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New study shows intervention alone does not decrease post-surgery deaths in Africa

A new study from a team of researchers, including from Queen Mary University of London, has provided valuable insight into reducing death following surgery in African hospitals. It found that intervention methods alone, such as having nurses conduct more regular checks of patients or placing patients in a higher care ward, are not enough to bring down the number of deaths.

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The research, published in Lancet Global Health randomised 332 hospitals across Africa to provide either enhanced surveillance of high-risk patients after surgery or the regular standard of care. This enhanced surveillance included:

  • Admitting the patient to a higher care ward
  • Increasing the frequency of checks by nurses
  • Assigning the patient to a bed in view of the nursing station
  • Allowing family members to stay in the ward
  • Placing a postoperative surveillance guide at the bedside for the benefit of staff

The study was a follow-up to the landmark original African Surgical Outcomes Study (ASOS) which showed that death after surgery is a major public health problem in Africa, with surgical patients in Africa being twice as likely to die in hospital following surgery when compared to the rest of the world. This appeared to be due to a failure to recognise and/ or respond to common postoperative complications.

While the interventions did not lead to fewer deaths following surgery, the latest study did lead to a number of useful insights as to why.

Nicola Vickery, from Queen Mary University of London and Barts Health NHS Trust, and one of the study authors, said: “The lack of resources in terms of staff and finance in these African hospitals is a major issue. Nurses are not easily able to monitor patients more frequently within their existing workload, and even when it was clear that a patient’s health was deteriorating, often the hospital lacked the tools, resources or sometimes communication to take the appropriate action.

“There is no ‘catch-all’ solution to the problem. But it will certainly require those on the ground to be closely involved and require teamwork of the highest level. We also can’t forget the immeasurable financial and staffing barriers, which means outside-the-box solutions may need to be identified through further research.”

A second study, published in the British Journal of Anaesthesia examined the contextual and environmental factors that contributed to these findings. Eight in-depth case studies and 96 questionnaire responses revealed that there were numerous challenges that lead to poor fidelity, and perhaps this was a key reason behind the results of the main trial.

This study also reinforced that while coordinated interventional research across Africa is possible, there are numerous reasons why the ‘common-sense’ intervention of greater scrutiny of patients did not work, the primary factor being a significant lack of finance and staffing. If the situation is to change, then additional support and a detailed understanding of the work environment and culture are paramount.

More information

Research paper: Enhanced postoperative surveillance versus standard of care to reduce mortality among adult surgical patients in Africa (ASOS-2): a cluster-randomised controlled trial. Lancet Global Health

Research paper: Understanding the performance of a pan-African intervention to reduce postoperative mortality: a mixed methods process evaluation of the ASOS-2 trial. British Journal of Anaesthesia