Assessing the capacity of Malawi’s district and central hospitals to manage traumatic diaphyseal femoral fractures in adults

Abstract

BackgroundThe burden of musculoskeletal trauma is growing worldwide, disproportionately affecting low-income countries like Malawi. However, resources required to manage musculoskeletal trauma remain inadequate. A detailed understanding of the current capacity of Malawian public hospitals to manage musculoskeletal trauma is unknown and necessary for effective trauma system development planning.MethodsWe developed a list of infrastructure, manpower, and material resources used during treatment of adult femoral shaft fractures–a representative injury managed non-operatively and operatively in Malawi. We identified, by consensus of at least 7 out of 10 experts, which items were essential at district and central hospitals. We surveyed orthopaedic providers in person at all 25 district and 4 central hospitals in Malawi on the presence, availability, and reasons for unavailability of essential resources. We validated survey responses by performing simultaneous independent on-site assessments of 25% of the hospitals.ResultsNo district or central hospital in Malawi had available all the essential resources to adequately manage femoral fractures. On average, district hospitals had 71% (range 41–90%) of essential resources, with at least 15 of 25 reporting unavailability of inpatient ward nurses, x-ray, external fixators, gauze and bandages, and walking assistive devices. District hospitals offered only non-operative treatment, though 24/25 reported barriers to performing skeletal traction. Central hospitals reported an average of 76% (71–85%) of essential resources, with at least 2 of 4 hospitals reporting unavailability of full blood count, inpatient hospital beds, a procedure room, an operating room, casualty/A&E department clinicians, orthopaedic clinicians, a circulating nurse, inpatient ward nurses, electrocardiograms, x-ray, suture, and walking assistive devices. All four central hospitals reported barriers to performing skeletal traction. Operative treatment of femur fracture with a reliable supply of implants was available at 3/4 hospitals, though 2/3 were dependent entirely on foreign donations.ConclusionWe identified critical deficiencies in infrastructure, manpower, and essential resources at district and central hospitals in Malawi. Our findings provide evidence-based guidance on how to improve the musculoskeletal trauma system in Malawi, by identifying where and why essential resources were unavailable when needed.

Deaths from surgical conditions in Malawi - a randomised cross-sectional Nationwide household survey

“…A study done in Zambia demonstrated that only 16.5% of the hospitals met the WHO minimum standards of safe surgical care [20]. There is a similar situation in Malawi with low standards of safe surgery in rural health facilities [21]. In addition, the need of improvement in global surgical care, particularly in low-income and middle-income countries is described in a review from 2019 [21].…”

The experiences of adult patients receiving treatment for femoral shaft fractures at Kamuzu Central Hospital, Malawi: a qualitative analysis

“…In fact, central hospitals face challenges in providing even skeletal traction due to broken drills, limited traction pins, and inadequate traction frames and weights. 28 Improving hospital infrastructure, bolstering surgical staff, and improving availability of material resources would all likely improve the patient experience navigating the Malawian health system. However, many of the patients' frustrations could be addressed by fostering a culture of quality improvement that is accountable to patients -a culture where patients' experiences and outcomes are noted, acknowledged, and addressed.…”

“…27 No public hospital nationwide has the minimum required resources to adequately treat FSF. 28 The public hospital system in Malawi has three tiers: rural health centers, providing basic medical and maternity care only; district hospitals, staffed by general doctors and clinical o cers (non-physician clinicians); and central hospitals staffed by specialists including surgeons. Operative treatment of FSFsthe international gold standard 29 -is performed only in central hospitals.…”

“…20,21 However, 24 of the 25 district hospitals and all four central hospitals in Malawi reported barriers to performing skeletal traction, the non-operative treatment that remains the standard of care in Malawi. 28,30 Patients receiving skeletal traction experience prolonged hospitalization, about 20% experience complications and 9% die in hospital. 31 Patients describe longstanding pain, emotional distress, and signi cant nancial strain for themselves and their families.…”

Title Knowledge, attitude and use of evidence based practice (EBP) among Registered Nurse-Midwives practicing in Central Hospitals in Malawi: A Cross-Sectional Survey

“…The study was conducted in all four central hospitals in Malawi. Central hospitals in Malawi are tertiary level institutions which provide specialist care (32).The study was conducted in the central hospitals because they serve as referral centres for all other facilities in all the three regions of Malawi (i.e. northern, central and southern regions).…”