Lady Willingdon Hospital

Background: COVID-19 disrupted healthcare delivery and hospital finances globally. In India, where private hospitals provide a substantial share of care, evidence on changes in service utilisation and financial performance remains limited. Methods: We conducted a multicentre interrupted time-series study using monthly hospital-level service, outcome, and financial data from 14 private sector hospitals in India from January 2018 to July 2021. Data were analysed across three periods: pre-pandemic baseline (January 2018 to March 2020), Pandemic Period 1 (April 2020 to February 2021), and Wave 2 (March to July 2021). Outcomes included service utilisation, patient outcomes, and hospital financial indicators. Findings: In April 2020, outpatient visits declined by 48% compared with the expected pre-pandemic trend (p<0·001), inpatient admissions by 40% (p<0·001), surgeries by 47% (p<0·001), and hospital income by 38% (p=0·020). Expenditure and concessions declined by 28% and 35%, respectively. During Pandemic Period 1, outpatient visits and surgeries showed significant monthly recovery trends of 3% and 4%, respectively. In March 2021, emergency visits increased by 24%, inpatient admissions by 21%, ICU admissions by 98%, and pharmacy income by 63%. Routine service disruption was greater among non-COVID-19 care centres. Interpretation: COVID-19 caused major disruption in routine and elective services, followed by partial recovery. The second wave increased acute and critical care demand. Strengthening service continuity and financial resilience is essential for future public health emergencies. Funding: This study received no specific funding.

The hospital environment can be a hotspot for the emergence of antimicrobial resistance (AMR), with high antibiotic usage and varied cleaning practices acting as a reservoir for AMR bacteria that can persist on surfaces such as bedside tables, door handles or medical equipment. In BARNARDS-II (Burden of Antimicrobial Resistance in Neonates in Developing Societies), incidence, AMR and antibiotic usage in neonatal sepsis are evaluated. Within the study, we also investigate whether hospital surfaces can contribute to the spread of MDR bacteria. To investigate potential sources of infection and determine the prevalence of ESBLs among bacteria colonizing hospital surfaces in maternity, delivery and neonatal wards across the BARNARDS network. Charcoal swabs were used to collect samples from low- and high-touch surfaces across neonatal, delivery and maternity wards for a period of three months in 13 hospitals across Bangladesh, Pakistan and Nigeria and shipped to Oxford under UN3373 regulations. Swabs were plated on non-selective and selective (cefotaxime and vancomycin) Chromatic Detection agar. Growth from antibiotic-supplemented media was recorded and multiplex PCRs were performed to assess the presence of ESBL resistance genes (blaCT-XM15, blaOXA-1, blaSHV-1 and blaTEM-1). Bacterial communities PCR positive for at least one target ARG were purified and separated to test morphologically distinct colonies and retested. Positive isolates were identified via MALDI-TOF MS. Out of 1854 swabs processed to date, 1636 produced microbial growth on non-selective media and 1271 samples produced growth on Chromatic Detection plates supplemented with vancomycin and cefotaxime. PCR testing for key ESBL genes revealed that 353 samples were positive for at least one gene, with a total of n=585 isolates recovered. The gene most commonly found was blaCT-XM15 (n=455), followed by blaTEM-1 (n=362), blaOXA-1 (n=272) and blaSHV-1 (n=120). Out of all the isolates recovered, 33% isolates carried one gene (n=193), 32.8% carried two (n=192), 28.4% carried three (n=166) and 5.8% carried all four (n=34). The most common species carrying ESBLs were Klebsiella pneumoniae (n=117, 20%), followed by Enterobacter hormaechei (n=87, 14.87%) and Klebsiella oxytoca (n=66, 11.28%). The majority of the K. pneumoniae isolates (n=105, 89.7%) carried more than one ESBL, with blaCT-XM15 being the most prevalent ARG across the species (n=105, 89.7%). ESBL-carrying bacteria were found on a variety of surfaces, including medication trolleys, sinks and bedside tables across the wards. Our findings revealed a widespread microbial contamination across a range of surfaces in all ward types tested, with a substantial proportion of these being clinically relevant bacteria carrying antibiotic resistance genes. The prevalence of ESBLs in these strains indicates that hospital surfaces serve as a significant reservoir of MDR bacteria. This highlights the role of the hospital environment as a reservoir of pathogenic bacteria and the contribution to the burden of AMR in LMICs. Future work will include further environmental sampling and comparison of environmental and blood culture isolates from the same locations to investigate transmission networks.

Antimicrobial resistance (AMR) is one of the fastest growing threats to global human health. Neonates are particularly vulnerable to AMR infections and this problem is exacerbated in LMICs where access to healthcare services and resources including antibiotics are limited. Carbapenem-resistant infections are a major healthcare challenge as carbapenems are often a last-line defence against MDR infections. Bacteria colonizing hospital environments serve as a reservoir of- and potential transmission risk for nosocomial infections. Determine the prevalence of carbapenemase-producing bacterial species colonizing hospital surfaces in neonatal, maternity and delivery wards in 13 hospitals across Bangladesh, Pakistan and Nigeria overall, by surface type and by facility. High-touch and low-touch hospital surfaces across 13 hospitals in Bangladesh, Pakistan and Nigeria were sampled on-site using sterile cotton swabs and saline monthly over three consecutive months. Swabs were stored using Amies charcoal media and transported to the UK where they were cultured for 24–48 h at 37°C on antibiotic-supplemented (vancomycin and ertapenem) and non-supplemented chromatic detection agar media (Liofilchem®). Species from bacterial growth from non-supplemented agar were identified via MALDI-TOF MS and PCR was employed for samples with growth on agar supplemented with vancomycin and ertapenem to screen for carbapenemase genes blaNDM, blaKPC, blaOXA-48-like, blaVIM and blaIMP. A total of 1854 hospital surface samples have been processed to date. Microbial growth was obtained from n=1636/1854 surface samples. The most common species cultured were Pseudomonas stutzeri (n=717/1854), Enterobacter hormaechei (n=165/1854) and Klebsiella pneumoniae (n=135/1854). Carbapenemase-producing isolates (n=744) were found in n=476/1854 surface samples, including blaNDM (n=249/1854), blaKPC (n=11/1854), blaOXA-48-like (n=60/1854), blaVIM (n=221/1854) and blaIMP (n=82/1854). The surfaces most commonly colonized by carbapenemase producers were in or around sinks including sink bowls/basins, taps and floors surrounding sinks. The species comprising the greatest number of isolates per gene were K. pneumoniae for blaNDM and blaKPC (n=59/394 and n=7/14, respectively), K. pneumoniae for blaOXA-48-like (n=21/76) and P. stutzeri for blaVIM and blaIMP: (n=122/263 and n=46/93, respectively). The high contamination rate of hospital surfaces with clinically relevant bacterial species across African and Asian hospitals is concerning. The prevalence of species harbouring carbapenemase genes is also of particular concern in terms of neonatal sepsis as they may be providing a route of transmission for AMR infections to neonatal patients born and treated within the hospitals. Future work will include further hospital surface sampling in addition to performing comparisons between isolates from hospital surfaces and pathogens found to cause neonatal sepsis from the same hospital sites, to investigate potential transmission networks.

First referral hospitals, often known as district hospitals, are neglected in the discourse on universal health coverage in low-income and middle-income countries (LMICs). However, these hospitals are important for delivering safe surgery for 313 million people. This study aims to understand the structures, processes and outcomes of patients undergoing surgery in these centres in LMICs. This is a preplanned secondary analysis using data from two high-quality randomised controlled trials undergoing major abdominal surgery across six LMICs. Type of hospital was the main explanatory variable, defined according to the WHO taxonomy as first referral (ie, district or rural) and referral (ie, secondary or tertiary). Of the included 15 657 patients across 80 hospitals from 6 countries, 3562 patients underwent surgery in first referral and 12 149 patients underwent surgery in referral centres. First referral centres have lower full-time surgeons (median: 1 vs 20, p<0.001) and medically trained anaesthetists (28.6% vs 87.1%, p<0.001) compared with referral centres. Patients undergoing surgery in first referral centres were more likely to have lower rates of American Society of Anaesthesiologist (ASA) grades III-V (8.1% vs 22.7%, p<0.001), but higher rates of emergency procedures (65.1% vs 56.6%, p<0.001). In first referral centres, there was a significantly higher use of WHO surgical safety checklist (99.4% vs 93.3%, p<0.001) compared with referral centres. In adjusted analyses, there were no differences in 30-day mortality (OR 1.09, 95% CI 0.73 to 1.62) and surgical site infection (OR 1.30, 95% CI 0.89 to 1.90) between first referral and referral centres. Postoperative mortality and surgical site infection remain similar between first referral and referral centres in LMICs. There may be a clear need to upscale surgical volume safely in first referral centres to meet global surgical needs. High-quality research is needed to drive safe expansion of surgical workforce and strengthen referral pathways within these surgical health systems in LMICs.

IntroductionSurgical care in first-referral hospitals (FRHs) in low- and middle-income countries (LMICs) is poorly characterized. Inguinal hernia repair can act as a good tracer condition. This study aimed to evaluate the variation in hernia repair across different hospital types in LMICs.MethodsWe conducted a secondary analysis of an international prospective cohort study of hernia surgery. Data was collected from consecutive patients undergoing primary inguinal hernia repair between 30 January and May 21, 2023. We characterized patients from LMICs, comparing first-referral, secondary, and tertiary hospitals. Emergency surgery, financing methods, mesh use, and complications were defined as key performance measures relevant for FRHs. A multilevel logistic regression model was used to test associations between complications and hospital type.ResultsThis analysis included 8155 patients undergoing hernia repair across 328 hospitals in 55 LMICs. Most patients were male (89.8%, 7324/8155), of working age (mean age 41.6, SD 25.3). Emergency surgery rates were similar across first-referral, secondary and tertiary hospitals (11.1%, 10.9%, and 9.6%, respectively). Patients in FRHs were most likely to experience out-of-pocket payments (31.4%, 9.4%, and 17.4%). They also had lower rates of mesh use (71.9%, 82.1%, and 84.1%) and higher postoperative complication rates (19.1%, 12.5%, and 14.0%), although complications were similar after adjustment (adjusted odds ratio 1.71, 95% CI 0.83-3.54, p = 0.148).DiscussionThis sample of FRHs is capable of delivering simple elective surgery, reducing the burden on subsequent referral hospitals. To scale these surgical pathways, FRHs need support to increase the use of mesh and ensure cost protection for patients.