Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana

Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana

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Benchmarking Global Trauma Care: Defining the Unmet Need for Trauma Surgery in Ghana Adam Gyedu, MD, MPH,a,* Barclay Stewart, MD, MScPH,b,c Cameron Gaskill, MD, MPH,b Peter Donkor, MDSc,a Robert Quansah, MD, PhD,a and Charles Mock, MD, PhDb,d,e a

Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana b Department of Surgery, University of Washington, Seattle, Washington c Department of Interdisciplinary Health Sciences, Stellenbosch University, Cape Town, South Africa d Harborview Injury Prevention & Research Center, Seattle, Washington e Department of Global Health, University of Washington, Seattle, Washington

article info


Article history:

Background: The Lancet Commission on Global Surgery recommended 5000 operations/

Received 8 July 2019

100,000 persons annually, but did not define condition-specific guidelines. New Zealand,

Received in revised form

Lancet Commission on Global Surgery’s benchmark country, documented 1158 trauma

1 October 2019

operations/100,000 persons, providing a benchmark for trauma surgery needs. We sought

Accepted 5 October 2019

to determine Ghana’s annual trauma operation rate compared with this benchmark.

Available online xxx

Methods: Data on all operations performed in Ghana from June 2014 to May 2015 were obtained from representative sample of 48/124 district (first level), 8/11 regional, and 3/5


tertiary hospitals and scaled up for nationwide estimates. Trauma operations were


grouped by hospital level and categorized into “essential” (most cost-effective, highest

Global health

population impact) versus “other” (specialized) as per the World Bank’s Disease Control


Priorities Project. Ghana’s annual trauma operation rate was compared with the New


Zealand benchmark to quantify current met needs for trauma surgery.

Low- and middle-income countries

Results: About 232,776 operations were performed in Ghana; 35,797 were for trauma. Annual trauma operation rate was 134/100,000 (95% UI: 98-169), only 12% of the New Zealand benchmark. District hospitals performed 62% of all operations in the country, but performed only 38% of trauma operations. Eighty seven percentage of trauma operations were deemed “essential”. Among specialized trauma operations, only open reduction and internal fixations had even modest numbers (3483 operations). Most other specialized trauma operations were rare. Conclusions: Ghana has a large unmet need for operative trauma care. The low percentage of trauma operations in district hospitals indicates an even greater unmet need in rural areas. Future global surgery benchmarking should consider benchmarks for trauma and other specialties, as well as for different hospital levels. ª 2019 Elsevier Inc. All rights reserved.

* Corresponding author. Department of Surgery, School of Medicine and Dentistry, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana University Hospital, Kumasi, Ghana. Tel.: þ233 248228838; fax: þ233 322022307. E-mail address: [email protected] (A. Gyedu). 0022-4804/$ e see front matter ª 2019 Elsevier Inc. All rights reserved.


j o u r n a l o f s u r g i c a l r e s e a r c h  - 2 0 1 9 ( - ) 1 e7

Introduction Injury is a major contributor to global mortality and loss of disability-adjusted life-years, accounting for 8.5% and 10% of the global burdens, respectively.1 Injury disproportionally affects low- and middle-income countries (LMICs) where lack of adequate health care resources and unorganized systems commonly add to the health, social, and financial burdens of trauma patients and their communities.2,3 Timely availability of surgical services are critical to quality care of injured patients. However, trauma and surgical care have not been prioritized by the global health community and many national governments.4 Resultantly, an estimated 48.5 million surgical procedures each year are needed to care for injured patients globally, most of which occur in LMICs.5 However, the degree to which current trauma surgical capacities are meeting the needs of LMIC populations is difficult to assess and no standard benchmarks exist.3,6 The Lancet Commission on Global Surgery recommended an annual rate of 5000 operations per 100,000 people as a benchmark at which LMICs could achieve most of the population-wide benefits of surgery.7,8 The Commission’s recommendations were derived by correlating operative rates and health outcomes from several countries with exemplary health care systems (e.g., New Zealand).5,9,10 While this provides an important guideline for surgical development in LMICs, the Commission did not define condition- or procedure-specific rates.11 Although such benchmarks may be considered reasonable targets for global surgery metrics, the unmet surgical needs of the New Zealand population are unknown and such figures represent the procedures performed for a high-income country (HIC) population with specific epidemiology and within a system that includes prehospital services. We have reported on the national rate of operations in Ghana.12 However, no LMIC has reported on a rate of trauma operations per population to support the development of or improvement in condition-specific surgical metrics. To fill this gap, we sought to estimate the number and rate of trauma operations performed in Ghana in 1 y as a secondary analysis of a data set of all operations performed in the country.12 In this analysis, we also sought to characterize the current volume of trauma operations by hospital level and procedure type to identify opportunities to decrease unmet needs. By doing so, a baseline estimate of trauma surgical output could be used as a benchmark for future capacity building initiatives and as a reference for other LMICs working to improve care for the injured.

provide medications for injuries (e.g., tetanus, pain medications beyond acetaminophen or nonsteroidal antiinflammatory drugs).13,14 District hospitals (government-run or faith-based) staff mostly medical officers and nurse anesthetists to provide some trauma and surgical services. Regional and tertiary hospitals staff higher trained anesthesia and specialized surgical providers to provide more complex care. Private hospital-based trauma care is rarely performed for moderate or severe injuries, and most of the population does not have access to these facilities.15 Therefore, we excluded the private sector from the analysis. Care for the injured is relatively ad hoc with little coordination between the developing prehospital emergency medical services and hospitals, and between hospitals. As such, injured patients have poor access to prehospital emergency care services and hospitals have critical trauma care capacity deficiencies.13,16 The impacts of low prehospital care capacity and high rates of preventable death on the proportion of injured patients who require an operation are unknown.17-20 Although several reports have described regional population-based or single-institution injury patterns in Ghana, there has not been a national hospital-based description of injury patterns or proportion of patients who need an operation after injury in Ghana to allow apposite comparison with the New Zealand National Trauma Registry.15,21-25

Background benchmarks The Lancet Commission on Global Surgery’s recommendation of 5000 operations annually per 100,000 population was derived from overall health outcomes (e.g., life expectancy, maternal mortality, and estimated surgical needs by region). Follow-on work reported annual operative rates for specific conditions using nationwide operative data from an exemplary HIC, New Zealand, because of its health care system achieving excellent outcomes while having one of the lowest surgery rates of all HICs. A total of 50,652 operations were reported for injury in 2010 in New Zealand.11 For the purpose of this study, we excluded operations for poisoning and drowning as these were not counted as trauma operations in our context, leaving 50,586 trauma operations for a 2010 New Zealand population of 4,368,000. This provided a trauma operations rate benchmark of 1158 surgeries per 100,000 population.

Data collection Methods Setting Ghana is a lower-middle-income country in West Africa with a population of over 26 million people. Surgical care is organized at four levels: primary health care posts, district (first level), regional (referral), and tertiary hospitals. Primary health care posts do not perform procedures (e.g., laceration repair, acute burn wound debridement, fracture reduction) or

The number and types of surgical operations performed in Ghana from June 2014 to May 2015 were determined by a retrospective review and analysis, in 2016, of surgical logbook data at 48 of 124 district hospitals selected by simple random sampling and all regional and tertiary hospitals. All selected district hospitals, 9/11 hospitals operating at the regional level, and 3/5 tertiary hospitals agreed to participate in the study. Detailed methods and sample size calculations are provided in a prior publication.12 Private hospitals were excluded as they account for fewer than 10% of hospital beds

gyedu et al  benchmarking trauma surgery in ghana

in the country and do not contribute significantly to the national surgical volume, especially for trauma.26 Procedure logs contain consecutive procedure number, name, date, diagnosis(es), procedure(s), anesthesia type (e.g., local, regional, general), outcome (i.e., intraoperative death, alive), and disposition (i.e., recovery area, intensive care, acute care, discharge). An operation was considered as any procedure performed in a hospital-defined procedure area or operating theater regardless of anesthesia or provider type. These areas often included operation theaters, preoperative or recovery units, accident and emergency units, intensive care units, and outpatient minor units. Procedures performed were designated as trauma procedures if a relevant indication (e.g., road-traffic crash, fall, burn) and/or procedure type (e.g., trauma laparotomy, irrigation and debridement of open fracture, burn excision, tube thoracostomy) was listed. Multiple major procedures were typically listed within a line of the log if performed (e.g., trauma laparotomy, splenectomy, bowel resection) in accordance with surgical documentation culture in Ghana. However, smaller procedures within a single operation may have been missed (e.g., unnamed bleeding vessel ligation during a laparotomy and splenectomy). Therefore, some procedures may have been missed and not included in the description by type or specialty.

Data analysis Operations were described with numbers and percentages per hospital level (i.e., district, regional, and tertiary) and by procedure type. Operations were also categorized into those deemed “essential” versus “other” by the World Bank’s Disease Control Priorities Project’s third edition.27 Disease Control Priorities Project’s third edition describes essential surgical procedures as those that are most cost-effective to provide and have the highest population-level impact. Operations performed at district hospitals were also categorized according to whether or not the hospitals were staffed by a surgeon provider. We defined a hospital to be staffed by a surgeon if the hospital had a surgeon(s) that was paid by the Ministry of Health, Ghana Health Service, a university, or a faith-based organization to provide care on a full-time basis. National estimates were calculated for each hospital level using probability weights. District and regional hospital numbers were scaled according to the proportion of hospitals sampled (i.e., 48/124 district hospitals and 9/11 hospitals operating at the regional level, respectively). Although we planned to sample all tertiary hospitals, two tertiary hospitals declined participation in the study. Given their different bed capacities and populations, tertiary hospitals numbers were scaled up according to the proportion of beds at the three facilities where data were collected to total bed capacity of the five hospitals operating at the tertiary level (i.e., 2000/4400 beds). Trauma surgical rates were provided in operations per 100,000 population. Surgical rates for Ghana were calculated by dividing the total number of surgical procedures performed over the 1-y period by the country’s 2014 population of 26,786,997. Analysis was completed using Excel (Microsoft) and Stata v14.2 (StataCorp).


Ethical approval The study was approved by the Committee for Human Publications and Ethics of Kwame Nkrumah University of Science and Technology.

Results An estimated 232,776 operations were performed over the 1-y period nationally, which resulted in an annual rate of 869 operations per 100,000 population.12 Of these, 35,797 operations (95% UI: 26,245-45,349) were performed for trauma (15% of all operations), giving a rate of 134 operations for trauma per 100,000 people (95% UI: 98-169) (Table 1). Comparing this with the benchmark rate of 1158 surgeries per 100,000 population, Ghana is meeting about 12% of its estimated trauma surgical need. This amounts to an estimated 274,299 trauma procedures left unperformed yearly. Tertiary hospitals performed most of Ghana’s trauma operations [17,623 (95% UI: 771-36,025); 49%], followed by district hospitals [13,622 (95% UI: 7920-19,329); 38%] (Table 1). The relative proportion of trauma operations was highest at tertiary (26%) and regional levels (23%), followed by 10% at district hospitals (Figure). Most of trauma operations performed were categorized as essential [31,114 (95% UI: 15,436-46,794); 87%]. The most common operations at all levels were wound debridement [15,614 (95% UI: 9561-21,668); 44%] and fracture reductions [9435 (95% UI: 224-19,095); 26%]. Trauma operations that were classified outside of the essential category were more often performed at tertiary facilities, constituting 20% of trauma operations at that level, compared with only 7% and 5% of trauma operations at district and referral hospitals, respectively. Open reduction and internal fixation of fractures was the most commonly performed operation within this category [3483 (95% UI: 4556412); 74% of all operations in this category]. Only a few other trauma operations were performed in the nation outside of the essential category: 221 craniotomies (95% UI: 20-463), 15 thoracotomies (95% UI: 4-34), and 17 vascular repairs (95% UI: 2-38) (Table 1). At the district hospital level, hospitals that were staffed by surgeon providers performed 8634 (63%) of trauma operations (95% UI: 2888-14,379) compared with 4991 (37%) operations performed by hospitals not staffed by a surgeon provider (95% UI: 2157-7824). District hospitals staffed by a surgeon provider performed more trauma operations classified outside of the essential category [776 (95% UI: 132-1418) versus 215 (95% UI: 105-534) for hospitals not staffed by a surgeon provider] (Table 2).

Discussion Our nationwide enumeration of surgical procedures demonstrated that trauma care comprises a significant portion (15%) of Ghana’s current surgical practice.12 However, the results from this secondary analysis suggests that the current 134 surgeries per 100,000 people may only be meeting 12% of Ghana’s trauma surgical need. Comparing this to New


j o u r n a l o f s u r g i c a l r e s e a r c h  - 2 0 1 9 ( - ) 1 e7

Table 1 e Annual estimates of operations performed for trauma in Ghana 2014-2015*.

Essential trauma procedures Suture laceration Surgical airway

Regional hospitals

Tertiary hospitals

All hospitals

N (%)

N (%)

N (%)

N (%)

12,633 (93)

4331 (95)

14,150 (80)

31,114 (87)

8899 (65)

3006 (66)

3709 (21)

15,614 (44) 117 (0.3)

11 (0.2)

101 (0.6)

Chest tube thoracostomy

209 (1.5)

82 (1.8)

411 (2.3)

702 (2.0)

Trauma laparotomy

276 (2.0)

98 (2.2)

301 (1.7)

675 (1.9)

2503 (18)

906 (20)

6026 (34)

9435 (26)

152 (1.1)

83 (1.8)

909 (5.2)

1144 (3.2)

Fracture reduction Open fracture irrigation and debridement

5 (0.04)

External fracture fixation or traction

238 (1.7)

31 (0.7)

1232 (7.0)

1501 (4.2)

Trauma amputation

139 (1.0)

56 (1.2)

211 (1.2)

406 (1.1)

18 (0.1)

10 (0.2)

29 (0.2)

57 (0.2)

191 (1.4)

48 (1.1)

972 (5.5)

1211 (3.4)

0 (0)

249 (1.4)

252 (0.7)

3473 (20)

4683 (13)

Fasciotomy or burn escharotomy Skin grafting Trepanning (burr hole) for intracranial hemorrhage Other trauma procedures

3 (0.02) 989 (7.0)

Spine procedure

103 (0.8)

Open-reduction, internal fixation of fracture

736 (5.4)

Contraction release

221 (4.9)

323 (1.8)

428 (1.2)

164 (3.6)

2583 (15)

3483 (10)

62 (0.5)

20 (0.4)

189 (1.1)

271 (0.8)

Tendon repair

85 (0.6)

31 (0.7)

132 (0.7)

248 (0.7)

Vascular repair

0 (0)

Thoracotomy Craniotomy Total *

District hospitals

3 (0.02) 0 (0) 13,622 (100)

2 (0.04)

2 (0.04)

15 (0.09)

1 (0.02)

11 (0.06)

17 (0.05) 15 (0.04)

1 (0.02)

220 (1.2)

221 (0.6)

4552 (100)

17,623 (100)

35,797 (100)

All numbers are presented as weighted estimates.

Zealand, where trauma operations make up 18% of the total surgical volume, we estimate that Ghana’s trauma surgical practices are deficient even within the country’s overall low surgical capacity. This suggests that within the larger efforts to scale surgical capacity, special attention needs to be dedicated to developing specific areas, further reinforcing the need for benchmarks for conditions and procedures. While our comparison to the New Zealand data is admittedly rudimentary and has several limitations outlined below, it highlights the utility of condition-specific benchmarks and should encourage future work to establish more reliable metrics. Eighty-seven percent of all trauma surgery in Ghana falls into the “essential” category.27 The capacity to perform these procedures is necessary at first-level hospitals to minimize preventable death and disability related to delays in care. We observed that 92% of trauma operations performed at this level were essential. These procedures were dominated by fracture reductions and laceration repairs at all levels, although more so at first-level hospitals where these two procedures accounted for 84% of all trauma procedures. More specialized procedures (i.e., those requiring more advanced resources and training) are ideally poised to occur at the larger referral hospitals. We observed that 79% of such procedures were performed in higher-level hospitals and were overwhelmingly constituted by open reduction and internal fixation and other advanced orthopedic procedures. Procedures such as thoracotomies, craniotomies, and vascular repairs were performed rarely, suggesting a lack of trained personnel or resources to perform such operations even at Ghana’s most

advanced hospitals. It may also be, in part, due to poor prehospital care and associated higher prehospital mortality. A combined 62% of trauma operations were performed at referral centers (i.e., regional or tertiary hospitals) within urban centers. District hospitals, while performing 62% of Ghana’s operations, performed only 38% of the nation’s trauma operations. A combination of low prehospital care capacity, insufficient trauma care training and resources, and a lack of district-level trauma system development initiatives has resulted in most trauma care being shifted to tertiary centers.13,16,28,29 Although regionalization of trauma and emergency surgical care has created superior results in highincome settings with robust prehospital, interhospital, and hospital-based care systems, the benefit of regionalization in low-resource settings in the absence of these resources is unknown.30,31 Ideally, more basic and damage control trauma care should be performed at the district hospital level to ensure that patients have immediately life-threatening injuries and hemorrhage controlled in a timely fashion proximate to the site of injury. However, the low rate of trauma operations at the first-level hospitals draws further attention to the need to address specific deficits in trauma care resources, training, and system maintenance at these sites. In the current situation, the referral centers appear to bear a larger burden of the essential procedures because they are not performed at the first-level hospitals. As road traffic injuries are by far the major cause of injury in Ghana,1,32 district hospitals located along major roadways may be important locations for trauma care development.16 Given the deficiency


gyedu et al  benchmarking trauma surgery in ghana

Table 2 e Annual estimates of operations performed for trauma at district hospitals staffed or not staffed by a surgeon provider*. Hospital staffed by surgeon Yes N (%) Essential trauma procedures Suture laceration Surgical airway Chest tube thoracostomy Trauma laparotomy

4911 (57)

3989 (80)

5 (0.1) 196 (2.3)

0 (0) 13 (0.3) 49 (1.0) 581 (12)

Open fracture irrigation and debridement

142 (1.6)

10 (0.2)

External fracture fixation or traction

196 (2.3)

41 (0.8)

Trauma amputation

101 (1.2)

39 (0.8)

Burn escharotomy or fasciotomy Skin grafting Trepanning (burr hole) for intracranial hemorrhage

10 (0.1)

8 (0.2)

145 (1.7)

46 (0.9)

3 (0.03) 776 (9.0)

0 (0) 215 (4.3)

Spine procedure

101 (1.2)

3 (0.1)

Open-reduction, internal fixation

550 (6.4)

186 (3.7)

Contraction release

57 (0.7)

5 (0.1)

Tendon repair

65 (0.8)

21 (0.4)

Vascular repair Thoracotomy Craniotomy Total *

4776 (96)

227 (2.6)

Other trauma procedures

in pre and interhospital care services, the regionalized care models espoused by many HICs may not be effective in many LMICs.33 However, as these services are developed, centralization of trauma care may be equally important. At district hospitals, 37% of trauma operations were performed by nonsurgeons (i.e., medical officers or primarily general doctors). Although many essential trauma care procedures fall under the scope of nonsurgeons (e.g., laceration repairs, thoracostomy tube insertions, closed fracture reductions), task-sharing for those procedures that require additional training for safe and effective performance (e.g., open fracture reduction, laparotomy) is a well-recognized strategy to increasing trauma surgical capacity in low resource settings.34 These findings further support the importance of training nonsurgeons to provide basic trauma care services to facilitate timely and quality care.35-37 While 80% of the nonsurgeons’ operative volume was woundrelated, nonsurgeons also performed 21% of all other operations for trauma performed at the district level. Efforts to formalize task-sharing programs through training, accreditation, and remuneration may promote trauma care improvement at district hospitals. Inclusion of telementoring programs for supervision and mentoring could also enhance the success of such task-sharing programs. Before drawing major conclusions from this study, several key limitations must be considered. First, estimating the met and unmet trauma surgical needs for a population poses several obstacles. Trauma surgical needs are dependent on population demography, injury prevention initiatives, injury epidemiology, and the presence or absence of prehospital care services.38 As such, a low rate of trauma operations may be appropriate in a population with a low incidence of injury or in systems without prehospital care and high rates of preventable prehospital mortality. Conversely, in a setting with high

N (%)

7858 (91)

1922 (22)

Fracture reduction

Fig e Trauma procedures compared with all surgical procedures performed in Ghana 2014-2015. Percentage of trauma procedures from all procedures performed at each level of care is indicated in parenthesis.


0 (0) 3 (0.03) 0 (0) 8634 (100)

0 (0) 0 (0) 0 (0) 4991 (100)

All numbers are presented as weighted estimates.

rates of road traffic injuries and reduced access to advance surgical procedures for other conditions, such as cancers,39 our estimated trauma operation rate may be an underrepresentation of the met need for trauma surgical care in the country. Given a lack of data from other LMICs, we settled on the accepted benchmark of New Zealand to open the discussion of condition-specific surgical benchmarking. This study and research from other countries can be used to develop more applicable benchmarks for LMICs. Second, despite making every effort to identify trauma-related procedures, some of the indications provided in the operative logs from which our data were extracted were vague and may not have designated the case as trauma-related. Similarly, when multiple procedures were performed during a single operation, some procedures may not have been recorded. Resultantly, smaller procedures that were performed as part of a larger operation may be under-represented. Together, these limitations introduce the potential for information bias that can only be remedied by a prospective registry. Finally, the capacity of hospitals across and within levels in Ghana varies markedly.13 As such, the logbooks of hospitals without


j o u r n a l o f s u r g i c a l r e s e a r c h  - 2 0 1 9 ( - ) 1 e7

functioning operating theaters would not reflect procedures performed in other areas of the hospital. To ensure that we captured all trauma-related procedures, we used logbooks from all areas of hospitals that would perform procedures (e.g., operating theater and other designated procedure areas). Despite these limitations, these results provide a basic and useful estimate of the met and unmet trauma surgical needs in Ghana. Our results highlight the importance of specialtyspecific metrics in the larger effort to improve surgical capacity in LMICs. Furthermore, as trauma surgical care is essential to decreasing the large burden of injury, this work reveals specific area deficits in Ghana’s trauma care that can be used to target future efforts and provides data for monitoring progress.

Conclusions There is potentially a large unmet need for trauma surgery in Ghana. The low percentage of trauma operations in district (first-level) hospitals indicates an even greater unmet need in rural areas. Most essential trauma operations were performed at referral facilities, indicating interventions are needed to improve capacity and access to first-level trauma care as well as interfacility triage and transfer systems. Nonsurgeons provide a substantial proportion of surgical care for injury in Ghana despite the lack of formal task-sharing programs. Future global surgery benchmarking should consider not only total rates, but also benchmarks for specific conditions, hospital levels, and essential and more advanced procedures.

Acknowledgment The authors wish to thank the Ghana Health Service and all participating hospitals. The authors thank the dedicated volunteers for extracting data needed for the study. Authors’ contributions: Study concept and design was contributed by Gyedu, Stewart, Quansah, and Mock. Acquisition, analysis, or interpretation of data was performed by Gyedu, Stewart, Gaskill, Donkor, and Quansah. Drafting of the manuscript and critical revision of the manuscript for important intellectual content were performed by all the authors. Administrative, technical, or material support was provided by all the authors. This study was funded by grants R25-TW009345 and D43-TW007267 from the Fogarty International Center, United States, US National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors thank the dedicated volunteers for extracting data needed for the study.

Disclosure The authors reported no proprietary or commercial interest in any product mentioned or concept discussed in this article.


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