Hyla-Louise Kluyts

BACKGROUND: The perioperative mortality rate in Africa is twice the global average. Postoperative complications independently associated with postoperative mortality have not been explored in this region and can provide insight into failure to rescue. The aim of this study was to determine which severe postoperative complications are independently associated with postoperative mortality in Africa and calculate the attributable fraction (AtF) for 30-day mortality for each complication. METHODS: Data from an African prospective observational study of perioperative adult patients conducted in 2016 were analyzed. We used a logistic mixed-effects model to assess the strength of association, expressed as an odds ratio (OR), between severe postoperative complications and 30-day postoperative mortality, adjusting for known patient and surgical factors. This model was used to calculate the AtF of death for each complication, representing the proportion of mortality due to that complication. RESULTS: We included 10,748 patients, of whom 222 (2.07%) died in hospital within the 30-day postoperative period. The severe postoperative complications with the highest adjusted ORs for mortality were pulmonary embolism (OR, 484; 95% confidence interval [CI], 85.2–2744; P < .001), pulmonary edema (OR, 53.5; 95% CI, 6.59–434; P < .001) and bloodstream infections (OR, 34.3; 95% CI, 16.3–72.3; P < .001). The highest AtF for 30-day postoperative mortality was severe bloodstream infections (average AtF 13.7%; 95% CI, 10–18.1). CONCLUSIONS: The AtF is a measure that can identify the complications with the greatest contribution to postoperative mortality and can guide prioritization. In this African cohort, pulmonary embolism, pulmonary edema, and bloodstream infections were most strongly associated with death, while severe bloodstream infections accounted for the largest proportion of 30-day mortality. Managing bloodstream infections is an important complication to address to improve postoperative outcomes in Africa.

Acute pain in hospitalised patients is common, yet African data are scarce. We conducted a prospective point-prevalence study of hospitalised adult patients across Africa to determine acute pain prevalence and severity and investigate associations of pain with critical illness and 7-day mortality. On a single day, investigators assessed patients' worst pain in the preceding 24 hours using a 0 to 10 visual-numerical scale and recorded vital signs. Critical illness was defined as ≥1 vital sign out of range, in line with an international consensus definition. In-hospital mortality was assessed at day 7. Data are presented as median [interquartile range], n (%), and odds ratios with 95% confidence intervals. Between September and December 2023, 19,438 patients from 180 hospitals in 22 African nations were included (age 40 [29; 59] years; 10,874 [56%] female). Pain prevalence [95% CI] was 67.9% [67.9-68.5], with 2795 (14.4%) patients reporting severe pain (≥7/10). Pain was more common among patients admitted for emergency or trauma care and in surgical and high-care wards. Pain severity did not differ meaningfully between sexes. There was no evidence of an association between pain severity and critical illness; however, increasing pain severity was associated with a higher likelihood of 7-day mortality. These findings are comparable to data from high-income countries despite substantial differences in healthcare resources, suggesting that acute pain remains a persistent and underaddressed problem globally. This study provides the first large-scale evidence of acute pain burden in African hospitals and lays a foundation for future research aimed at comprehensively characterising in-hospital pain.

Surgical care is essential to achieving universal health coverage, yet many African low-income, lower-middle-income countries (LMICs) and upper-middle-income countries - including South Africa—struggle to harness healthcare data for surgical system strengthening. Despite global advocacy efforts and the adoption of surgical indicators such as perioperative mortality rate and surgical volume, fragmented routine health information systems, limited human resource capacity and siloed data architecture hinder effective, data-informed planning and policy. Drawing on a South African case study, this high-level perspective highlights institutional momentum for integrating routine perioperative data into strategic health planning, while also identifying key technical and operational challenges. The study demonstrated the inability of clinician-led initiatives to generate routine perioperative health information to guide practice at an institutional level. To close the implementation gap, a context-adapted approach, that includes participatory network weaving, stakeholder-driven data use cases and collaborative planning for interoperable data systems, is proposed. These elements are positioned within an implementation framework designed to support policy development, guide clinical practice and improve access to safe, high-quality surgical care across African countries. We propose taking advantage of opportunities for concurrent implementation assessment and adaptation of a clinical health information system module for South African surgical patients.

Background: Perioperative patient-reported outcomes (PROs) allow patients to share their experiences of surgical procedures with their health care teams using standardized measures. Despite increasing recognition of their value, PROs are not routinely used in clinical practice, partly due to limited evidence of their impact on traditional clinical outcomes and uncertainty among clinicians about their use. Digital health tools offer a promising way to integrate PROs into clinical workflows and enhance patient-clinician interaction, but their success depends on person-centered design to ensure usability and relevance. Safe Surgery South Africa, a nonprofit organization, developed the Perioperative Shared Health Record (PSHR), a secure web-based tool that enables patients to share personal health information and PROs with their anesthetist and surgeon before and after surgery. Initial implementation revealed significant user experience challenges, which contributed to poor uptake. Objective: This study aimed to explore factors influencing the PSHR user experience in a low- and middle-income country (LMIC) using human-centered design principles. Methods: This observational qualitative user experience study followed the 5 design thinking stages: empathize, define, ideate, prototype, and test. Semistructured interviews were conducted with postoperative patients from both the public and private health care sectors, including those with and with no prior experience using the PSHR. Thematic analysis followed the 6-phase framework described by Braun and Clarke and was structured using Karagianni’s Optimized Honeycomb user experience model. A problem statement was developed, followed by ideation to explore solutions. Paper prototypes were created, refined, and tested through observation, interviews, and validated usability questionnaires. Results: In the empathize stage, 22 interviews were conducted in the private and public health care sectors in South Africa; 7 participants had previous experience using the PSHR. In the define stage, participants emphasized the need for connection, feedback, information, and support through their surgical journey. Contrary to expectations, patients were not discouraged by the length of questionnaires if they perceived them as purposeful. In the ideate stage, the team considered user expectations and PSHR integration into care processes. In the prototype stage, low-fidelity mock-ups were created and refined into paper prototypes. In the test stage, testing with 5 participants highlighted the importance of trust, communication, and user-friendly interfaces. Feedback loops and clinician engagement were identified as key motivators for sustained use. The mean usability questionnaire scores indicated excellent usability and high levels of user satisfaction across most domains. Conclusions: This study is one of the first to apply human-centered design principles to a perioperative digital health tool in an LMIC setting, addressing usability challenges and patient engagement. Key user experience factors influencing patient engagement included communication, feedback, and access to information throughout the surgical journey. Digital health tools such as the PSHR can strengthen communication and support person-centered perioperative care by integrating PROs into clinical workflows and care processes.

Background: It is often difficult for clinicians in African low‐ and middle‐income countries middle‐income countries to access useful aggregated data to identify areas for quality improvement. The aim of this Delphi study was to develop a standardised perioperative dataset for use in a registry.Methods: A Delphi method was followed to achieve consensus on the data points to include in a minimum perioperative dataset. The study consisted of two electronic surveys, followed by an online discussion and a final electronic survey (four Rounds).Results: Forty‐one members of the African Perioperative Research Group participated in the process. Forty data points were deemed important and feasible to include in a minimum dataset for electronic capturing during the perioperative workflow by clinicians. A smaller dataset consisting of eight variables to define risk‐adjusted perioperative mortality rate was also described.Conclusions: The minimum perioperative dataset can be used in a collaborative effort to establish a resource accessible to African clinicians in improving quality of care.

Background: This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle‐income countries (LMIC's) for elective abdominal and gynecologic care.Methods: The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC's. The group consisted of seven members from the ERAS® Society and eight members from LMIC's. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta‐analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC's and LMIC's were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC's. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC's and determined through discussions and consensus.Results: In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno‐nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.Conclusions: These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data‐driven, evidence‐based care in LMIC's.