Priorities for content for a short-course on postoperative care relevant for low- and middle-income countries: an e-Delphi process with training facilitators

Most surgical and anaesthetic mortality and morbidity occurs postoperatively, disproportionately affecting low- and middle-income countries. Various short courses have been developed to improve patient outcomes in low- and middle-income countries, but none specifically to address postoperative care and complications. We aimed to identify key features of a proposed short-course addressing this topic using a Delphi process with low- and middle-income country anaesthesia providers trained as short-course facilitators. An initial questionnaire was co-developed from literature review and exploratory workshops to include 108 potential course features. Features included content; teaching method; appropriate participants; and appropriate faculty. Over three Delphi rounds (panellists numbered 86, 64 and 35 in successive cycles), panellists indicated which features they considered most important. Responses were analysed by geographical regions: Africa, the Americas, south-east Asia and Western Pacific. Ultimately, panellists identified 60, 40 and 54 core features for the proposed course in each region, respectively. There were high levels of consensus within regions on what constituted core course content, but not between regions. All panellists preferred the small group workshop teaching method irrespective of region. All regions considered anaesthetists to be key facilitators, while all agreed that both anaesthetists and operating theatre nurses were key participants. The African and Americas regional panels recommended more multidisciplinary healthcare professionals for participant roles. Faculty from high-income countries were not considered high priority. Our study highlights variability between geographical regions as to which course features were perceived as most locally relevant, supporting regional adaptation of short-course design rather than a one-size-fits-all model.

Prospective, observational study of perioperative critical incidents, anaesthesia and mortality in elective paediatric surgical patients at a national referral hospital in Niger

Aims: To describe perioperative critical incidents, the conduct of anaesthesia and perioperative mortality in elective paediatric surgery patients in a national referral hospital in Niger.

Methods: This is a prospective, observational study conducted from January to March 2018. All paediatric patients 15 years an younger, who underwent elective surgery in the Niamey National Hospital were included. The following variables were studied: age, sex, type of surgery, American Society of Anesthesiologists physical status (ASA PS) classification, monitoring system, anaesthesia technique, critical incidents, blood transfusion, analgesia, qualification of the anaesthesia practitioner, postoperative destination and mortality. Data were analysed with Excel 2007 and Epi Info 6™ (Centers for Disease Control and Prevention Atlanta, GA). The chi2 test was used for univariate associations with critical incidents. Statistical significance was considered if p < 0.05. Results: There were 231 (27.2%) paediatric patients of 849 surgical patients during the study period. Within the paediatric group, the mean age was 6 ± 4 years. The male:female sex ratio was 1.65. A full blood count was completed preoperatively in all patients. Three per cent of the patients received a preoperative blood transfusion. The most frequently performed surgery was abdominal (42.4%). Most patients were classified as ASA PS I (55%) and ASA PS II (45%). General anaesthesia was performed in 96.1% of cases and spinal anaesthesia in 3.9%. The median duration of general anaesthesia was 63 (interquartile range 45–90) minutes. There were 27 reported critical incidents (11.7%), ten of which occurred during induction (4.9%), five intraoperatively (2.2%) and 12 postoperatively (5.2%). Multimodal postoperative analgesia was used in 33.8% of these patients. One patient died in the postoperative period (0.43%). Conclusion: Perioperative critical incidents in paediatric surgical patients in Niger remain high. To improve this situation requires paediatric training of anaesthetic staff, and improved paediatric monitoring and the use of safer anaesthesia agents.

The structure, function and implementation of an outcomes database at a Ugandan secondary hospital: the Mbarara Surgical Services Quality Assurance Database

The Mbarara Surgical Services Quality Assurance Database (Mbarara SQUAD) is an outcomes database of surgical, obstetric and anaesthetic/critical care at Mbarara Regional Referral Hospital, a secondary referral hospital in southwestern Uganda. The primary scope of SQUAD is the assessment of the outcomes of care. The primary outcome is mortality. The aim is to improve the quality of care, guide allocation of resources and provide a platform for research. The target population includes all inpatients admitted for treatment to the surgery service, the obstetrics and gynaecology services, and the intensive care unit (ICU). Data collection was initiated in 2013 and closed in 2018. Data were extracted from patient charts and hospital logbooks. The database has over 50 000 patient encounters, including over 20 000 obstetrics and gynaecology admissions, 15 000 surgical admissions and 16 000 otolaryngology outpatient visits. Entries are coded using the International Classification of Diseases, Tenth Revision (ICD-10) for diagnoses, and the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) for procedures. The completeness and accuracy of the data entry and the coding were validated. Governance of data use is by a local steering committee in Mbarara. The structure, function and implementation of this database may be relevant for similar hospital databases in low-income countries.

Paediatric anaesthesia care in Africa: challenges and opportunities

In 2015, the World Health Organization and member states recognised surgery and anaesthesia care as a component of universal health coverage, yet 1.7 billion children and adolescents continue to lack access to safe surgical care. An overwhelming proportion of these children are from low- and middle-income countries (LMICs).1,2 In Africa, where almost 50% of the population is under the age of 15, children are disproportionately affected. Without sustained global efforts, these inequities and injustices will persist.1 Findings from previous studies suggest a 10–100 times increase in paediatric perioperative mortality in children in LMICs as compared to high-income countries (HICs).3,4 While pieces of the puzzle may be missing, it is clear that not only is access a problem, but also the safety and quality of the perioperative care provided is of concern.

Perioperative registries in resource-limited settings: The way forward for Pakistan

Capable of improving surgical quality, perioperative registries can allow performance benchmarking, reliable reporting and the development of risk-prediction models. Well established in high-income countries, perioperative registries remain limited in lower- and middle-income countries due to several challenges. First, ensuring comprehensive data entry forums to power the registries is difficult because of limited electronic medical records requiring sustained efforts to develop and integrate these
into practice. Second, lack of adequate expertise and resources to develop and maintain registry software necessitates the involvement of software developers and information technology personnel. Third, case ascertainment and item completion are challenging secondary to poor-quality medical records and high lossto- follow-up rates, requiring telemedicine initiatives as an
adjunct to existing care for the assessment of postdischarge outcomes.

Surgical Capacity in Rural Southeast Nigeria: Barriers and New Opportunities

Background: Remarkable gains have been made in global health with respect to provision of essential and emergency surgical and anesthesia care. At the same time, little has been written about the state of surgical care, or the potential strategies for scale-up of surgical services in sub-Saharan Africa, southeast Nigeria inclusive.

Objective: The aim was to document the state of surgical care at district hospitals in southeast Nigeria.

Methods: We surveyed 13 district hospitals using the World Health Organization (WHO) tool for situational analysis developed by the “Lancet Commission on Global Surgery” initiative to assess surgical care in rural Southeast Nigeria. A systematic literature review of scientific literatures and policy documents was performed. Extraction was performed for all articles relating to the five National Surgical, Obstetric and Anesthesia Plans (NSOAPs) domains: infrastructure, service delivery, workforce, information management and financing.

Findings: Of the 13 facilities investigated, there were six private, four mission and three public hospitals. Though all the facilities were connected to the national power grid, all equally suffered electricity interruption ranging from 10–22 hours daily. Only 15.4% and 38.5% of the 13 hospitals had running water and blood bank services, respectively. Only two general surgeon and two orthopedic surgeons covered all the facilities. Though most of the general surgical procedures were performed in private and mission hospitals, the majority of the public hospitals had limited ability to do the same. Orthopedic procedures were practically non-existent in public hospitals. None of the facilities offered inhalational anesthetic technique. There was no designated record unit in 53.8% of facilities and 69.2% had no trained health record officer.

Conclusion: Important deficits were observed in infrastructure, service delivery, workforce and information management. There were indirect indices of gross inadequacies in financing as w

Harvard Medical School Department of Global Health and Social Medicine COVID-19 seminar series: COVID and surgical, anesthetic and obstetric care

On May 21, 2020, the Harvard Program in Global Surgery and Social Change (PGSSC) hosted a webinar as part of the Harvard Medical School Department of Global Health and Social Medicine’s COVID-19 webinar series. The goal of PGSSC’s virtual webinar was to share the experiences of surgical, anesthesia, and obstetric (SAO) providers on the frontlines of the COVID pandemic, from both high-income countries (HICs), such as the United States and the United Kingdom, as well as low- and middle-income countries (LMICs). Providers shared not only their experiences delivering SAO care during this global pandemic, but also solutions and innovations they and their colleagues developed to address these new challenges. Additionally, the seminar explored the relationship between surgery and health system strengthening and pandemic preparedness, and outlined the way forward, including a roadmap for prioritization and investment in surgical system strengthening. Throughout the discussion, other themes emerged as well, such as the definition of elective surgery and its implications during a persistent global pandemic, the safe and ethical reintroduction of surgical services, and the social inequities exposed by the stress placed on health systems by COVID-19. These proceedings document the perspectives shared by participants through their invited lectures as well as through the panel discussion at the end of the seminar.

Job Satisfaction and Its Determinants among Nurse Anesthetists in Clinical Practice: The Botswana Experience

Job satisfaction (JS) correlates positively with patients’ satisfaction and outcomes and employees’ well-being. In Botswana, the level of job satisfaction and its determinants among nurse anesthetists were not investigated. A cross-sectional study was conducted from January 2020 to June 2020 encompassing all nurse anesthetists in clinical practice in Botswana. A self-administered questionnaire was used that incorporated demographic data, reasons to stay on or leave their job, and a validated 20-item short form of the Minnesota Satisfaction Questionnaire which was pretested on five of our nurse anesthetists. Percentage is used to describe the data. The independence of categorical variables was examined using chi-square or Fisher’s exact test. value <0.05 was considered statistically significant. In Botswana, a total of 76 nurse anesthetists were in clinical practice during the study period. Sixty-six (86.9%) responded to the survey. Gender distribution was even, 50.0%. The overall JS was 36.4%. Males had significantly higher JS than females, . Significantly higher job satisfaction was found in married nurse anesthetists (), expatriate nurse anesthetists (), nurse anesthetists in non-referral hospitals (), and nurse anesthetists with ≥10 years’ experience (). Nurse anesthetists were satisfied with security, social service, authority, ability utilization, and responsibility in ≥60.0% of the cases. They were not satisfied in compensation, working condition, and advancement in a similar percentage. The main reason to stay on their job was to serve the public in 68.2%. In Botswana, employers should make an effort to address the working conditions, compensation, and advancement of nurse anesthetists in clinical practice.

ERAS Society Recommendations for Improving Perioperative Care in Low- and Middle-Income Countries Through Implementation of Existing Tools and Programs: An Urgent Need for the Surgical Safety Checklist and Enhanced Recovery After Surgery

The Lancet Commission and Global Surgery Foundation in 2015 highlighted the need for access to safe and affordable surgical and anesthetic care in low- and middle-income countries (LMICs) [1]. Patients that do have access to care in LMICs, however, have a higher risk of complications and mortality than in high-income countries (HICs). Ninety-six percent of all perioperative deaths worldwide occur in LMICs, and the economic impact of this is a staggering 2.6% of the combined gross domestic product of LMICs [1]. Although it is a common belief that the greatest contributors to adverse outcomes in LMICs are poor access to care and late presentation, deficits in the quality of accessible care are a substantial concern.

Following the Lancet Commission and the World Health Assembly Resolution 68.15, all member countries committed to developing a National, Surgical, Obstetric and Anaesthesia Plan (NSOAP) to assist in improving access to safe surgery and anesthesia [1]. The missing link in the NSOAP strategy is support for the implementation of standardized, evidence-based perioperative care guidelines and tools to measure guideline compliance and outcomes. This is crucial not only because of the need to improve perioperative care but as access to safe surgery and anesthesia improves, there is likely to be increased patient volume and pressure on the healthcare system to provide quality surgical care. A new set of tools need not be developed to improve perioperative care in LMICs. These tools already exist with evidence for their effectiveness. The Surgical Safety Checklist (SSC) and Enhanced Recovery After Surgery (ERAS) Program are two examples [2, 3]. Barriers to acceptance, adoption, and implementation of existing tools present the greatest hurdles that must be overcome to improve perioperative outcomes in LMICs.

The SSC is a communication tool used by the surgical team to confirm that appropriate actions are taken in the perioperative period to maintain patient safety. At the same time, the three pause points within the checklist include conversation prompts to ensure there is a shared understanding between the surgical team members. The SSC was designed to optimize its effectiveness in LMICs with a focus on influencing globally relevant outcomes using recommendations that are applicable and supported by the resources in LMICs. As a result, the use of the SSC has been shown to significantly reduce perioperative morbidity and mortality in LMICs as well as in HIC settings, and its impact may be larger when implemented well in LMICs [2].

Despite evidence of effectiveness, the acceptance and adoption of the SSC remain poor in LMICs with ranges between 20 and 40% when compared with facilities in HIC where rates of adoption range between 80 and 95% [4]. The reasons for this failed penetrance relate to a lack of resources and infrastructure for initial and ongoing implementation and audits and surgical hierarchies that may not support aspects of the SSC, such as encouraging all members of the team to vocalize concerns if they exist. The barriers to successful implementation are further exacerbated by checklist fatigue and similar factors that also lead to decreased meaningful use in HICs. The need for improved implementation of the SSC in LMICs has been recognized by global health organizations. With this increased focus on quality and safety initiatives and implementation, it is time to consider other strategies for improvement.

ERAS is another tool that has the potential to benefit LMICs with strategies that have demonstrated benefits across a variety of settings and clinical outcomes [3]. The ERAS program is based on implementation of evidence-based clinical practice guidelines performed by a multidisciplinary perioperative team, using tools to monitor and evaluate compliance to the guidelines and patient outcomes concurrently. Randomized trials of ERAS-based care vs traditional care conducted in HICs have shown a significant reduction in length of stay (20–40%) and complications (20–30%). Cost studies of ERAS have demonstrated a return-on-investment ratio up to 7.3 (i.e., a savings of $7.3 for every $1 invested), showing that ERAS is value-based surgery [3].

There are few established ERAS programs in LMICs, however, data from these centers demonstrate similar benefits to HICs [5]. Whether these benefits can be achieved at scale remains unknown, and the crux of the issue relates to how ERAS is applied in tertiary-university centers in LMICs compared to the district and regional levels. ERAS guidelines in their current format are specialty-specific, predominantly for elective procedures, and thus likely to be easily implemented in tertiary-university LMIC hospitals, which have similar subspecialty units. The implementation in these units will have the added benefit of facilitating the teaching and training of all perioperative team members.

The greatest unmet surgical and anesthetic need is, however, at the district and regional level in LMICs [1]. Unlike tertiary hospitals, surgery in these centers is often performed on an emergency basis by surgeons with no sub-specialty training. To address this gap, the ERAS® Society, in partnership with the World Bank and perioperative leaders in LMICs, has undertaken the development of a generic perioperative ERAS® Society guideline for elective and emergency surgery. This approach will integrate the SSC and be applied to patients undergoing a variety of operations including general and obstetrical surgery. These practices will focus on key ERAS measures such as patient education/engagement, avoidance of opioids and prolonged fasting, early mobilization, and early feeding. In addition to these guidelines, the ERAS® Society and World Bank are developing a tailored implementation program and monitoring tool to assess guideline compliance and patient outcomes specifically targeted to LMICs.

ERAS and the SSC share a similar quality that makes them well-suited for adoption in poorly resourced settings—that is their adaptability. Both tools are designed to be tailored to suit the context in which they will be adopted. Combining the NSOAP strategy with existing tools such as SSC and ERAS have the potential to provide a platform to improve the quality of surgical care in LMICs with improved patient outcomes and service efficiency, at scale, rapidly and make a significant contribution to addressing the unmet surgical and anesthetic need in LMICs.

Estimating the Specialist Surgical Workforce Density in South Africa

Background: South Africa is an upper middle-income country with inequitable access to healthcare. There is a maldistribution of doctors between the private and public sectors, the latter which serves 86% of the population but has less than half of the human resources.

Objective: The objective of this study was to estimate the specialist surgical workforce density in South Africa.

Methods: This was a retrospective record-based review of the specialist surgical workforce in South Africa as defined by registration with the Health Professionals Council of South Africa for three cadres: 1) surgeons, and 2) anaesthesiologists, and 3) obstetrician/gynaecologists (OBGYN).

Findings: The specialist surgical workforce in South Africa doubled from 2004 (N = 2956) to 2019 (N = 6144). As of December 2019, there were 3096 surgeons (50.4%), 1268 (20.6%) OBGYN, and 1780 (29.0%) anaesthesiologists. The specialist surgical workforce density in 2019 was 10.5 per 100,000 population which ranged from 1.8 in Limpopo and 22.8 per 100,000 in Western Cape province. The proportion of females and those classified other than white increased between 2004–2019.

Conclusion: South Africa falls short of the minimum specialist workforce density of 20 per 100,000 to provide adequate essential and emergency surgical care. In order to address the current and future burden of disease treatable by surgical care, South Africa needs a robust surgical healthcare system with adequate human resources, to translate healthcare services into improved health outcomes.