Effect of in‐hospital delays on surgical mortality for emergency general surgery conditions at a tertiary hospital in Malawi

• Published in: BJS open Vol. 3; no. 3; pp. 367 - 375
• Main Authors: Maine, R. G., Kajombo, C., Purcell, L., Gallaher, J. R., Reid, T. D., Charles, A. G.
• Format: Journal Article
• Language: English
• Published: Chichester, UK John Wiley & Sons, Ltd 01-06-2019; Oxford University Press
• Subjects: Abdomen; Adolescent; Adult; Emergency Service, Hospital - standards; Female; General Surgery - statistics & numerical data; Hospital Mortality - trends; Hospitalization - statistics & numerical data; Hospitals; Humans; Intervention; Intestinal Perforation - epidemiology; Intestinal Perforation - mortality; Laboratories; Malawi - epidemiology; Male; Middle Aged; Mortality; Original; Patient Acceptance of Health Care; Patients; Peritonitis - epidemiology; Peritonitis - mortality; Prospective Studies; Risk Assessment; Studies; Surgery; Tertiary Care Centers; Time-to-Treatment - statistics & numerical data; Time-to-Treatment - trends; Vital signs; Young Adult; Malawi; Nigeria; Africa
• ISSN: 2474-9842; 2474-9842
• DOI: 10.1002/bjs5.50152

Background
In sub‐Saharan Africa, surgical access is limited by an inadequate surgical workforce, lack of infrastructure and decreased care‐seeking by patients. Delays in treatment can result from delayed presentation (pre‐hospital), delays in transfer (intrafacility) or after arrival at the treating centre (in‐hospital delay; IHD). This study evaluated the effect of IHD on mortality among patients undergoing emergency general surgery and identified factors associated with IHD.
Methods
Utilizing Malawi's Kamuzu Central Hospital Emergency General Surgery database, data were collected prospectively from September 2013 to November 2017. Included patients had a diagnosis considered to warrant urgent or emergency intervention for surgery. Bivariable analysis and Poisson regression modelling was done to determine the effect of IHD (more than 24 h) on mortality, and identify factors associated with IHD.
Results
Of 764 included patients, 281 (36·8 per cent) had IHDs. After adjustment, IHD (relative risk (RR) 1·68, 95 per cent c.i. 1·01 to 2·78; P = 0·045), generalized peritonitis (RR 4·49, 1·69 to 11·95; P = 0·005) and gastrointestinal perforation (RR 3·73, 1·25 to 11·08; P = 0·018) were associated with a higher risk of mortality. Female sex (RR 1·33, 1·08 to 1·64; P = 0·007), obtaining any laboratory results (RR 1·58, 1·29 to 1·94; P < 0·001) and night‐time admission (RR 1·59, 1·32 to 1·90; P < 0·001) were associated with an increased risk of IHD after adjustment.
Conclusion
IHDs were associated with increased mortality. Increased staffing levels and operating room availability at tertiary hospitals, especially at night, are needed.
At a tertiary referral centre in the capital of Malawi, almost 40 per cent of patients with emergency surgical conditions waited more than 24 h for their operation. This delay was associated with a 67 per cent higher risk of mortality. Female sex, night‐time admission and time to obtain preoperative laboratory test results were associated with an increased risk of delayed surgery.
A significant cause of mortality