By Author
  By Title
  By Keywords

February 2019, Volume 69, Issue 1

Research Article

Geospatial mapping of patients presenting for Emergency Laparotomy to a Private Sector Tertiary Care Hospital in Pakistan

Authors: Muhammad Sohaib Khan  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )
Syed Arish Haider  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )
Areeb Ashfaq  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )
Sadaf Khan  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )
Amir Hafeez Shariff  ( Department of Surgery, Aga Khan University, Karachi, Pakistan )


Methods: The cross-sectional study was conducted at Aga Khan University Hospital, Karachi, from July 1, 2015, to June 30, 2018, and comprised patients who underwent emergency laparotomy. Demographic characteristics of all patients were recorded. Google Maps was used to measure the distance from their home locality to the hospital.
Results: Of the 259 patients, 184(71%) presented from within the city and 75(29%) were from outside. The overall mean age was 50±20.2 years. The most common diagnosis was bowel obstruction 121(46.7%) followed by bowel perforation 112(43.2%). Of the total, 25(9.7%) patients died The median distance travelled by patients from outside the city was significantly greater than for patients from within the city (p<0.001).
Conclusions: Data on where patients are presenting from to an institution is critical for life-saving surgical procedures.
Keywords: Global surgery, Geospatial mapping, Emergency laparotomy. (JPMA 69: S-37; 2019)


The global burden of surgical disease is enormous, but still it is inadequately described and quantified. According to estimates, just four surgical conditions requiring emergency laparotomy result in 7.1 deaths per 100,000 population per year globally.1 Emergency laparotomy is one of the three Bellwether procedures, which together reflect a hospital\'s capacity to perform 44 essential surgeries.2 Under the umbrella of Global Surgery (GS) and the Lancet Commission, it is aimed that by the year 2030, 80% of the world\'s population will have access within 2 hours to facilities with the capacity of providing essential surgical care. A specialist surgical work force density of 20 per 100,000 population is another goal.3 Even though estimates suggest that 84% of the Pakistani population is at a 2-hour driving distance to hospital staffed with a surgeon, there is just 1 surgeon for 139,299 individuals.4 The surgical capacity andsafety of healthcare centres  across Pakistan has been frequently assessed as being dismal.5,6 In pursuit of safe and effective surgical care, the health-seeking behaviour of patients requiring emergency laparotomy has not been studied. Our hospital is one of the prime centres of the country and one of the only few that has acquired international accreditations over the years. The current study was planned to geospatially map the addresses of patients who underwent emergency laparotomies. The hypothesis was that the hospital receives patients from all across the country for emergency general surgical conditions.

Subjects and Methods

The cross-sectional study was conducted at Aga Khan University Hospital (AKUH), Karachi, from July 1, 2015, to June 30, 2018, and comprised patients who underwent emergency laparotomy. All adult patients aged 16 and above were included. After approval was obtained from the institutional ethics review board, hospital-based
software was used to identify patients and to retrieve records. Patients\' age, gender and addresses were recorded. Based on the addresses, two groups were formed, Within the City (WC) or Out of City (OC). Operative diagnoses were divided into categories; gastro-intestinal (GI) obstruction, perforation, bleeding, ischaemia, and other miscellaneous conditions. The outcomes of the patients were recorded as either being discharged, expired or having left against medical advice. Google Maps was used to measure the distance between AKUH and the patient\'s address. Normally and non-normally distributed continuous variables were recorded as mean±standard deviation (SD) and median±inter-quartile range (IQR) respectively. Categorical variables were recorded as frequencies and percentages. To test for statistical significance of difference between the two groups, chi-square test was used for
categorical variables, independent sample t-test for normally distributed continuous variables and Mann Whitney U Test for non-normally distributed continous variables. The distance from the addresses to the hospital was plotted on Google Maps for better visualisation (Figures 1-2).



Of the 259 patients, 184(71%) were in te WC group, while 75(29%) were from the OC group. The overall mean age was 50±20.2 years. The most common diagnosis was bowel obstruction 121(46.7%) followed by bowel perforation 112(43.2%). Of the total, 25)9.7%) patients died The two groups were similar in their age, gender distribution and diagnoses. The median distance travelled by patients in the OC group was significantly greater thanfor patients in the WC group (p<0.001]. Mortality in the
OC group was proportionately greater than the WC group  but the difference was not statistically significant (p=0.08) (Table).


The study results show that for conditions requiring emergency laparotomy at our hospital, patients travelled very long distances from all across the country and the city. This raises a number of important questions with regards to the access, quality and safety of available surgical care facilities and health-seeking behaviour of patients. In this study, compared to WC patients, proportionately more OC patients died. Even though the difference was not statistically significant, delay in surgical intervention is proven to be an important determinant of mortality in emergency general surgery.7 In the event of delays in definitive care, the outcomes of emergency laparotomy become grimmer.7 In-patient delay in surgery of more than 24 hours is one of the 6 indicators tha together are the best predictors of mortality in perforated peptic ulcer.8 The odds of survival decrease by 2.4% each hour from admission to surgery in patients with perforated peptic ulcer.9 However, most of these studies cited here focussed on in-hospital delays. Factors associated with pre-hospital delays in patients requiring emergency laparotomy and their impact on outcomes have not been well-studied. Even in developed health systems of the West, patients with perforated peptic ulcers are less likely to receive ambulance transportation compared to other emergency conditions.10 Of the various factors that may have determined our patients\' decision to travel long distances, arguably the most important is lack of access to care in their vicinities. Globally, 5 billion people are reported to lack access to safe and essential surgical care.11 Pakistan is a densely populated country of over 200 million. The healthcare needs of this huge population are largely met by the private sector, with over 70% of the population making out-of-pocket payments for their healthcare needs.12 Only 21% population has access to healthcare from publicsector hospitals.12 The possible reasons for this may be a severe shortage of surgical care providers in district-level hospitals that was reported in a survey of 19 hospitals conducted in 1983.5 This shortage still exists, and it is estimated that there is 1 surgeon for 139,299 Pakistanis.4 Recent data regarding the availability of surgical care is lacking.
Certain procedure-specific surveys do shed light on the present state of facilities at these hospitals. The availability of signal functions of Emergency Obstetric and Newborn Care (EO&NC) was observed at only 7 out of 32 health care facilities in four districts of the province of Punjab that were surveyed in 2012.6 Of interest are the distances travelled by patients within Karachi which is the largest metropolis of Pakistan and is one of the most populous cities in the world. With the prevalent traffic conditions and state of the roads, even travelling relatively shorter distances may mean a disproportionate length of time spent in reaching the hospital. Couple this with the fact that the ambulance services are stretched thin, most patients will arrive at the  hospital via private or public transport, thus incurring further delays. A number of patient-related, environmental, health systems and provider related variables have been identified as being barriers for patients in accessing surgical and pregnancy-related care in Pakistan.13,14 The preference for males and male children over females, and young over the elderly, illiteracy, lack of awareness and presence of untrained and alternative healers have been reported to negatively influence access to surgical care.13 The role of husbands and mothers in-law in seeking maternal healthcare is reported to be very significant.14 Within maternal health, inequalities exist between the rich and the poor and between rural and urban mothers.15 Financial well-being, education and presence in cities are associated with an increased likelihood of having caesarean section.15 Caesarean section rates are reportd to be 5.3% in the poorest compared to 35.3% amongst the richest women, and 11.5% in rural compared to 25.6% in urban women.15 The current study has its limitations. While it has reported the geographical location of patients, it does not account for the burden of disease. It is a single-centre study and thus results cannot be generalised. Moreover, it does not describe the impact geographical location and longdistance travel has on the disease severity and on the outcomes of surgical intervention. However, the study has raised important questions with regards to patients\' access to emergency laparotomy. Further prospective and population-based studies are needed to understand the factors influencing accessibility to emergency general surgery and to better elucidate the health-seeking behaviour of our population.


Data on where patients are presenting from to an institution is critical for life-saving surgical procedures. The impact that time to presentation has on the outcomes of emergency laparotomy, however, needs to be explored further.

Disclaimer: None.
Conflict of Interest: None.
Source of Funding: None.


1. Stewart B, Khanduri P, McCord C, Ohene-Yeboah M, Uranues S, Vega Rivera F, et al. Global disease burden of conditions requiring emergency surgery. Br J Surg 2014;101:e9-22. doi: 10.1002/bjs.9329.
2. O\'Neill KM, Greenberg SL, Cherian M, Gillies RD, Daniels KM, Roy N, et al. Bellwether procedures for monitoring and planning essential surgical care in low- and middle-income countries: caesarean delivery, laparotomy, and treatment of open fractures. World J Surg 2016;40:2611-9.
3. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624.
4. Raykar NP, Bowder AN, Liu C, Vega M, Kim JH, Boye G, et al. Geospatial mapping to estimate timely access to surgical care in nine low-income and middle-income countries. Lancet 2015;385 Suppl 2: S16. doi: 10. 1016/S0140-6736(15)60811-X.
5. Blanchard RJ, Blanchard ME, Toussignant P, Ahmed M, Smythe CM. The epidemiology and spectrum of surgical care in district hospitals of Pakistan. Am J Public Health 1987;77:1439-45.
6. Utz B, Zafar S, Arshad N, Kana T, Gopalakrishnan S, van den Broek N. Status of emergency obstetric care in four districts of Punjab, Pakistan - results of a baseline assessment. J Pak Med Assoc 2015;65:480-5.
7. Sharoky CE, Bailey EA, Sellers MM, Kaufman EJ, Sinnamon AJ, Wirtalla CJ, et al. Outcomes of hospitalized patients undergoing emergency general surgery remote from admission. Surgery 2017;162:612-9.
8. Thorsen K, Søreide JA, Søreide K. What is the best predictor of mortality in perforated peptic ulcer disease? A population-based, multivariable regression analysis including three clinical scoring systems. J Gastrointest Surg 2014;18:1261-8.
9. Buck DL, Vester-Andersen M, Møller MH; Danish Clinical Register of Emergency Surgery. Surgical delay is a critical determinant of survival in perforated peptic ulcer. Br J Surg 2013;100:1045-9.
10. Bonnesen K, Friesgaard KD, Boetker MT, Nikolajsen L. Prehospital triage of patients diagnosed with perforated peptic ulcer or peptic ulcer bleeding: an observational study of patients calling 1-1-2. Scand J Trauma Resusc Emerg Med 2018;26:25. doi: 10.1186/s13049- 018-0494-1.
11. Alkire BC, Raykar NP, Shrime MG, Weiser TG, Bickler SW, Rose JA, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015;3:e316-23. doi: 10.1016/S2214-109X(15)70115-4.
12. Nishtar S, Boerma T, Amjad S, Alam AY, Khalid F, ul Haq I, et al. Pakistan\'s health system: performance and prospects after the 18th Constitutional Amendment. Lancet 2013;381:2193-206.
13. Irfan FB, Irfan BB, Spiegel DA. Barriers to accessing surgical care in
Pakistan: healthcare barrier model and quantitative systematic review. J Surg Res 2012;176:84-94.
14. Qureshi RN, Sheikh S, Khowaja AR, Hoodbhoy Z, Zaidi S, Sawchuck D, et al. Health care seeking behaviors in pregnancy in rural Sindh, Pakistan: a qualitative study. Reprod Health 2016;13 Suppl 1:34. doi: 10.1186/s12978-016-0140-1.
15. Mumtaz S, Bahk J, Khang YH. Rising trends and inequalities in cesarean section rates in Pakistan: evidence from Pakistan Demographic and Health Surveys, 1990-2013. PLoS One 2017 ;12:e01865 63. doi: 10.137 1/journal.pone.01 86563.


Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: