Access to pediatric surgery delivered by general surgeons and anesthesia providers in Uganda: Results from 2 rural regional hospitals

Background
Significant limitations in pediatric surgical capacity exist in low- and middle-income countries, especially in rural regions. Recent global children’s surgical guidelines suggest training and support of general surgeons in rural regional hospitals as an effective approach to increasing pediatric surgical capacity.

Methods
Two years of a prospective clinical database of children’s surgery admissions at 2 regional referral hospitals in Uganda were reviewed. Primary outcomes included case volume and clinical outcomes of children at each hospital. Additionally, the disability-adjusted life-years averted by delivery of pediatric surgical services at these hospitals were calculated. Using a value of statistical life calculation, we also estimated the economic benefit of the pediatric surgical care currently being delivered.

Results
From 2016 to 2019, more than 300 surgical procedures were performed at each hospital per year. The majority of cases were standard general surgery cases including hernia repairs and intussusception as well as procedures for surgical infections and trauma. In-hospital mortality was 2.4% in Soroti and 1% in Lacor. Pediatric surgical capacity at these hospitals resulted in over 12,400 disability-adjusted life-years averted/year. This represents an estimated economic benefit of 10.2 million US dollars/year to the Ugandan society.

Conclusion
This investigation demonstrates that lifesaving pediatric procedures are safely performed by general surgeons in Uganda. General surgeons who perform pediatric surgery significantly increase surgical access to rural regions of the country and add a large economic benefit to Ugandan society. Overall, the results of the study support increasing pediatric surgical capacity in rural areas of low- and middle-income countries through support and training of general surgeons and anesthesia providers.

Qualities of Effective Vital Anaesthesia Simulation Training Facilitators Delivering Simulation-Based Education in Resource-Limited Settings

BACKGROUND:
Lack of access to safe and affordable anesthesia and surgical care is a major contributor to avoidable death and disability across the globe. Effective education initiatives are a viable mechanism to address critical skill and process gaps in perioperative teams. Vital Anaesthesia Simulation Training (VAST) aims to overcome barriers limiting widespread application of simulation-based education (SBE) in resource-limited environments, providing immersive, low-cost, multidisciplinary SBE and simulation facilitator training. There is a dearth of knowledge regarding the factors supporting effective simulation facilitation in resource-limited environments. Frameworks evaluating simulation facilitation in high-income countries (HICs) are unlikely to fully assess the range of skills required by simulation facilitators working in resource-limited environments. This study explores the qualities of effective VAST facilitators; knowledge gained will inform the design of a framework for assessing simulation facilitators working in resource-limited contexts and promote more effective simulation faculty development.

METHODS:
This qualitative study used in-depth interviews to explore VAST facilitators’ perspectives on attributes and practices of effective simulation in resource-limited settings. Twenty VAST facilitators were purposively sampled and consented to be interviewed. They represented 6 low- and middle-income countries (LMICs) and 3 HICs. Interviews were conducted using a semistructured interview guide. Data analysis involved open coding to inductively identify themes using labels taken from the words of study participants and those from the relevant literature.

RESULTS:
Emergent themes centered on 4 categories: Persona, Principles, Performance and Progression. Effective VAST facilitators embody a set of traits, style, and personal attributes (Persona) and adhere to certain Principles to optimize the simulation environment, maximize learning, and enable effective VAST Course delivery. Performance describes specific practices that well-trained facilitators demonstrate while delivering VAST courses. Finally, to advance toward competency, facilitators must seek opportunities for skill Progression.

Interwoven across categories was the finding that effective VAST facilitators must be cognizant of how context, culture, and language may impact delivery of SBE. The complexity of VAST Course delivery requires that facilitators have a sensitive approach and be flexible, adaptable, and open-minded. To progress toward competency, facilitators must be open to self-reflection, be mentored, and have opportunities for practice.

CONCLUSIONS:
The results from this study will help to develop a simulation facilitator evaluation tool that incorporates cultural sensitivity, flexibility, and a participant-focused educational model, with broad relevance across varied resource-limited environments.

Building an ecosystem of safe surgery and anesthesia through cleft care

Cleft lip and/or palate (CLP) is among the world’s most common congenital anomalies, affecting an estimated 1 in 700 live births. CLP can lead to a wide range of health problems, including feeding difficulties that contribute to malnutrition, oral health challenges, delays in speech and language development, and long-term emotional and physical health issues. Receiving timely high-quality cleft surgical and anesthesia care, in addition to a range of interdisciplinary health services, is critical to the health and development of children impacted by CLP.

Too often, however, whether a baby receives this essential treatment is dependent upon the city, country, or region in which they are born. The global burden of surgical disease is a significant and long-neglected area within global health that disproportionately affects low-and middle-income countries (LMICs) compared to high-income countries (HICs). The estimated 1.7 billion children who live without access to surgical care around the globe, including many with CLP, live with a greater risk of life-long disability and a higher risk of mortality.

Barriers to surgical care in LMICs include a lack of trained health-care providers, inadequate infrastructure, high out-of-pocket costs, and lack of political prioritization. Historically, short-term missions have sought to address the burden of surgical conditions such as CLP, but this short-term, siloed approach fails to address – and in many cases has only perpetuated – the systemic causes of global surgical inequity, which cuts across sectors, disciplines, and borders. As momentum for the prioritization of surgical care grows, it is also clear that outdated models must be replaced by approaches that strengthen the entire ecosystem of safe surgery and anesthesia car

Anaesthesia facility evaluation: a Whatsapp survey of hospitals in Burundi

Background: Data regarding the capacity to provide safe anaesthesia is lacking in many low-income countries. With the increasing popularity of WhatsApp for both personal and professional communication in Africa, we sought to test the feasibility of using this platform to administer a brief survey of anaesthesia equipment availability in Burundi. The aims of the study were to survey a subset of anaesthesia equipment availability in Burundi and to assess the suitability of using a WhatsApp chat group to administer such a survey.

Methods: The survey was distributed via WhatsApp by ATSARPS (Agora des Techniciens Supérieurs Anesthésistes Réanimateurs pour la Promotion de la Santé), an association of anaesthesia providers in Burundi. The questions focused on the presence of five pieces of anaesthesia equipment recommended by the World Health Organization – World Federation of Societies of Anesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anesthesia, namely a Lifebox pulse oximeter, anaesthesia machine, capnograph, ECG and defibrillator. Questions were sent as free text, and responses were received as a reply or as a personal message to the president of ATSARPS who sent the survey.

Results: Responses received represented data from 55 (85%) of the 65 hospitals that offer anaesthesia care across Burundi. Eightynine per cent of hospitals had a Lifebox pulse oximeter, 91% had an anaesthesia machine, 16% had capnography, 24% had an ECG and 14% had a defibrillator. Among hospitals which responded to our survey, only 60% reported perfoming general endotracheal anaesthesia on a monthly basis.

Conclusion: Data collection in low- and middle-income countries (LMICs) can be challenging; therefore, simple, low-cost methods of data collection need to be developed. We have demonstrated the feasibility of using a WhatsApp chat group among a national society of anaesthesia providers in Burundi to perform an initial abbreviated audit of anaesthesia facilities. We have also identified significant deficits in anaesthesia equipment in Burundi.

Awake prone positioning for COVID-19 patients at Eka Kotebe General Hospital, Addis Ababa, Ethiopia: A prospective cohort study

OBJECTIVES:
The objectives of the study were to evaluate the benefit of awake prone positioning in COVID-19 patients hospitalized at Eka Kotebe General Hospital, Addis Ababa, Ethiopia.

MATERIALS AND METHODS:
Consecutive patients with COVID-19 who require supplemental oxygen to maintain oxygen saturation of ≥90% during the month of October 2020 were enrolled. Structured questionnaires were employed to collect data. Admission oxygen saturation was recorded for each patient before and after their first proning session. Analysis of descriptive and comparison statistics was done using SPSS version 25.

RESULTS:
A total of 61 patients were included in the study. The mean age (+SD) for the cohort was 55.4 (+16.9) years. The average duration of proning was 5+2.5 h/session and 8+6 h/day. The average oxygen saturation before proning was 89% (SD 5.2) and 93% (SD 2.8) 1 h after proning (P < 0.001); supplemental oxygen requirements significantly decreased with prone ventilation, before proning: FiO2 0.33 (+0.14) versus 1 h after prone ventilation: FiO2 0.31 (+0.13) (P < 0.001). Oxygen improvement with prone ventilation was not associated with duration of illness or total prone position hours. When assessed at 28 days after admission, 55.7% (n = 34) had been discharged home, 1.6% (n = 1) had died, and 42.6 (n = 26) were still hospitalized. CONCLUSION: Awake prone positioning demonstrated improved oxygen saturation in our oxygen requiring COVID-19 patients. Even though further studies are needed to support causality and determine the effect of proning on disease severity and mortality, early institution of prone ventilation in appropriate oxygen requiring COVID-19 patients should be encouraged.

An Assessment of Anesthesia Capacity in Liberia: Opportunities for Rebuilding Post-Ebola

BACKGROUND:
The health system of Liberia, a low-income country in West Africa, was devastated by a civil war lasting from 1989 to 2003. Gains made in the post-war period were compromised by the 2014–2016 Ebola epidemic. The already fragile health system experienced worsening of health indicators, including an estimated 111% increase in the country’s maternal mortality rate post-Ebola. Access to safe surgery is necessary for improvement of these metrics, yet data on surgical and anesthesia capacity in Liberia post-Ebola are sparse. The aim of this study was to describe anesthesia capacity in Liberia post-Ebola as part of the development of a National Surgical, Obstetric, and Anesthesia Plan (NSOAP).

METHODS:
Using the World Federation of Societies of Anaesthesiologists (WFSA) Anaesthesia Facility Assessment Tool (AFAT), we conducted a cross-sectional survey of 26 of 32 Ministry of Health recognized hospitals that provide surgical care in Liberia. The surveyed hospitals served approximately 90% of the Liberian population. This assessment surveyed infrastructure, workforce, service delivery, information management, medications, and equipment and was performed between July and September 2019. Researchers obtained data from interviews with anesthesia department heads, medical directors and through direct site visits where possible.

RESULTS:
Anesthesiologist and nurse anesthetist workforce densities were 0.02 and 1.56 per 100,000 population, respectively, compared to 0.63 surgeons per 100,000 population and 0.52 obstetricians/gynecologists per 100,000 population. On average, there were 2 functioning operating rooms (ORs; OR in working condition that can be used for patient care) per hospital (standard deviation [SD] = 0.79; range, 1–3). Half of the hospitals surveyed had a postanesthesia care unit (PACU) and intensive care unit (ICU); however, only 1 hospital had mechanical ventilation capacity in the ICU. Ketamine and lidocaine were widely available. Intravenous (IV) morphine was always available in only 6 hospitals. None of the hospitals surveyed completely met the minimum World Health Organization (WHO)-WFSA standards for health care facilities where surgery and anesthesia are provided.

CONCLUSIONS:
Overall, we noted several critical gaps in anesthesia and surgical capacity in Liberia, in spite of the massive global response post-Ebola directed toward health system development. Further investment across all domains is necessary to attain minimum international standards and to facilitate the provision of safe surgery and anesthesia in Liberia. The study results will be considered in development of an NSOAP for Liberia.

Assessment of feasibility and acceptability of family-centered care implemented at a neonatal intensive care unit in India

Background
A family-centered care (FCC) parent participation program that ensures an infant is not separated from parents against their will was developed for the caring of their small or sick newborn at a neonatal intensive care unit (NICU) in Delhi, India. Healthcare provider sensitization training directed at psychosocial and tangible support and an audio-visual training tool for parent-attendants were developed that included: 1) handwashing, infection prevention, protocol for entry; 2) developmentally supportive care, breastfeeding, expression of breastmilk and assisted feeding; 3) kangaroo mother care; and 4) preparation for discharge and care at home. The study aimed to examine the feasibility and acceptability of the FCC model in a NICU in India.

Methods
A prospective cohort design collected quantitative data on each parent-attendant/infant dyad at enrollment, during the NICU stay, and at discharge. Feasibility of the FCC program was measured by assessing the participation of parent-attendants and healthcare providers, and whether training components were implemented as intended. Acceptability was measured by the proportion of parent-attendants who participated in the trainings and their ability to accurately complete program activities.

Results
Of 395 NICU admissions during the study period, eligible participants included 333 parent-attendant/infant dyads, 24 doctors, and 21 nurses. Of the 1242 planned parent-attendant training sessions, 939 (75.6%) were held, indicating that program fidelity was high, and the majority of trainings were implemented as intended. While 50% of parent-attendants completed all 4 FCC training sessions, 95% completed sessions 1 and 2; 60% of the total participating parent-attendants completed session 3, and 75% completed session 4. Compliance rates were over 96% for 5 of 10 FCC parent-attendant activities, and 60 to 78% for the remaining 5 activities.

Conclusions
FCC was feasible to implement in this setting and was acceptable to participating parent-attendants and healthcare providers. Parents participated in trainings conducted by NICU providers and engaged in essential care to their infants in the NICU. A standard care approach and behavior norms for healthcare providers directed psychosocial and tangible support to parent-attendants so that a child is not separated from his or her parents against their will while receiving advanced care in the NICU.

Did COVID-19 Pandemic change Anaesthesia Practices in India: A Multi-centre Cross-sectional Study

Introduction
The anaesthetic management for surgeries during the COVID-19 pandemic has posed unique challenges. Safety of all healthcare workers is an additional concern along with heightened risk to patients during General Anesthesia (GA). COVID-19 pneumonia and aerosol generation may be exacerbated during airway intervention and GA. We aimed to assess the change in the mode of anaesthesia due to the pandemic.

Methods
A research consortium led by WHO Collaboration Centre for Research in Surgical Care Delivery in Low and Middle Income countries, India, conducted this retrospective cross-sectional study in 12 hospitals across the country. We compared the anaesthesia preferences during pandemic (April 2020) to a corresponding pre pandemic period (April 2019)

Results
A total of 636 out of 2,162 (29.4%) and 156 out of 927 (16.8%) surgeries were performed under GA in April 2019 and April 2020 respectively, leading to a fall of 13% in usage of GA. A 5% reduction in GA and a 12% increase in the usage of regional anaesthesia was observed for cesarean sections. There was no significant change in anesthesia for laparotomies and fracture surgeries. However, 14% increase in GA usage was observed in surgeries for local soft tissue infections and necrotic tissues.

Conclusion
Though overall usage of GA reduced marginally, the change was mainly contributed by anesthesia for caesarean births. The insignificant change in anaesthesia for other surgeries may be attributed to the lack of facilities for spinal anaesthesia and may reflect the risk taking behaviour of healthcare professionals in COVID-19 pandemic.

The Preparing Residents for International Medical Experiences (PRIME) Simulation Workshop: Equipping Surgery and Anesthesia Trainees for International Rotations

Abstract
Introduction: Although global health training expands clinical and sociocultural expertise for graduate medical trainees and is increasingly in demand, evidence-based courses are limited. To improve self-assessed competence for clinical scenarios encountered during international rotations, we developed and assessed a simulation-based workshop called Preparing Residents for International Medical Experiences. Methods: High-fidelity simulation activities for anesthesiology, surgery, and OB/GYN trainees involved three scenarios. The first was a mass casualty in a low-resource setting requiring distribution of human and material resources. In the second, learners managed a septic operative patient and coordinated postoperative care without an ICU bed available. The final scenario had learners evaluate a non-English-speaking patient with pre-eclampsia. We paired simulation with small-group discussion to address socio-behavioural factors, stress, and teaching skills. Participants evaluated the quality of the teaching provided. In addition, we measured anesthesiology trainees’ self-assessed competence before and after the workshop. Results: The workshop included 23 learners over two iterations. Fifteen trainees (65%) completed the course evaluation, 93% of whom strongly agreed that the training met the stated objectives. Thirteen out of 15 (87%) anesthesiology trainees completed the competence survey. After the training, more trainees indicated confidence in providing clinical care with indirect supervision or independently. Mean self-assessed competency scores on a scale of 1–5 increased for all areas, with a mean competency increase of 0.3 (95% CI, 0.2–0.5). Discussion: Including simulation in a pretravel workshop can improve trainees’ self-assessed competence for a variety of scenarios involving clinical care in limited-resource settings

Cardiac anesthesiologist and the global capacity building to tackle rheumatic valvular heart disease

Rheumatic heart disease (RHD) is considered the neglected disease of the tropics and is endemic in several low- and middle-income countries (LMIC). 1 It still is an important cause of preventable morbidity and mortality associated with cardiovascular disease among children and young adults. The disease has seen a sharp decrease in most high-income countries (HIC) and primarily, the LMICs of Asia and Africa face the brunt of RHD, which also imposes huge economic burden. 2 In addition, RHD is also a significant cause of maternal mortality. 3 For precise understanding of the burden of RHD, it needs to be appreciated that LMICs are more populous (more than 5 times that of HICs) and that RHD remains the single most common cardiovascular disease in young adult and adolescent patients in need of heart surgery. 4 Furthermore, LMICs provide very different levels of cardiac surgical services for their population. There has been an impressive significant growth in the cardiac surgical capacity in middle-income countries, even so, there is a wide gap between patients in need of intervention / surgery and those who actually receive it. In addition, the diversity of health care facilities in these countries has led to availability of state-of-the art facilities to a select few (affluent) with majority (poor and under-privileged) having to rely on the overwhelmed public hospitals. The situation in the low-income countries is even worse.