|Year : 2022 | Volume
| Issue : 2 | Page : 102-109
Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study
Justina O Seyi-Olajide1, Christopher O Bode2, George C Ihediwa1, Olumide A Elebute2, Felix M Alakaloko1, Oluwaseun A Ladipo-Ajayi1, Adesoji O Ademuyiwa2
1 Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, Lagos, Nigeria
2 Paediatric Surgery Unit, Department of Surgery, Lagos University Teaching Hospital, 2Department of Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Submission||07-Dec-2021|
|Date of Decision||08-Feb-2022|
|Date of Acceptance||08-Mar-2022|
|Date of Web Publication||23-Apr-2022|
Justina O Seyi-Olajide
Department of Surgery, Paediatric Surgery Unit, Lagos University Teaching Hospital, Lagos
Source of Support: None, Conflict of Interest: None
Background: The impact of the corona virus disease 2019 (COVID-19) pandemic on global health, has reached far beyond that caused by the disease itself. With ongoing mutations and the emergence of new strains of the virus alongside repeated waves of the pandemic, the full impact of the pandemic is still evolving and remains difficult to predict or evaluate. In paediatric surgery, it has led to significant disruptions in patient care, the extent and consequence of which are not fully documented in Nigeria. Aim: This study aims to evaluate the impact of COVID-19 on services, training and research in a busy paediatric surgery unit during the initial 3-month period of the COVID-19 pandemic lockdown. Methods: This study was an ambispective evaluation of the preceding 3 months before lockdown and the initial 3 months of lockdown. Clinic cancellations, elective and emergency surgeries, delays in access, extra cost of care to patients, impact on training and research, and the psychologic impact of the pandemic on staff and guardians were evaluated. Results: During the 3-month lockdown period, an estimated 78 new cases and 637 follow-up cases could not access care. Ninety-seven elective surgeries in 91 patients were postponed. Two (2.2%) patients' symptoms progressed. All emergency patients received care. Out-of-pocket expenditure increased averagely by $124. The pandemic contributed to delays in seeking (13%), reaching (20%) and receiving care (6%). Trainee participation in surgeries was reduced and academic programmes were suspended. Five staff were exposed to the virus and 3 infected. Conclusion: Paediatric surgery has been negatively impacted by COVID-19. Efforts must focus on planning and implementing interventions to mitigate the long-term impact.
Keywords: Access, corona virus disease 2019, impact, paediatric surgery
|How to cite this article:|
Seyi-Olajide JO, Bode CO, Ihediwa GC, Elebute OA, Alakaloko FM, Ladipo-Ajayi OA, Ademuyiwa AO. Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study. Niger Postgrad Med J 2022;29:102-9
|How to cite this URL:|
Seyi-Olajide JO, Bode CO, Ihediwa GC, Elebute OA, Alakaloko FM, Ladipo-Ajayi OA, Ademuyiwa AO. Impact of corona virus disease 2019 pandemic on paediatric surgery in a sub-saharan tertiary hospital: An observational study. Niger Postgrad Med J [serial online] 2022 [cited 2022 Aug 10];29:102-9. Available from: https://www.npmj.org/text.asp?2022/29/2/102/343740
| Introduction|| |
The coronavirus disease 2019 (COVID-19) pandemic has resulted in global disruptions across all spheres affecting the health, socioeconomic, educational, security and political sectors among others. While the short-term implications are becoming evident, the long-term consequences are yet to be determined.
The pandemic has brought an unprecedented strain on the health-care delivery system and on the population seeking care. These effects are highly pronounced in low- and middle-income countries (LMICs) who already have fragile health-care systems. Multiple waves of the pandemic have been experienced in Nigeria and globally and the recent emergence of the Omicron strain of the virus has sparked new concerns with reinstitution of measures targeted at limiting its spread. How successful these measures will be and the compounding effects on already strained health systems in LMICs is yet unknown. Health-care workers are at particular risk with several contracting the COVID-19 infection, resulting in mortalities. By June 2020, more than 700 health workers had been infected in Nigeria while more than 100 health workers at the Lagos University Teaching Hospital have been infected. Difficulties with implementing social distancing guidelines necessitated cancellation of physical out-patient clinics in several hospitals., The risk of contracting the virus during surgeries and other procedures like endoscopies led to recommendations by several surgical specialities for the postponement of elective surgical cases., However, it has been estimated that more than 50% of all elective cases in adults and children have a potential to inflict significant harm on patients if cancelled or delayed. In settings where patients often present late, the effects of these cancellations will be more pronounced. Lockdowns instituted during the peaks of the pandemic resulted in difficulties with the transportation of patients to facilities where they can receive adequate healthcare. There was also the fear of contracting the COVID-19 infection while seeking care, especially at centres managing COVID-19 patients. In March 2021, Nigeria received nearly 4 million doses of the COVID 19 vaccines, and the vaccination exercise commenced. Eight months later, only 1.66% of the population had been fully vaccinated and 1.33% partly vaccinated.
Although the actual burden of paediatric surgical diseases in Nigeria is unknown, children constitute about half of the estimated population of over 200 million inhabitants. One report has shown that approximately 85% of children will have a surgically treatable condition by the age of 15 years. The COVID-19 pandemic has disrupted paediatric surgical care in Nigeria with likely impacts on service delivery, training and research. The extent and consequence of this disruption have not been adequately quantified. The aim of this study, therefore, is to evaluate the impact of the COVID-19 pandemic on the delivery of paediatric surgical service, training and research as well as on patients' access to paediatric surgical care.
| Methods|| |
Lagos is a cosmopolitan state in western Nigeria with a population of over 20 million people nearly half of which are children. The COVID-19 pandemic prompted the institution of a gradual lockdown within Lagos state from the 23 March, 2020. This led to a total lockdown with a gradual easing of the lockdown from August 2020. Lagos University Teaching Hospital (LUTH) is a 776-bed hospital catering for both adult and paediatric patients within the state and from its environs. LUTH has an established paediatric surgical unit offering neonatal surgery, general paediatric surgical, paediatric urology, hepatobiliary, colorectal, thoracic and laparoscopic services to children living within Lagos and its environs.
Using a structured pro forma, the impact of the pandemic on paediatric surgery in LUTH was evaluated. Information was obtained from the theatre and clinic logs/registers, the patients' medical records, through parents and guardian interviews, using survey monkey and through a review of the unit's statutory training and research activities.
Evaluation of impact on service delivery and patients
The number of clinics that took place and weekly patient attendance at clinics in the first 11 weeks of 2020 was used to estimate the number of new and follow-up cases likely affected by the cancellation of clinics during the first 3 months of COVID-19 lockdown. Data were also collected during the lockdown on the number of cancelled elective surgeries, number of emergency cases presenting at the paediatric emergency room that could not receive surgical care, changes to routine protocol of patient care, the extra cost of surgical care directly related to the pandemic and delays in access to care using the World Health Organisation 3-delay framework.
Evaluation of effect on training and research
To evaluate training, reduction in number and spectrum of cases operated by the paediatric surgery resident and cancelled academic activities were assessed. Data on the number of research activities stalled by the pandemic were documented.
Evaluation of impact on workforce
This was done by analysing the reduction in staff strength and staff COVID-19 exposure and positivity rate.
Fear of corona virus disease 2019
Fear of COVID-19 among the workforce and the parent/guardian of the patients was also assessed using a validated tool.
Primary outcome measures were the proportion of patients with no access and delayed access to care, the proportion of surgeries done and assisted by the trainee and the percentage of research and academic activities suspended. Secondary outcome measures were staff exposure and positivity rate and fear of COVID-19 score and additional expenditure by families.
Ethical approval was obtained from the Health Research and Ethics Committee of LUTH.
Data were analysed using the IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp. IBM Corp. Released 2013, P < 0.05 was statistically significant.
| Results|| |
The paediatric surgery outpatient clinic takes place once a week on Mondays. Before the lockdown, there were 11 outpatient clinics in 11 weeks with an average of 6 new patients and 49 follow-up cases weekly. Based on these figures, an estimated 78 new cases and 637 follow-up cases could not access needed care.
Major elective paediatric surgeries are carried out every Thursday and minor elective surgeries on Wednesdays except on public holidays. Twenty-four elective surgery lists were cancelled resulting in the postponement of 97 elective surgeries for 91 patients [Table 1]. Eighty-two (90.1%) parents of patients with cancelled surgeries responded to phone call enquiry about the health status of their children. Two (2.2%) patients had progression of their symptoms. One of the patients with Hirschsprung disease developed worsening constipation while a 2nd Hirschsprung's disease patient on colostomy had worsening colostomy prolapse. No patient had sought care at another health-care facility during the period.
|Table 1: Comparing frequency and type of postponed elective surgeries between 23 March 2020 and 30 June 2020 (lockdown period) to performed elective surgeries from 23 March 2019 to 30 June 2019|
Click here to view
There were 35 emergency surgeries over 11 weeks before the lockdown with a range of 1–5 surgeries per week (median 3). During the lockdown, weekly emergency surgeries ranged between 0 and 6 per week with a total of 42 surgeries and a median of 3 [Figure 1]. No new patient presented to the hospital with an emergency surgical condition the week total lockdown was commenced. All emergency surgeries done that week were for patients already on admission. No patient previously scheduled for elective surgery presented as an emergency. As patients were not routinely tested for COVID-19 infection, the status of those who had emergency surgery could not be ascertained.
|Figure 1: Number of emergency surgeries per week before and during lockdown|
Click here to view
All patients with emergency paediatric surgical conditions that presented at the children's emergency room were admitted and managed by the unit. There was no statistically significant difference in the number of emergency surgeries pre-lockdown and during lockdown (P = 0.899) [Table 2]. The perioperative mortality rate following emergency surgery during the pre-lockdown period was 20% and 30% during the lockdown period.
Changes to the protocol of care
The only change to patients' protocol of care was the suspension of all laparoscopic procedures. During the lockdown period, three patients with acute appendicitis who would have had laparoscopic appendectomy were offered open appendectomy.
Extra cost of care to patients from procurement of personal protective equipment
All the patients that presented for emergency surgery during the lockdown lacked health insurance resulting in out-of-pocket expenditure for all health care received. Additional cost from the purchase of personal protective equipment (PPE) was between $52.80 and $333.33 (average $123.98) per patient. The overall health insurance status of patients did not differ from the pre-COVID era.
Timeliness of care
Data on the timeliness of care were available for 15 (35.7%) patients that presented at the emergency room for paediatric surgical care [Figure 2]. Only 1 (6.6%) patient had no delay in seeking, reaching or receiving care. Six patients (40%) experienced delay in seeking care. This was due to the lockdown (1, 16.0%), fear of COVID-19 (1, 17.0%), financial constraints (1, 17.0%), initial home treatment (1, 17.0%) and ignorance (2, 33%) [Figure 3]. Eleven (73.3%) patients experienced delay in reaching an adequate care facility. Six (55.0%) had delayed referral from a private hospital, 2 (18.0%) were delayed by the lockdown, 2 (18.0%) had delayed referral from a general hospital and 1 (9.0%) was delayed by the fear of COVID-19 [Figure 4]. Eleven patients (73.3%) experienced delay in receiving care. Four (37.0%) due to financial constraints, 4 (36.0%) due to electrolyte derangements, 1 (9.0%) due to diagnostic dilemma, 1 (9.0%) due to lack of PPE and awaiting the result of COVID screening and 1 (9.0%) due to lack of theatre space [Figure 5].
|Figure 2: Percentage of patients who experienced delays in accessing care|
Click here to view
|Figure 5: Reasons for delay in receiving definitive care at adequate care facility|
Click here to view
Of the paediatric surgical team, there were 14 doctors actively involved in patient care and 13 nurses. While nurses missed work due to lack of transportation during the lockdown all the doctors were available during the lockdown.
Before the lockdown, there were 3 nursing shifts every 24 h with 2–3 nurses on the morning shift and 2 nurses each on the afternoon and night shifts. During the lockdown, there were only 2 shifts with a single nurse manning each shift.
Three doctors were exposed to COVID-19 positive patients on the paediatric medical ward and 2 eventually tested positive to the virus. Both recovered fully and returned to work. Two nurses were exposed to a confirmed COVID-positive doctor of which one eventually tested positive, recovered fully and returned to work.
Fear of corona virus disease 2019 score
Using the fear of COVID-19 scale, the fear of COVID-19 score for 9 paediatric surgery interns and resident doctors ranged from 13 to 29 (mean ± standard deviation [SD], 17.4 ± 5.6), for 13 nurses ranged from 12 to 32 (mean ± SD, 20.2 ± 5.5), for 5 consultant paediatric surgeons 9–19 (mean ± SD, 12.8 ± 4.0) and 9 parents/guardian of paediatric surgery patients 8–35 (mean ± SD, 17 ± 8.6) [Table 3], [Table 4], [Table 5]. The highest mean score was among nurses with consultants having the lowest mean score. There was however no statistically significant difference between the mean scores of the various groups (P = 0.192).
|Table 3: Comparison of the fear of corona virus disease 2019 mean scores|
Click here to view
|Table 4: Comparison of categorised fear of corona virus disease 2019 scores|
Click here to view
|Table 5: Pairwise comparison of difference of fear of corona virus disease 2019 mean scores (Tukey HSD)|
Click here to view
Evaluation of the surgeries participated in by the paediatric surgery resident before and during the lockdown showed a significant reduction in the number of elective surgical procedures due to the cancellation of electives. Minor elective surgical procedures such as herniotomy, orchidopexy, full-thickness rectal biopsy and major electives like urethroplasty, PSARP and Pull through were not performed. Emergency herniotomies were done during the lockdown period. There was a 58.8% reduction in the number of emergency exploratory laparotomies, stoma formations and appendectomies.
Clinical and academic meetings
Academic meetings in the unit include weekly seminars, weekly radiology conferences, weekly clinical reviews of emergencies and surgeries performed, monthly morbidity and mortality meeting and monthly journal clubs. All these activities were suspended following the institution of the lockdown and suspension of clinical meetings. Online zoom meetings commenced on the 22nd of June (after 3 months) with the weekly clinical review. Subsequently, all other meetings have been recommenced on the zoom platform. Challenges of the online platform include poor Internet connectivity and lack of institutional Internet service.
Two dissertations (1 in paediatric surgery and 1 in anaesthesia) and 3 ongoing research on laparoscopic appendectomy, day case surgery and surgical site infection were all hampered by the pandemic due to postponement of elective surgeries. During the lockdown period, the institutional ethics office, suspended review of research unrelated to the COVID-19 pandemic. No new non-COVID-19 research was instituted in the unit.
| Discussion|| |
The coronavirus disease 2019 (COVID-19) is a communicable respiratory disease caused by a new strain of coronavirus. COVID-19 was first reported in China but has now resulted in a worldwide pandemic. With multiple waves of the pandemic, ongoing mutations of the virus and the emergence of poorly understood strains, the pandemic still poses a huge challenge worldwide. By 5 December 2021, there were 8,737,269 confirmed cases in Africa with 223,967 deaths while by 6 December 2021, Nigeria had 214,622 confirmed cases and 2980 reported deaths., Nigeria's health care system still battles testing challenges, inadequate PPEs, ongoing need for human resources, drugs, beds, ventilators and other hospital consumables and equipment.
A survey of the early impact of the pandemic on paediatric surgical practice in Nigeria showed that majority of the centres had inadequate PPEs, had stopped elective surgeries with an acute decline in emergency surgeries, and there was no strategy for handling the increasing backlog of patients. While the immediate effect of the pandemic on patient care, health-seeking behaviour and overall well-being of health-care professionals may be determined without much difficulty, the long-term impacts are yet to be seen. It is important to note the negative impact of the measures instituted to prevent its spread.
The commencement of a lockdown led to a scaling down of service delivery within the hospital. Clinics and elective surgeries were temporarily suspended. The paediatric surgery unit stopped all physical meetings (clinical and academic) and discontinued minimal access surgery. These measures which were put in place to stem the spread of the virus within the hospital impacted several aspects of paediatric surgery. The effect between 23 March, 2020 and 30 June, 2020 was evaluated.
Impact on services and patients
An estimated 1.7 billion children and adolescents worldwide lacked access to surgical care in 2017. This occurred overwhelmingly in LMICs. The closure of the surgical out-patient clinics and suspension of elective surgeries leading to delayed access to care, worsened this already existing poor access to surgical care for children [Table 1] and [Table 6]. Delayed access to surgical care invariably results in worse patient outcomes, increased morbidity and mortality and increases surgical backlog and reduces averted DALYs with an ultimate increase in the burden of untreated surgical disease. This has important implications for achieving universal health coverage and sustainable development goals. Although, emergency surgical services were continually offered during the lockdown period no new patient presented to the hospital with an emergency surgical condition the week total lockdown was commenced. All emergency surgeries done that week were for patients already on admission. While the outcome of patients that would normally have presented is unknown, it may well have been worse as most of the first level hospitals do not have the capacity to manage pediatric surgical cases and most families cannot afford good quality private health care. A recent survey showed that it may take up to 2 years to work through the current surgical backlog in the United States. Such estimates are not available for LMICs. Comparing the number of postponed planned surgeries during the lockdown and the performed surgeries during the same period in 2019 showed that performed surgeries are <50% of planned surgeries [Table 1]. While this is not directly related to the pandemic, it reveals the existing state of the waiting list which is being markedly exacerbated by the measures instituted to limit the spread of the pandemic.
|Table 6: Pre-lockdown clinic attendance from 6 January2020 to 16 March 2020|
Click here to view
An understanding of the properties of the SARS-CoV-2 is still evolving several months after the onset of the pandemic with reports of emerging new variants. Since viruses had been detected in aerosols generated during procedures it was recommended that laparoscopic surgeries be suspended except when absolutely essential for urgent and emergency cases where specific guidelines were elaborated. Suspension of laparoscopic surgeries in the hospital implies that patients were denied the opportunity of benefitting from the advantages of laparoscopy with a longer duration of hospitalisation and increased post-operative pain. Increased length of hospital stay ultimately increases the health expenditure and this has important implications for patients paying for health care out-of-pocket.
According to the 2018 Nigeria Demographic and Health Survey (2018), about 97% of Nigerians do not use health insurance, relying on out-of-pocket payments for healthcare. A study showed that all families with children presenting at a tertiary hospital in Nigeria for treatment of typhoid intestinal perforation were at risk of catastrophic health expenditure from the cost of surgery alone. Extra payment for PPE required for surgical care of patients, increases financial burden and tendency towards impoverishing expenditure in a country where more than 50% of the population are multidimensionally poor. The effect of the pandemic was evident in all 3 aspects of the 3 delays framework, thereby having a direct impact by limiting access to much needed surgical care.
Impact on training and research
The reduction in case numbers for trainees and a suspension of academic meetings stalled the progress of post-graduate surgical training. The eventual postponement of the post-graduate examinations prevented those who had completed their junior residency training programmes from commencing their specialist training and those who had completed their training from exiting the training programme. While this reduces the paediatric surgical specialist workforce, it also reduces the available training slots. In the US, reduction in case numbers prompted the American Board of Surgery to reduce case number requirements so trainees can achieve board eligibility. In Nigeria, requirements for trainees were not revised. This implies that there may be the prolongation of the training period for current residents in training.
The zoom online meeting platform has been invaluable for continuing training activities, there are however challenges of poor Internet connectivity and lack of institutional Internet service.
Research remains the keystone for advancement in medicine and surgery and is the backbone for the development of surgery with clinical research significantly improving patient outcomes., Paediatric surgical research plays a vital role in the advancement of universal health coverage for children. However, most research is conducted in high-income countries. The distinct clinical needs and financial constraints in LMICs imply that research findings in HICs cannot always be directly extrapolated to LMICs. This further emphasizes the need for locally contextualised research in LMICs. The pandemic resulted in a lot of interest and emphasis on corona virus-related research. The postponement of patient-centred surgical research however is a significant limitation in efforts to increase research and develop research capacity in this region.
Impact on workforce
There is an ongoing surgical workforce crisis globally with a critical impact on paediatric surgery. Among the paediatric surgical team members in the hospital, nurses were most affected during the lockdown with a reduction in number of shifts per day and number of nurses per shift. While good quality nursing care is vital to the care of children with surgical needs, nurses in LMICs are known to be often too overworked to provide quality care. Inadequate nursing levels invariably lead to increased mortality and prolongation of hospital stay. This may be responsible for the apparent increase in emergency perioperative mortality rate seen during the lockdown period.
The fear of COVID-19 score varied widely between members of the paediatric surgical team and parents and guardian of patients. The lack of any statistically significant difference between the mean scores of the various groups evaluated suggests that the psychological impact was universal. The impact on the functionality of various team members at work was however not specifically evaluated.
This a single institution study with a limited number of patients and paediatric surgical team members thereby giving only a limited overview of the impact of the pandemic.
| Conclusion|| |
The COVID-19 pandemic has had an unprecedented impact on healthcare delivery with highly significant detrimental effects on nearly all aspects of pediatric surgical care and delivery in this region. There is an urgent need for developing and implementing sustainable solutions that will allow for a more resilient children surgical system. Nigeria has 20 Federal teaching hospitals offering paediatric surgical services. In addition, there are state teaching hospitals, federal medical centres and general hospitals where paediatric surgical services are offered. A nationwide impact evaluation will give a more wholesome comprehension of the effects of the pandemic on paediatric surgical care. This will allow for a more centrally coordinated approach in developing and implementing solutions to mitigate the impact of this pandemic and subsequent similar occurrences.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
The Lancet. COVID-19: Protecting health-care workers. Lancet 2020;395:922.
Stahel PF. How to risk-stratify elective surgery during the COVID-19 pandemic? Patient Saf Surg 2020;14:8.
Mogaji E. Impact of COVID-19 on transportation in Lagos, Nigeria. Transp Res Interdiscip Perspect 2020;6:100154.
Ritchie H, Mathieu E, Rodés-Guirao L, Appel C, Giattino C, Ortiz-Ospina E, et al
. Coronavirus Pandemic (COVID-19). Our World Data; March 05, 2020. Available from: https://ourworldindata.org/covid-vaccinations
. [Last accessed on 2021 Dec 01].
Bickler SW, Telfer ML, Sanno-Duanda B. Need for paediatric surgery care in an urban area of The Gambia. Trop Doct 2003;33:91-4.
Ogundele IO, Alakaloko FM, Nwokoro CC, Ameh EA. Early impact of COVID-19 pandemic on paediatric surgical practice in Nigeria: A national survey of paediatric surgeons. BMJ Paediatr Open 2020;4:e000732.
Mullapudi B, Grabski D, Ameh E, Ozgediz D, Thangarajah H, Kling K, et al.
Estimates of number of children and adolescents without access to surgical care. Bull World Health Organ 2019;97:254-8.
Juran S, Broer PN, Klug SJ, Snow RC, Okiro EA, Ouma PO, et al.
Geospatial mapping of access to timely essential surgery in sub-Saharan Africa. BMJ Glob Health 2018;3:e000875.
Angioni S. Laparoscopy in the coronavirus disease 2019 (COVID-19) era. Gynecol Surg 2020;17:3.
Agha R, Muir G. Does laparoscopic surgery spell the end of the open surgeon? J R Soc Med 2003;96:544-6.
Seyi-Olajide JO, Anderson J, Enivwaene AO, Ibrahim SH, Farmer D, Ameh EA. Catastrophic healthcare expenditure from typhoid perforation in children in Nigeria. Surg Infect (Larchmt) 2020;21:586-91.
Fu SJ, George EL, Maggio PM, Hawn M, Nazerali R. The consequences of delaying elective surgery: Surgical perspective. Ann Surg 2020;272:e79-80.
Toledo-Pereyra LH. Importance of medical and surgical research. J Invest Surg 2009;22:325-6.
Medeiros AC, Medeiros AC. Research in surgery. Rev Colégio Bras Cir 2016;43:407-9.
National Institute for Health Research Global Health Research Unit on Global Surgery. Prioritizing research for patients requiring surgery in low- and middle-income countries. Br J Surg 2019;106:e113-20.
Day S, Hollis R, Challinor J, Bevilacqua G, Bosomprah E;
SIOP PODC Nursing Working Group. Baseline standards for paediatric oncology nursing care in low to middle income countries: Position statement of the SIOP PODC Nursing Working Group. Lancet Oncol 2014;15:681-2.
Haegdorens F, Van Bogaert P, De Meester K, Monsieurs KG. The impact of nurse staffing levels and nurse's education on patient mortality in medical and surgical wards: An observational multicentre study. BMC Health Serv Res 2019;19:864.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]