After a recent study revealed abysmal outcomes after anaesthesia and surgery for African children with complication rates up to four-fold higher and mortality rates 11-fold higher than high-income countries, researchers called for urgent strengthening of health systems.
Funded by the Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anaesthesiologists of Uganda, the study was published in The Lancet, and in a linked editorial, a group of experts corroborated this conclusion. Additionally, they highlighted the crucial need for the championing of perioperative paediatric nursing care and improved detection of complications, as well as more paediatric critical care beds.
Most people cannot reliably access surgical care when they need it, including 1.7bn children globally – and when surgery is performed, often, there is insufficient capacity to provide safe, high-quality perioperative care, resulting in 4.2m deaths annually post-surgery, wrote Joshua Ng-Kamstra, Godfrey Sama Philipo and Kate Isoken Obayagbona.
Benchmarking surgical outcomes can motivate and inform quality improvement, and although perioperative mortality data remain elusive at the national level, snapshot studies conducted by international consortia of investigators have compared surgical outcomes across country income levels and regions.
In 2016, a study by the GlobalSurg Collaborative group showed that the risk-adjusted odds of 30-day mortality after emergency abdominal surgery was 2.97 (95% CI 1.84–4.81; p<0.001) times higher in low-income countries than in high-income countries.
The African Surgical Outcome Study (ASOS) was the first pan-African study to use this approach. The authors found that on the continent, the risk of perioperative mortality after inpatient surgery was twice the global average.
Notably, the ASOS investigators excluded paediatric patients, given the specialised expertise, resources, and infrastructure required to provide surgery for children. Because of these needs, global inequities in access to and outcomes from paediatric surgery are more pronounced than in adult surgery, prompting a movement to expand access to and improve the quality of children's surgical care worldwide.
However, quantifying paediatric outcomes in Africa has been limited by a shortage of data, with only one multicentre study in South Africa reporting on outcomes for a broad cohort of children undergoing surgery.
The Lancet study by the ASOS-Paeds Investigators represents a leap forward in African paediatric surgical science. This prospective study, involving 1 268 named collaborators, includes data from 8 625 recruited children (mean age 6.1 [SD 4.9] years; 66% [5 675 of 8 600] male and 34% [2 925 of 8 600] female) who underwent surgery at 249 hospitals in 31 countries.
Most surgeries were elective (5 325 [61.9%] of 8 604 patients), and almost three-quarters of the children (6 110 [71.2%] of 8 579 patients) had no comorbidities (American Society of Anaesthesiologists class I). This study has used pragmatic sampling of centres, each collecting comprehensive surgical data during a 14-day window.
Although there is no formal mechanism for external audit of the surgical denominator at each site, the completeness of data entry for each variable suggests commendable attention to detail.
Among sites, tertiary health centres were over-represented (147 [61.3%] of 240 hospitals), making the results less relevant to first-level health centres, which provide most hospital-based care and are often the first point of contact for surgical emergencies.
The primary outcome of the study was in-hospital complications, censored at 30 days. Complications ensued in 18.0% (1 532 of 8 515) of patients, leading to death in 10.8% (166 of 1 530) of these children. In total, 199 of 8 596 children died (2.3%) after surgery and 23 of them (11.6%) died on the day of surgery.
Comparatively, the rate of complications was up to four times the rate seen in high-income country cohorts. Increased failure-to-rescue (mortality after complications), had a multiplicative effect on this high complication rate, resulting in a perioperative mortality ratio 11 times higher than a pooled estimate from high-income country studies identified in an accompanying meta-analysis.
These comparisons were crude and did not account for population-level differences in risk factors like case urgency or illness severity. Given the need for a pragmatic dataset, data collection did not include diagnostic or procedure codes.
However, in the absence of regional, multicentre data for rare, high-mortality congenital conditions, this omission seems a missed opportunity.
Among 199 total deaths, 105 (52.8%) occurred after gastrointestinal surgery, and of these, 68 (64.8%) occurred in neonates and infants, signalling high-yield target populations for improvement efforts.
The results of the ASOS-Paeds Investigators’ trial can be used to generate political priority for mobilising the resources necessary for safe paediatric surgery. To inform continuous quality improvement, ongoing measurement will be required.
This trial shows again that standardised surgical outcomes data can be collected in African hospitals with sufficient human resources, co-ordination and infrastructure.
A natural next step could be the implementation of an African data platform, similar to the American College of Surgeons National Surgical Quality Improvement Programme, that would allow for collection, central analysis, and reporting of risk-adjusted external comparisons of key outcomes to hospitals to inform ongoing process improvement.
Some of these authors have elsewhere laid the groundwork for such a continental registry, establishing a minimum dataset, and building a community of practice.
Although this approach could reduce complication rates, reducing failure-to-rescue after complications requires an additional set of strategies implemented by multidisciplinary teams.
Early detection of complications can be facilitated through technology-based innovations in patient monitoring, but technology cannot replace a safe nurse to patient ratio and surgical nursing expertise.
More data are needed on the African nursing workforce, particularly on nurses trained to manage paediatric and surgical patients. There is an active community of African nursing leaders focused on conducting research and building capacity, and this study by the ASOS-Paeds Investigators shows an opportunity to champion perioperative paediatric nursing care.
Beyond the detection of complications, access to the resources needed to manage them must be improved. The median number of paediatric critical care beds in each participating hospital was only two, probably limiting the ability to treat life-threatening deterioration.
Ultimately, optimising outcomes will require broader solutions beyond what local surgical leaders can achieve – for example, increasing the paediatric surgical workforce, expanding hospital infrastructure, and incorporating surgery into universal health coverage to reduce financial barriers to timely care.
Moreover, not every hospital will be able to manage every patient, nor every complication. Although improving resources across all levels of the health system ensures that children get the highest quality care, the sickest children depend on systems that facilitate transfer to higher levels of care when local resources are insufficient.
These solutions require complex planning, and although many national surgical, obstetric, and anaesthesia plans have been developed to improve surgical care in African nations, only a quarter included dedicated sections on improving surgical care for children.
This absence is an oversight, particularly in sub-Saharan Africa where 42% of the population is under 15.
Children’s surgery saves lives, alleviates suffering, and is among the most cost-effective forms of medical care.
To ensure the best outcomes for these children undergoing surgery, investment in surgical systems attuned to their needs is imperative and urgent.
Study details
Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study
The ASOS-Paeds Investigators
Published in The Lancet on 22 March 2024
Summary
Background
Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa.
Methods
This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available.
Findings
We recruited 8 625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8 579 patients) were from category 1 of the American Society of Anaesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8 604 patients). Postoperative complications occurred in 1 532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8 538 children). Deaths occurred in 199 (2·3%) of 8 596 patients, 169 (84·9%) of 199 patients after emergency surgeries. Deaths after postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children under sixyears (188 [84·3%] of 223 hospitals).
Interpretation
Outcomes after anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4–14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue.
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