Management outcome of intestinal obstruction done by integrated emergency surgical offi cers and its associated factors in selected district hospitals of South Wollo Zone, North East Ethiopia in 2019 G.C

Abbreviations: ASE: Abdominal Surgical Emergence. BLH: Black Lion Hospital; CAF: Chloramphenicol; CBC: Complete Blood Count; CV: Ceacal volvulus; IO: Intestinal obstruction; IESO: Integrated Emergence surgery offi cers; IV: Intravenous; LBO: Large Bowel Obstruction; NGT: Naso Gastric Tube; RA: Resection and Anastomosis; SBO: Small Bowel Obstruction; SBV: Small Bowel Volvulus; SIV: Small Intestinal Volvulus; SSI: Surgical Site Infection; WU: Wollo University


Introduction
Intestinal obstruction is the failure of propagation of intestinal contents, and may be due to a mechanical or functional pathology. Acute mechanical intestinal obstruction (IO) is one of the leading causes of surgical admissions in most emergency departments' worldwide and is a signi icant cause of morbidity and mortality, especially when associated with bowel gangrene or perforation [1,2].
Intestinal obstruction is one of the commonest abdominal surgical emergencies. When intestinal obstruction is not relieved in time, the patient may die hence; early diagnosis and prompt management are mandatory. The causes of intestinal obstruction are several and their relative incidence varies in different populations, between countries and has also changed over the decades. Several factors are described to be responsible for these differences. Socioeconomic factors and diet have mostly been incriminated to be responsible for the observed difference [3][4][5]. The leading causes of intestinal obstruction in Africans have mostly been hernia and volvulus whereas adhesions are most frequent in the developed world [6][7][8]10,11].
The plan of treatment is dependent on diagnosis and patient's condition at admission. Knowing common complications of intestinal obstruction and its outcome is important for care of the patients and prevention of complications [9].
Management of intestinal obstruction includes the correction of physiologic impairment, hypovolemia, and electrolytes depletion caused by obstruction. Mechanical IO can generally be relieved through conservative treatments like naso-gastric tube insertion, intravenous antibiotics, or intravenous luid resuscitation; with certain exceptions like peritonitis, tumor, and abdominal sepsis caused by complications of an obstructive syndrome (perforation, ischemia, necrosis) that necessitates for further surgical exploration [17,18].
Dif iculties in using the checklist, postoperative intraabdominal infections, the inadequacy of training, and insuf icient amount of anesthesiologists, nurses, and support staff were some of the challenges which lead to poor management outcomes [19][20][21][22].
Except few studies, in north and central Ethiopia [5,6] there are no adequate studies conducted on management outcome of intestinal obstruction and its associated factors. However up to researcher's knowledge there is no study conducted totally throughout in Ethiopia on management outcome of intestinal obstruction done by IESO (integrated emergency surgical of icers who are non-physician surgical of icers from nursing and other health professional origin) thus this study was aimed to assess intestinal obstruction management outcome done by IESO professionals and associated factors of surgically treated patient at South Wollo zone, Amhara Regional State, in 2019 G.C.

Study area and period
The study was conducted in South Wollo zone, South Wollo (Amharic: ደቡብ ወሎ) is one of 12 Zones in the Amhara Region of Ethiopia. It acquired its name from the former province of Wollo. South Wollo is bordered on the south by North Shewa and the Oromia Region, on the west by East Gojjam, on the northwest by South Gondar, on the north by North Wollo, on the northeast by Afar Region, and on the east by the Oromia Zone and the Argobba special woreda.  So the sample size was = 216

Sampling technique
All patients operated for intestinal obstruction during one year treated from January 01/2019 to December 31/2019 G.C and those have completed `information was selected by systematic random sampling technique, that means card numbers of the patients are obtained from log book of the operation room operated for IO during the study period. Retrieving patient cards from card room and conduct chart reviewing; and then charts with incomplete information was excluded (Table 1).

Dependent variable
 Management outcome of intestinal obstruction (favorable or unfavorable) Data collection procedures: The data was collected by four trained BSc nurse, using operation room registration book and retrieved patients' records by using structured and pre-tested questionnaire. Instrument/tool: Data was collected by using structured data collecting check list prepared and developed from different literatures for this purpose.

Data collectors` selection and training:
To maintain the quality of the data, training was given for two supervisors and four data collectors for three days by the principal investigator about the con identiality of the information and how to extract the data from cards and registered log-books as secondary data.

Data collection method
The data collection method was recorded by document review. Two year records were used from records of patients operated for intestinal obstruction. First, the card numbers was collected from operation room registration book to get the main iles of the patient in record room. Then, Socio-demographic characteristics, duration of symptoms, preoperative diagnosis, operative indings, surgical procedure done, length of hospital stay, and outcome of management was collected from the main ile.

Data quality management
The data was evaluated & checked for its completeness & consistency through pretest on data collection format. The supervisors & principal investigator performed immediate supervision on daily basis, & every completed questionnaire was checked for completeness & consistency. Finally, the completed data was cleaned before entering into SPSS version 20 by the principal investigator.

Data processing, analysis, interpretation and presentation
The collected data was cleaned, coded and analyzed by SPSS version 20 statistical package. First descriptive statics was done for categorical and analyzed using frequencies and percentage. Binary logistic regression analysis was done to see if there is any signi icant association between selected variables. Multiple logistic regression models was used to determine the association factors on the management outcome of intestinal obstruction the strength of statistical association was measured by adjusting odds ratio and 95% con idence interval. Statistical signi icance was taken at p -value < 0.05.

Ethical consideration
Data collection was started after the study was approved by the Institutional Ethics Review Committee of the College of Health Sciences of Wollo University and secured a permission letter from South Wollo zone. Con identiality of the records have maintained throughout the study period. Reports will not including names and identi iers of patient. Operation theater staffs were informed.

Operational defi nitions
Length of hospital stay in day: is the term to describe the duration of single episode of hospitalization. In patient days are calculated by subtracting the day of admission from the day of discharge.
Prolonged length of hospital stay: if the duration of time from admission to discharge is more than 8 days [12].
Management outcome: the condition of the patient after the procedure that means whether favorable or unfavorable.
Unfavorable management outcome: the condition of the patient after the procedure has been done that a patient develops postoperative complications or died in the hospital.
Favorable management outcome; the condition of the patient after the procedure has been done that a patient does not develops postoperative complications.

Dissemination plan
The results of the study was presented to Wollo University, College of medicine and health sciences, School of nursing and midwifery & it will also get shared to South Wollo zone and Amhara regional health bureau, Dessie Administrative Town health department. Efforts was made to present the results on scienti ic conferences and peer reviewed journal publications was considered.

Socio-demographic characteristics of respondents
Out of the total two hundred sixteen planned samples of patients of intestinal obstruction in four public hospitals of South Wollo zone, all of them were included in the study giving a response rate of 100 percent. The mean age of respondents was 45.5, out of the respondents 37% were within 35-55 age groups. From all respondents 62.5% were Farmers/house wives. Out of the total study participants with intestinal obstruction 93.1% of them were done by male IESO. From the total of the study subjects, 72.2% were lived in rural area. Out of the study participants 70.4% of them were Muslims.
From the study subjects 46.8% had managed by IESO of nursing background the rest 53.2% of them were managed by IESO with health of icer background. Out of all 42.6% of the respondents were managed by IESO of less than one year experience ( Table 2).

Clinical related factors for management outcome of Intestinal obstruction
The indings of this study had shown that from all respondents 68.1% were diagnosed with small bowel obstruction preoperatively. Out of the total study participants with intestinal obstruction 72.7% of them were managed by resection and anastomosis. From the total of the study subjects, 51.4% were come to hospital within 24 hours. From the study subjects 35.9% of them had hematoma as complication after surgery and 30.8% of them had surgical site infection. Out of all 48.7% of the respondents were complicated within 4 days of undergoing surgery (Table 3).  Overall management outcome of intestinal obstruction respondents in public hospitals of South Wollo Zone, September, 2020, Dessie, Ethiopia (n = 216) (Figure 1). From the total of 216 patients undergoing surgery of intestinal obstruction 177(82%) of them had Good surgical outcome and 39(18%) of them had poor surgical outcome.

Factor aff ecting management outcome of intestinal obstruction
Bi-variable analysis showed that there were signi icant association between management outcome of intestinal obstruction and sex, occupation, Back ground of IESO, Year of experience of IESO Workers, Sex of IESO, Age of IESO staff, preoperative diagnosis, intraoperative diagnosis, intraoperative management and Time of surgery. With multiple logistic analyses only year of experience of IESO Workers, preoperative diagnosis and time of surgery of the respondents maintain their signi icant association with management outcome of intestinal obstruction. Multivariable analysis revealed that there was statistical association between management outcome of intestinal obstruction and year of experience of IESO Workers. Study participants who were managed by 1-3 years of work experience of IESO were 7.2 times more likely to have good surgical outcome as compared with those who were managed by IESO of more than 3 years of work experience. {(p = 0.004, AOR (95% CI) = 7.2 [1.89, 27.68]}. Study subjects who were diagnosed as small bowel obstruction preoperatively were 4.5 times more likely to have good surgical outcome as compared with subjects who were diagnosed as large bowel obstruction preoperatively {(p = 0.001, AOR (95% CI) = 4.5 [1.91,10.40]. Study participants whose intestinal obstruction management were conducted at day time were 2.8 times more likely to have good surgical outcome as compared with subjects who had undergoing intestinal obstruction surgery during night time {(p = 0.03, AOR (95% CI) = 2.8[1.06,7.16]} (Table 4).

Discussion
This study was conducted with the intention to assess management outcome of intestinal obstruction and associated factors among patients with intestinal obstruction in public hospitals of south Wollo Zone hospitals. This study 82% 18%   From all study participants about 177 (82%) of them had good surgical outcome. This result was similar to the study conducted in Gonder, Ethiopia (83.3%), higher than study in Eastern Ethiopia (79.7%) and lower than study conducted in Dilla Ethiopia [14][15][16]. This might be due to difference in sample size, socio-economic status of population, health service coverage of countries and year of study conducted.

Management outcome of Intestinal obstruction
This study ascertained that there is statistical association between management outcome of intestinal obstruction with year of experience of IESO Workers, preoperative diagnosis and time of surgery of the respondents.
Study participants who were managed by 1-3 years of work experience of IESO were 7.2 times more likely to have good surgical outcome as compared with those who were managed by IESO of more than 3 years of work experience. {(p = 0.004, AOR (95% CI) = 7.2 [1.89, 27.68]}. This might be related to the fact that IESO professionals with medium working experience become less negligent and more careful to prevent surgical errors, which affects patient's surgical outcome positively. In other way, IESO professionals with higher working experience may face burnout leading to more negligent that leads to surgical errors that directly associated to unfavorable outcome.
Study subjects who were diagnosed as small bowel obstruction preoperatively were 4.5 times more likely to have good surgical outcome as compared with subjects who were diagnosed as large bowel obstruction preoperatively. This is almost similar study to another study conducted in Eastern Ethiopia which showed that pre-operative diagnosis of gangrenous LBO respectively were signi icantly associated with unfavorable outcome [16]. This might be due to the fact that patients with LBO have become more gangrenous due to gross distension of large bowel that leads to risk of bowel rupture which directly associated to hematoma, surgical site infection and peritonitis.
In this study there was statistical association between time of surgery and management outcome of intestinal obstruction. Study participants whose intestinal obstruction management was conducted at day time were 2.8 times more likely to have good surgical outcome as compared with subjects who had undergoing intestinal obstruction surgery during night time. This might be due to the fact that surgeries under gone at night time have risks of complication because of fatigue and burnout of IESO professionals, Nurses and anesthesia personnels.

Strength of study
 Four government hospitals were included to make the study representative since the surgical outcome of hospitals may be different.
 More data collectors were recruited and adequate training was given to keep quality of data collection.

Limitations of study
 Dif iculty of getting some variables since the data collection was through reviewing documents.
 Limitation of related literatures to compare and discuss some of the indings since this is new study that is only compared with surgical outcome of intestinal obstruction done by surgeon (physicians).
 Because the data are cross sectional, the direction of causal relationship between variables can't always be determining.

Conclusion
Majority patients with intestinal obstruction had good surgical outcome done by IESO professionals. Year of experience of IESO Workers, preoperative diagnosis and time of surgery of the respondents had shown positive association for the occurrence of chronic liver disease whereas. In this study we can conclude that surgeries of intestinal obstruction conducted by IESO professionals are as good as intestinal obstruction surgeries conducted by physicians.

Recommendation
 Ethiopian health minister and regional health of icials should advance training of more IESO professionals to deliver decentralized surgical service to rural areas.
 More research should be carried out to investigate the level of surgical outcome for intestinal obstruction conducted by IESO professionals in broader social context and larger sample size.
 All academic higher educational health institutions should produce more IESO professionals to overcome shortage of surgeon physicians in Ethiopia.
 All nurses and health of icers should show willingness to specialize by IESO.