources and facilities to address the needs of their patients, such as using locally available materials for burn wound care such as honey or to fashion dressings [17,18]. Training programs and workshops should be established for motivated surgeons and other burn care staff. Additionally, when logistically feasible, arrangements can be made for local personnel to visit centers of burn excellence in the surrounding region or continent to learn essential surgical techniques and management to be applied in their own facility. Along with continued evaluation of existing resources and an understanding of the specific barriers to burn treatment in LMICs, successful burn management strategies should be established to systematically provide advanced burn care. Though the global surgery literature for surgical capacity data in LMICs is increasing, there still exists a paucity of information on burn management criteria data, which needs to be incorporated in baseline surgical capacity data. 5. Limitations Many limitations are present in this study. A large limitation is that not all data were reported in the published studies for each country. Although each study may have deciphered our criteria for burn management capacity, this may not have been published. As future studies aim to better document surgical capacity in LMICs, data on burn management capacity should also be published. Another limitation to our study is the use of binary categories of “available” versus “unavailable”. Some published studies had
Please cite this article in press as: S. Gupta, et al., Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.353
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criteria that were “sometimes available” e we counted these as “unavailable”. Thus, by including the hospitals that consistently had the burn management capacity available, a possible underestimation of the actual availability may have occurred. Similarly, some of seven criteria that were used to assess burn management capacity may be problematic. The authors decided to use consultant surgeons and consultant anesthesiologists as opposed to nurse anesthetists or general physicians who practice surgery but were not specifically trained to do so. This is one way to enumerate the data, but likely underestimates the number of skilled workers who are able to provide burn care. Furthermore, many of the studies did not define “acute burn management”, which could very well include basic resuscitation. Given that this information was not provided, the authors decided to differentiate between basic resuscitation and acute burn management, given that some hospitals were not equipped with IV infusion sets. The studies reviewed did not enumerate specialist staff such as plastic surgeons or burn care specialists, who are an important part of burn care management. Thus this was not included in the criteria. The most recent data from the included studies is 2013, thus the current burn capacity management may have changed since these studies have been published. Further studies and documentation will be needed to more accurately assess burn capacity management. 6. Conclusions Many hospitals in LMICs are capable of initial burn management and basic resuscitation, but are deficient in further burn management criteria. Lack of fundamental infrastructure and health care personnel will remain a significant challenge to burn care in LMICs if funds are not allocated to improve documentation and availability of such resources. Efforts should be made to better document resources in order to inform good public health policy and guide burn management strategy. Ethical approval This review did not require such approval. Sources of funding No sources of funding were used for this research. Author contribution SG, EW and ALK performed the literature review; SG, EW and UM collected the data; SG, EW, UM and ALK wrote the report; all authors participated in the study design, analysis of the data and critical revision. Conflicts of interest No conflicts of interest to declare. References [1] WHO, Global Burden of Disease 2004 Summary Tables, World Health Organization, Geneva, 2008. www.who.int/healthinfo/global_burden_disease/ estimates_regional/en/index.html (accessed 02.04.14.). [2] Institute for Health Metrics and Evaluation, The Global Burden of Disease: 2010 Update, IHME, Seattle, 2012. viz.healthmetricsandevaluation.org/gbdcompare/ (accessed 02.04.14.). [3] WHO, The Global Burden of Disease: 2004 Update, World Health Organization, Geneva, 2008. www.who.int/healthinfo/global_burden_disease/GBD_report_ 2004update_full.pdf (accessed 02.04.14.).
[4] R.B. Ahuja, S. Bhattacharya, ABC of burns: Burns in the developing world and burn disasters, Br. Med. J 7463 (2004) 447e449. [5] S. Ndiritu, Z.W.W. Ngumi, O. Nyaim, Burns: the epidemiological pattern, risk and safety awareness at Kenyatta National Hospital, Nairobi, East Afr. Med. J. 83 (8) (2006) 455e460. [6] S.N. Forjuoh, B. Guyer, H.T. Ireys, Burn-related physical impairments and disabilities in Ghanaian children: prevalence and risk factors, Am. J. Public Health 86 (1996) 81e83. [7] Y.S. Lau, An insight into burns in a developing country: a Sri Lankan experience, Public Health 10 (2006) 958e965. [8] S.C. Hodges, C. Mijumbi, M. Okello, et al., Anaesthesia services in developing countries: defining the problems, Anaesthesia 62 (2007) 4e11. [9] R.S. Groen, T.B. Kamara, R. Dixon-Cole, S. Kwon, T.P. Kingham, A.L. Kushner, A tool and index to assess surgical capacity in low income countries: an initial implementation in sierra leone, World J. Surg. 36 (8) (2012) 1970e1977, http://dx.doi.org/10.1007/s00268-012-1591-3. [10] World Health Organization, WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care(TSAAEESC), 2010. [11] World Bank, World Development Report 1993. Investing in Health, Oxford University Press, New York, NY, 1993. [12] World Bank. World Development Indicators: Health Systems. http://wdi. worldbank.org/table/2.15. (accessed 04.04.14.). [13] M.D. Peck, Epidemiology of burns throughout the world. Part I: distribution and risk factors, Burns 37 (2011) 1087e1100 (November(7)). [14] J.H. Stevenson, E. Borgstein, E. Van Hasselt, I. Falconer, The establishment of a burns unit in a developing country e a collaborative venture in Malawi, Br. J. Plast. Surg. 52 (1999) 488e494. [15] B. Atiyeh, A. Masellis, F. Conte, Optimizing burn treatment in developing lowand middle-income countries with limited health care resources (Part 3), Ann. Burns Fire Disasters 23 (1) (2010 March 31) 13e18. [16] D. Heimbach, Burn patients, then and now, Burns 25 (1999) 1e2. [17] Y. Nakajima, K. Mukai, Nasruddin, E. Komatsu, T. Iuchi, Y. Kitayama, J. Sugama, T. Nakatani, Evaluation of the effects of honey on acute-phase deep burn wounds, Evid. Based Complement. Altern. Med. 2013 (2013) 784959. [18] B. Atiyeh, A. Masellis, C. Conte, Optimizing burn treatment in developing lowand middle-income countries with limited health care resources (part 2), Ann. Burn Fire Disasters 22 (4) (Dec 31, 2009) 189e195. [19] S. Contini, A. Taqdeer, M. Cherian, A.S. Shokohmand, R. Gosselin, P. Graaff, L. Noel, Emergency and essential surgical services in Afghanistan: still a missing challenge, World J. Surg. 34 (2010) 473e479. [20] A. Markin, R. Barbero, J.J. Leow, R.S. Groen, E.J. Skow, K.N. Apelgren, A.L. Kushner, B.C. Nwomeh, A quantitative analysis of surgical capacity in Santa Cruz, Bolivia, J. Surg. Res. (2013). Q4 [21] A. Iddriss, N. Shivute, S. Bickler, R. Cole-Ceesay, B. Jargo, F. Abdullah, M. Cherian, Emergency, anaesthetic and essential surgical capacity in the Gambia, Bull. World Health Organ. 89 (2011) 565e572. [22] S. Choo, H. Perry, A.A. Hesse, F. Abantanga, E. Sory, H. Osen, C. FleischerDjoleto, R. Moresky, C.W. McCord, M. Cherian, et al., Assessment of capacity for surgery, obstetrics and anaesthesia in 17 Ghanaian hospitals using a WHO assessment tool, Trop. Med. Int. Health. 15 (2010) 1109e1115. [23] L. Sherman, P.T. Clement, M.N. Cherian, N. Ndayimirije, L. Noel, B. Dahn, W.T. Gwenigale, A.L. Kushner, Implementing Liberia's poverty reduction strategy: an assessment of emergency and essential surgical care, Arch. Surg. 146 (2011) 35e39. [24] D.A. Spiegel, S. Choo, M. Cherian, S. Orgoi, B. Kehrer, R.R. Price, S. Govind, Quantifying surgical and anesthetic availability at primary health facilities in mongolia, World J. Surg. 35 (2011) 272e279. [25] J.A. Henry, O. Windapo, A.L. Kushner, R.S. Groen, B.C. Nwomeh, A survey of surgical capacity in rural southern Nigeria: opportunities for change, World J. Surg. 36 (2012) 2811e2818. [26] R.T. Petroze, A. Nzayisenga, V. Rusanganwa, G. Ntakiyiruta, J.F. Calland, Comprehensive national analysis of emergency and essential surgical capacity in Rwanda, Br. J. Surg. 99 (2012) 436e443. [27] T.P. Kingham, T.B. Kamara, M.N. Cherian, R.A. Gosselin, M. Simkins, C. Meissner, L. Foray-Rahall, K.S. Daoh, S.A. Kabia, A.L. Kushner, Quantifying surgical capacity in Sierra Leone: a guide for improving surgical care, Arch. Surg. 144 (2009) 122e127 discussion 128. [28] E.S. Natuzzi, A. Kushner, R. Jagilly, D. Pickacha, K. Agiomea, L. Hou, P. Houasia, P.L. Hendricks, D. Ba'erodo, Surgical care in the Solomon Islands: a road map for universal surgical care delivery, World J. Surg. 35 (2011) 1183e1193. [29] B.R. Taira, M.N. Cherian, H. Yakandawala, R. Kesavan, S.M. Samarage, M. DeSilva, Survey of emergency and surgical capacity in the conflict-affected regions of Sri Lanka, World J. Surg. 34 (2010) 428e432. [30] T. Penoyar, H. Cohen, P. Kibatala, A. Magoda, G. Saguti, L. Noel, S. Groth, D.H. Mwakyusa, M. Cherian, Emergency and surgery services of primary hospitals in the United Republic of Tanzania, BMJ Open. 2 (2012) e0003692011-000369. Print 2012. [31] I.A. Walker, A.D. Obua, F. Mouton, S. Ttendo, I.H. Wilson, Paediatric surgery and anaesthesia in South-western Uganda: a cross-sectional survey, Bull. World Health Organ. 88 (2010) 897e906. [32] K.G. Bowman, G. Jovic, S. Rangel, W.R. Berry, A.A. Gawande, Pediatric emergency and essential surgical care in Zambian hospitals: a nationwide study, J. Pediatr. Surg. 48 (2013) 1363e1370.
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Contents lists available at ScienceDirect
International Journal of Surgery journal homepage: www.journal-surgery.net
Original research
Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries Q5 Q1
Shailvi Gupta a, b, c, *, Evan Wong b, c, d, Umbareen Mahmood e, Anthony G. Charles f, Benedict C. Nwomeh c, g, Adam L. Kushner b, c, h a
Department of Surgery, University of California, San Francisco East Bay, Oakland, CA, USA Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA Surgeons OverSeas (SOS), New York, NY, USA d Centre for Global Surgery, McGill University Health Centre, Montreal, QC, Canada e Department of Plastic Surgery, University of South Florida, Tampa, FL, USA f Department of Surgery, UNC School of Medicine, Chapel Hill, NC, USA g Department of Pediatric Surgery, Nationwide's Children Hospital, Columbus, OH, USA h Department of Surgery, Columbia University, New York, NY, USA b c
h i g h l i g h t s Disproportionately burns are greater in low and middle-income countries (LMICs). Given lack of data on burns, our review assesses burn management capacity in LMICs. Fourteen studies were reviewed, data from 458 hospitals in fourteen countries. Our review suggests that LMICs do not appear to be equipped for burn management. Efforts are needed to document resources to inform policy & guide burn management.
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2014 Received in revised form 23 June 2014 Accepted 13 August 2014 Available online xxx
Importance: More than 90% of thermal injury-related deaths occur in low-resource settings. While baseline assessment of burn management capabilities is necessary to guide capacity building strategies, limited data exists from low and middle-income countries (LMICs). Objective: The objective of our review is to assess burn management capacity in LMICs. Evidence review: A PubMed literature review was performed based on studies assessing baseline surgical capacity in individual LMICs. Seven criteria were used to assess burn management capabilities: presence of surgeon, presence of anesthesiologist, basic resuscitation capabilities, acute burn management, management of burn complications, endotracheal intubation and skin grafts. Findings: Fourteen studies were reviewed using data from 458 hospitals in fourteen countries. Of these, 82.3% (284/345) of hospitals had the capacity to provide basic resuscitation and 84.9% (275/324) were capable of providing acute burn management. Endotracheal intubation was only available at 38.3% (51/133) of hospitals. Moreover, only 35.6% (111/312) and 37.9% (120/317) of hospitals were able to provide skin grafts and treat burn complications, respectively. Conclusion: Many hospitals in LMICs are capable of initial burn management and basic resuscitation. However, deficiencies still exist in the capacity to systematically provide advanced burn care. Efforts should be made to better document resources in order to guide burn management resource allocation. © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Keywords: Burns Global surgery Surgical capacity Low and middle income Countries
1. Background
Q2
* Corresponding author. Johns Hopkins Bloomberg School of Public Health, 850 Aliceanna Street, Baltimore, MD 21202, USA. E-mail addresses: [email protected], [email protected] (S. Gupta), [email protected] (E. Wong), [email protected] (U. Mahmood), anthchar@ med.unc.edu (A.G. Charles), [email protected] (B.C. Nwomeh), [email protected] (A.L. Kushner).
There is a disproportionate increased burden and prevalence of burn injury and its associated morbidity and mortality in low and middle-income countries (LMICs), particularly in Sub Saharan Africa. The incidence of burns in LMICs is 1.3 per 100,000 population compared with an incidence of 0.14 per 100,000 population in
http://dx.doi.org/10.1016/j.ijsu.2014.08.353 1743-9191/© 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: S. Gupta, et al., Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.353
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high-income countries, ranking itself in the top 15 leading causes of burden of disease globally [1,2]. Furthermore, the incidence of burn injuries requiring medical care is approximately 20 times higher in the Western Pacific as compared to the Americas [3]. Despite this, there is a paucity of literature dedicated to burn injury in LMICs. Existing studies focus largely on epidemiology with an emphasis on prevention, with limited investigation on surgical capacity and available burn care resources. Assuming timely and appropriate recognition of burn injury, the initial barrier to treatment is often the long distance and poor transport system for patients to reach a burn or advanced treatment center, as most are situated in large cities [4]. Inadequate access to health care facilities often leads to dependence on traditional medicine and a delay in presentation to the hospital, lending patients to a higher risk of infection and greater complications [5]. Within burn centers of LMICs, the lack of resources, inadequate operating rooms, and shortage of intravenous fluid, medications, and blood has been well documented [4e7]. Hodges et al. demonstrated in their study of Ugandan anesthetists that only 23% had the facilities to deliver safe anesthesia to an adult, and 13% to deliver safe anesthesia to a child. Items most frequently unavailable included a pulse oximeter (74% of anesthetists), a tilting operating table (23%), an oxygen source (22%) and appropriately sized tracheal tubes (21%). Furthermore, fundamental items noted to be inconsistently available included running water for 44% of respondents, electricity for 80%, and intravenous fluids for 30% [8]. Additionally, the dearth of qualified health care workers, particularly general surgeons and indeed dedicated burn or plastic surgeons within LMICs, inevitably results in burn care management being delivered by personnel without formal burn training [8]. In order to allocate burn management resources for advanced care centers in LMICs, an evaluation of their existing capabilities, surgical capacity and resources (both equipment and personnel), must be specifically identified. We therefore sought to review and summarize available data on burn management capacity in LMICs. 2. Methods Available literature assessing baseline surgical capacity in individual LMICs utilizing the World Health Organization's (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care (TSAAEESC) and the Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) survey, was accessed using MEDLINE [9,10]. The classification of LMICs in this review is defined according to the World Bank for the World Development Report; this classification is based on the level of socio-economic development, epidemiological homogeneity and geographic location [11]. Combined controlled vocabulary and related key words such as “survey tool” and “surgical capacity” were used (see Fig. 1). Additional resources were identified through expert sources and the bibliographies of included articles. If there were multiple studies from a single country, the study with the most facilities was used. A study was excluded if it did not have at least two of the seven criteria for burn management capacity enumerated below. Two reviewers (SG, EGW) screened all the studies; a third party reviewer (ALK) evaluated the study if any discrepancies existed. Two reviewers (SG, EGW) independently extracted the data. Seven criteria for burn management capacity were used: presence of surgeon (consultant), presence of anesthesiologist (consultant), basic resuscitation, endotracheal intubation, acute burn management, skin graft and burn complications (contracture release). Endotracheal intubation was used in the criteria as a proxy for access to critical care treatment. Availability of each item was scored using a binary system for each hospital. An item was given a
Fig. 1. Study selection methodology.
point if cited as always available; other responses received no points. Efforts were made to record items at all facilities, however, when data were not reported, the denominator only included the facilities for which data were available. When only percentages of facilities were available, the absolute number of facilities was calculated. For the studies in which the data were reported as a range, the mean was calculated and used. All data were then analyzed into a single file and analyzed with descriptive statistics.
3. Results Fourteen individual country studies with relevant data were identified documenting our burn management capacity criteria from 458 hospitals (Table 1). Overall, of the 458 hospitals identified, most hospitals had the capability to perform basic resuscitation at 82.3% (284/345), but only 35.6% (111/312) of the hospitals had the capability to perform a skin graft. Endotracheal tubes and treatment of burn complications (contracture release) were both deficient, present in only 38.3% (51/133) and 37.9% (120/317) of hospitals identified, respectively. The proportion of hospitals able to perform skin grafts ranged widely from 0% (noted in Sri Lanka, 0/47) to as much as 70% in Sierra Leone (7/10). The ability to treat burn complications varied by country from 23% in Bolivia (7/31) to 59% in Afghanistan (10/17). Not one country identified was able to provide 100% of any of the criteria of burn management capacity. The only countries documenting each criterion were Nigeria and Mongolia. The number of surgeons and anesthesiologists was calculated as number of respective consultants per hospital. The Afghan study reported number of facilities with surgeons and number of facilities with anesthesiologists, thus this study not included in the total calculation. Data available revealed that 0.71 surgeons per hospital were present over 379 hospitals and only 0.18 anesthesiologists
Please cite this article in press as: S. Gupta, et al., Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.353
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3
Table 1 Surgical burn management capacity per country [19e32]. Country
Number of hospitals
Number of surgeons
Number of anesthesiologists
Basic Endotracheal resuscitation intubation
Acute burn management
Skin graft
Burn complications
Afghanistan (Contini) Bolivia (Markin) Gambia (Iddriss) Ghana (Choo) Liberia (Sherman) Mongolia (Spiegel) Nigeria (Henry) Rwanda (Petroze) Sierra Leone (Kingham) Solomon Islands (Natuzzi) Sri Lanka (Taira)
17
11a
4.6b
17
X
13
10
10
31 18 17 16 44
X 14 7 3 0
X 4 0 0 0
X 12 17 15 25
X X X X 11
X 15 17 15 35
6 7 6 X 11
9 X 6 5 11
41 44 10
26 50 14
6 13 2
36 X 8
14 X X
36 X X
17 X 3
12 X X
9
4
3
7
X
X
X
X
31
X
1
X
X
64
11
26
8 (of 20 hospitals) 43
0
48
12 (of 22 hospitals) 42
X
16
29 103
43 44
9 25
X 93
X X
X 93
X 51
X 51
458 facilities
0.71 surgeons per hospital (269/379)
0.18 anesthesiologists per hospital (74/410)
82.3% (284/ 345)
38.3% (51/133)
84.9% (275/324) 35.6% (111/312)
Tanzania (Penoyar) Uganda (Walker) Zambia (Bowman) Total a b
Number denotes number of facilities with surgeons, not number of surgeons, not counted in total. Number denotes number of facilities with anesthesiologists, not number of anesthesiologists, not counted in total.
were present over 410 hospitals; thus with the data collected, not even one surgeon or anesthesiologist per hospital was present to provide care. For comparison, the number of physicians per 1000 people is noted in Table 2 [12]; these statistics are not specific to surgeons or anesthesiologists, but provides a context about the availability of health care personnel in the specific LMICs. 4. Discussion It is estimated that almost 11 million people have burns severe enough to require medical attention annually and this number is greater in LMICs. Our review elucidates that overall, hospitals in LMICs do not appear to be equipped for burn management [13]. While prevention of burn injury cannot be underemphasized, beyond this, it is clear that deficiencies still exist in the capacity to systematically deliver burn care. Stevenson et al. outlined key objectives in establishing a burn unit based on their experience in Malawi. These include: developing treatment protocols with local medical and nursing staff, training a core group of nursing staff in burn dressing techniques, training medical staff in burn
Table 2 Number of physicians per country. Country
Number of physicians per 1000 people [12],a
Afghanistan Bolivia Gambia Ghana Liberia Mongolia Nigeria Rwanda Sierra Leone Solomon Islands Sri Lanka Tanzania Uganda Zambia
0.2 X 0.0 0.1 1.9 2.8 0.4 0.1 0.0 0.2 0.5 0.0 0.1 0.1 (2009)
a
37.9% (120/ 317)
2010 data unless otherwise indicated.
management, skin grafting techniques and management of contractures, establishing physiotherapy as an integral part of the unit, and auditing the work of the unit to continuously address deficiencies and ensure ongoing quality improvement [14]. Irrefutably, practitioners in LMICs are burdened by limitations in infrastructure and are therefore unable to provide the same technical support and resources as in HICs [15]. Resources needed for burn care in developing countries are not necessarily centered on the need for costly equipment; they are knowledge, fundamental surgical skills and dedicated health care providers [16]. Local health care providers must continue to be innovative in adapting existing resources and facilities to address the needs of their patients, such as using locally available materials for burn wound care such as honey or to fashion dressings [17,18]. Training programs and workshops should be established for motivated surgeons and other burn care staff. Additionally, when logistically feasible, arrangements can be made for local personnel to visit centers of burn excellence in the surrounding region or continent to learn essential surgical techniques and management to be applied in their own facility. Along with continued evaluation of existing resources and an understanding of the specific barriers to burn treatment in LMICs, successful burn management strategies should be established to systematically provide advanced burn care. Though the global surgery literature for surgical capacity data in LMICs is increasing, there still exists a paucity of information on burn management criteria data, which needs to be incorporated in baseline surgical capacity data. 5. Limitations Many limitations are present in this study. A large limitation is that not all data were reported in the published studies for each country. Although each study may have deciphered our criteria for burn management capacity, this may not have been published. As future studies aim to better document surgical capacity in LMICs, data on burn management capacity should also be published. Another limitation to our study is the use of binary categories of “available” versus “unavailable”. Some published studies had
Please cite this article in press as: S. Gupta, et al., Burn management capacity in low and middle-income countries: A systematic review of 458 hospitals across 14 countries, International Journal of Surgery (2014), http://dx.doi.org/10.1016/j.ijsu.2014.08.353
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criteria that were “sometimes available” e we counted these as “unavailable”. Thus, by including the hospitals that consistently had the burn management capacity available, a possible underestimation of the actual availability may have occurred. Similarly, some of seven criteria that were used to assess burn management capacity may be problematic. The authors decided to use consultant surgeons and consultant anesthesiologists as opposed to nurse anesthetists or general physicians who practice surgery but were not specifically trained to do so. This is one way to enumerate the data, but likely underestimates the number of skilled workers who are able to provide burn care. Furthermore, many of the studies did not define “acute burn management”, which could very well include basic resuscitation. Given that this information was not provided, the authors decided to differentiate between basic resuscitation and acute burn management, given that some hospitals were not equipped with IV infusion sets. The studies reviewed did not enumerate specialist staff such as plastic surgeons or burn care specialists, who are an important part of burn care management. Thus this was not included in the criteria. The most recent data from the included studies is 2013, thus the current burn capacity management may have changed since these studies have been published. Further studies and documentation will be needed to more accurately assess burn capacity management. 6. Conclusions Many hospitals in LMICs are capable of initial burn management and basic resuscitation, but are deficient in further burn management criteria. Lack of fundamental infrastructure and health care personnel will remain a significant challenge to burn care in LMICs if funds are not allocated to improve documentation and availability of such resources. Efforts should be made to better document resources in order to inform good public health policy and guide burn management strategy. Ethical approval This review did not require such approval. Sources of funding No sources of funding were used for this research. Author contribution SG, EW and ALK performed the literature review; SG, EW and UM collected the data; SG, EW, UM and ALK wrote the report; all authors participated in the study design, analysis of the data and critical revision. Conflicts of interest No conflicts of interest to declare. References [1] WHO, Global Burden of Disease 2004 Summary Tables, World Health Organization, Geneva, 2008. www.who.int/healthinfo/global_burden_disease/ estimates_regional/en/index.html (accessed 02.04.14.). [2] Institute for Health Metrics and Evaluation, The Global Burden of Disease: 2010 Update, IHME, Seattle, 2012. viz.healthmetricsandevaluation.org/gbdcompare/ (accessed 02.04.14.). [3] WHO, The Global Burden of Disease: 2004 Update, World Health Organization, Geneva, 2008. www.who.int/healthinfo/global_burden_disease/GBD_report_ 2004update_full.pdf (accessed 02.04.14.).
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